Creating a tool to understand university students' experiences regarding inappropriate, disrespectful, and coercive (IDC) healthcare interactions

Objective: The purpose of this study was to develop a survey tool to capture inappropriate, disrespectful, and coercive (IDC) interactions with healthcare providers among a diverse sample of university students. Participants: Participants were university students at one large Midwestern public university. Methods: An exploratory qualitative approach was used to create a survey tool to capture IDC interactions. Results: In Phase I, 9 focus group discussions (FGDs) and 3 individual interviews were conducted with a total of 38 participants. In Phase II, 18 participants completed cognitive interviews. Themes across all FGDs included: (1) communication; (2) respect for identity; (3) institutional practices; (4) power imbalances; and (5) lack of patient education and empowerment. Queer participants discussed unique considerations of how queer identity influences one's IDC healthcare experiences. Conclusions: This study resulted in the development of a 64-70 item tool, the IDC Survey, to measure the prevalence and characteristics of IDC healthcare interactions.

Greener on the other side? an analysis of the association between residential greenspace and psychological well-being among people living with spinal cord injury in the United States

STUDY DESIGN

Secondary analysis of cross-sectional data from a multisite survey study.

OBJECTIVES

To describe associations between residential greenspace and psychological well-being among adults living with chronic spinal cord injury (SCI).

SETTING

Community.

METHODS

Participants were from the Spinal Cord Injury-Quality of Life (SCI-QOL) Calibration Study (N = 313). Geographic Information Systems (GIS) analysis was used to define five- and half-mile buffer areas around participants' residential addresses to represent community and neighborhood environments, respectively, and to create measures of natural and developed open greenspace. Associations of greenspace measures with two SCI-QOL psychological well-being domains (positive affect and depressive symptoms) were modeled using ordinary least squares (OLS) regression, adjusted for demographic, injury-related, and community socioeconomic characteristics.

RESULTS

People living in a community with a moderate amount of natural greenspace reported less positive affect and more depressive symptoms compared to people living in a community with low natural greenspace. At the neighborhood level, a moderate amount of developed open space was associated with less positive affect and more depressive symptoms than a low amount of developed open space.

CONCLUSIONS

Contrary to expectations, residential greenspace had a negative relationship with psychological well-being in this sample of adults with SCI. Understanding how and why natural spaces are associated with quality of life for people with mobility disabilities can influence public policy and urban planning designs to ensure that residential greenspaces are accessible and beneficial to all.

Physical Function Recovery Trajectories following Spinal Cord Injury

OBJECTIVE

Explore trajectories of functional recovery that occur during the first two years after spinal cord injury (SCI).

DESIGN

Observational cohort study.

SETTING

Eight SCI Model System sites.

PARTICIPANTS

479 adults with SCI completed four Spinal Cord Injury-Functional Index (SCI-FI) item banks within 4 months of injury and again at 2 weeks, 3, 6, 12, and 24 months following baseline assessment.

INTERVENTION

None.

MAIN OUTCOME MEASURES

SCI-FI Basic Mobility/Capacity (C), Fine Motor Function/C, Self-Care/C, and Wheelchair Mobility/Assistive Technology (AT) item banks.

RESULTS

Growth mixture modeling was used to identify groups with similar trajectory patterns. For the Basic Mobility/C and Wheelchair Mobility/AT domains, models specifying 2 trajectory groups were selected. For both domains, a majority class exhibited average functional levels and gradual improvement, primarily in the first six months. A smaller group of individuals made gradual improvements but had greater initial functional limitations. The Self Care/C domain exhibited a similar pattern; however, a third, small class emerged that exhibited substantial improvement in the first six months. Finally, for individuals with tetraplegia, trajectories of Fine Motor Function/C scores followed two patterns, with individuals reporting generally low initial scores and then making either modest or large improvements. In individual growth curve models, injury/demographic factors predicted initial functional levels but less so with regard to rates of recovery.

CONCLUSIONS

Trajectories of functional recovery followed a small number of change patterns, though variation around these patterns emerged. During the first two years after initial hospitalization, SCI-FI scores showed modest improvements; however, substantial improvements were noted for a small number of individuals with severe limitations in fine motor and self-care function. Future studies should further explore the personal, medical, and environmental characteristics that influence functional trajectories during these first two years and beyond.

Patient and Provider-Reported Satisfaction of Cancer Rehabilitation Telemedicine Visits During the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has accelerated the growth of telemedicine services across the United States. In this study, we examined cancer rehabilitation patient and physician satisfaction with telemedicine visits. We also sought to evaluate the types of provider services that are given during telemedicine visits.

OBJECTIVE

To assess overall patient and provider satisfaction with telemedicine visits and explore whether satisfaction varied by contact method (phone or video) and encounter type (new problem, worsening problem, stable/improving problem).

DESIGN

Prospective survey study.

SETTING

Cancer rehabilitation program at an academic medical center.

PARTICIPANTS

Three cancer rehabilitation providers and 155 unique patients participated in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Provider and patient satisfaction measured by customized surveys.

RESULTS

One hundred eighty-four encounters with 169 unique patients were scheduled. Of these, 14 were new visits and 170 were follow-up visits. Eighteen encounters (9.8%) were either no shows or rescheduled, making for 166 encounters with 155 unique patients. Patient and provider responses comprised the following: 94.8% of patient responses reported "quite a bit" or "very much" for the telemedicine visit being a good experience; 63.1% of patient responses reported "quite a bit" or "very much" for interest in using telemedicine visits in the future; and 83.9% of provider responses reported "quite a bit" or "very much" for the patient's main problem being addressed by the visit. Providers were more likely to prefer an in-person visit for a new or worsening problem versus a stable/improving problem. The most common services provided were medication prescription/titration and education/counseling. The least common services provided were making of new diagnoses, ordering interventional procedures, and making referrals.

CONCLUSION

Telemedicine visits were well received by both patients and providers in a cancer rehabilitation medicine clinic setting. However, in the case of a new or worsening problem, satisfaction declined. These data support that telemedicine visits should be considered essential as part of comprehensive cancer rehabilitation care, especially during a public health crisis.

Differences among participants' response to a wellness intervention for individuals with spinal cord injuries

BACKGROUND

Individuals with spinal cord injuries (SCI) often struggle with lifestyle adjustment following injury. Effective wellness interventions may aid in improving quality of life; however, treatment response heterogeneity is a concern for behavioral interventions.

OBJECTIVE

To identify differences among adults with SCI who were responders and non-responders in a wellness intervention.

METHODS

There were 29 persons with SCI who received a wellness intervention. Participants engaged in six in-person workshops over a 3-month period, led by wellness experts with peer mentors available. Individual intervention participant change was compared to the mean among control group participants target outcomes variables (i.e., satisfaction with life, self-efficacy for health practices, secondary conditions, health promoting behaviors, and perceived stress) to classify responders versus non-responders.

RESULTS

Of the 29 participants, 18 who completed the intervention were classified as responders and 11 were non-responders. The mean age was 43.2 ± 11.2 years, and years post-injury were 12.0 ± 9.8. Decision tree regression analysis for demographic variables and injury characteristics showed that single/divorced participants were more likely to not respond to the intervention (52%), compared to married participants (17%). Further, participants who were single/divorced and ≤50 years old were more likely to not respond to the intervention (62%) than those who were older (25%).

CONCLUSIONS

Single/divorced individuals with SCI may respond differently to behavioral wellness interventions than married individuals. Additionally, the effects of age on treatment response in behavioral interventions should be further examined. Identifying non-modifiable factors related to response heterogeneity may help guide the creation of tailored interventions specific to patient characteristics.

The association between the etiology of a spinal cord injury and time to mortality in the United States: A 44-year investigation

Objective: To determine the association between spinal cord injury (SCI) etiology categories and mortality, and examine the association between etiology sub-categories and mortality. Design: Prospective cohort study. Setting: Model Systems and Shriners Hospital SCI units. Participants: Data were analyzed from 42,627 cases in the SCI Model System Collaborative Survival Study Database from 1973 to 2017. Those with SCI etiologies categorized as vehicular, violent, sports, falls, pedestrian, and medical were included. Interventions: Not applicable. Outcome Measure: Time to mortality after SCI. Results: Relative to the sports related etiology category, those with medical, pedestrian, violence, falls, and vehicular related SCIs had a 2.00 (95% confidence intervals (CIs): 1.79-2.24), 1.57 (CIs: 1.34-1.83), 1.54 (CIs: 1.41-1.68), 1.35 (CIs: 1.25-1.45), and 1.26 (CIs: 1.17-1.35) higher hazard for mortality, respectfully. Persons with SCIs from automobile crashes had a 1.38 (CIs: 1.23-1.56) higher hazard for mortality, whereas those with SCIs from motorcycle crashes had a 1.21 (CIs: 1.04-1.39) higher hazard for mortality, relative to other etiologies within the vehicular category. Those with SCIs from diving had a 1.37 (CIs: 1.18-1.59) higher hazard for mortality relative to other etiologies within the sports category. Conclusions: Injury etiology categories and certain sub-categories were associated with a higher risk for early mortality. Understanding how additional factors such as socioeconomic status, co-occurring injuries, medical co-morbidities, and environmental aspects interact with SCI etiologies may provide insights for how etiology of injury impacts survival. These findings may serve as a development for extending long-term life expectancy by informing SCI prevention programs and care post-injury.

Priorities for the design and control of upper limb prostheses: A focus group study

BACKGROUND

Common prosthetic options do not allow for enough independent control signals to control all the movements of the arm. Invasive approaches to obtain prosthetic control signals are being developed to provide people with upper limb loss improved prosthetic control and feedback.

OBJECTIVE/HYPOTHESIS

This study explored the prosthetic qualities that are important to users and examined the factors that play into the decision to consider invasive prosthetic interfaces that allow for enhanced prosthetic control.

METHODS

Individuals participated in semi-structured focus groups or in individual semi-structured interviews (N = 11). A semi-structured interview guide containing open-ended questions was used to learn about ideal prosthesis qualities and interest in prosthetic technology interfaces including targeted muscle reinnervation, peripheral nerve interface, and cortical interface. Qualitative content analysis with an inductive approach was used for transcript analysis.

RESULTS

Participants were most interested in improving the dexterity and durability of prosthetic options. Recovery time, anticipated risk, medical co-morbidities, and baseline functional status influenced willingness to consider invasive prosthetic interfaces. Participants were interested in learning more about all three invasive interfaces but had the most concerns about cortical interfaces.

CONCLUSIONS

Attitudes toward invasive control interfaces vary. Further education on invasive control interfaces and additional conversations between prosthetic developers and people with limb loss will help to develop effective prosthetic devices that potential consumers will use.

Well on wheels intervention: Satisfaction with life and health for adults with spinal cord injuries

Objective/Background: To examine how demographic and injury characteristics identify satisfaction with life (SWL), and assess the differential effects of a wellness intervention by baseline SWL groups.Design: Baseline and longitudinal analysis of a randomized controlled pilot intervention using decision tree regression and linear mixed models.Setting: Community based.Participants: Seventy-two individuals with spinal cord injury (SCI) were randomized to an intervention group (n = 39) or control group (n = 33). Participants were aged 44.1 ± 13.0 years and 13.1 ± 10.6 years post-injury. Most participants were male (n = 50; 69.4%) and had paraplegia (n = 38; 52.7%). Participants were classified as high versus low SWL at baseline using a cutoff score of 20.Interventions: The intervention aimed to increase self-efficacy, and in turn, increase engagement in health-promoting behaviors related to SWL. Six 4-hour in-person workshops were conducted over a 3-month period led by experts and peer-mentors who were available for support.Outcome measure(s): Self-efficacy for health practices, secondary condition severity, health-promoting behaviors, perceived stress, and SWL.Results: At baseline, participants with low SWL were recently injured (<4.5 years), while persons with high SWL were married and younger (<49 years old). Intervention participants with low SWL at baseline significantly improved SWL over time compared to those with high SWL (P = 0.02).Conclusion: Certain injury and demographic characteristics were associated with SWL, and intervention participants with low SWL at baseline improved their SWL over 2 years. Healthcare providers should consider time post-injury, marital status, and age in identifying individuals at risk for low SWL that may benefit from wellness interventions.

The Association of Performance Status and Disease Severity in Patients With Chronic Graft-vs-Host Disease

OBJECTIVE

Determine the relationship between functional status and degree of specific organ involvement, physical performance, and subjective well-being chronic graft-vs-host disease (cGVHD) after allogeneic hematopoietic stem cell transplantation.

DESIGN

Observational cohort.

SETTING

Outpatient clinic.

PARTICIPANTS

Adult patients (N=121) with cGVHD with 634 assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Karnofsky Performance Status (KPS). Skin, fascia/joints, lungs, upper and lower extremity range of motion, liver, eye, mucosal, and gastrointestinal involvement were measured using the National Institutes of Health GVHD scale. Physical performance was assessed with the 2-minute walk test (2MWT) and hand grip strength. Subjective measures were the Patient Health Questionnaire 9 (PHQ-9) and Lee Symptom Burden (LSB) scale.

RESULTS

Myofascial (P<.001) and lung (P=.001) involvement, 2MWT (P<.001), LSB (P<.001), and PHQ-9 (P=.03) had the largest associations with KPS with liver (P=.05) and hand grip strength (P<.001) more modest associations with KPS.

CONCLUSIONS

Patients with cGVHD experience multifactorial impairment in function associated with potentially modifiable symptoms physiatrists have the expertise to address to enhance function. More research is needed to determine rehabilitation interventions to mitigate the impact of cGVHD on function.

Contextualizing disability: a cross-sectional analysis of the association between the built environment and functioning among people living with spinal cord injury in the United States

STUDY DESIGN

Secondary analysis of cross-sectional data from a multisite cohort study.

OBJECTIVES

To analyze the association between the built environment and physical functioning reported by adults living with chronic spinal cord injury (SCI).

SETTING

Four US Spinal Cord Injury Model Systems centers in New Jersey, Colorado, Illinois, and Michigan.

METHODS

Participants were from the Spinal Cord Injury-Functional Index/Capacity (SCI-FI/C) development study. Survey data from N = 402 participants were geocoded for analysis. Geographic Information Systems (GIS) analysis was used to define five- and half-mile buffer areas around participants' residential addresses to represent the community and neighborhood environments, respectively, and to create measures of land use, residential density, destination density, and park space. The relationships between these built environment features and four domains of physical functioning-basic mobility, wheelchair mobility, self-care, and fine motor function-were modeled using ordinary least squares (OLS) regression.

RESULTS

People with paraplegia living in neighborhoods with more destinations and a nearby park reported higher levels of self-care functioning. For people with tetraplegia, living in a community with more destinations was associated with better wheelchair mobility and fine motor functioning, and living in a neighborhood with high land use mix was associated with higher fine motor functioning scores.

CONCLUSIONS

The association between the built environment and functioning after SCI is supported and in need of further investigation. Understanding the environmental context of disability may lead to community-based interventions and effective public policy that will attenuate the experience of limitations and promote accessibility on a larger scale.

Functional Outcomes of Acute Inpatient Rehabilitation in Patients With Chronic Graft-Versus-Host Disease

BACKGROUND

Growing numbers of allogeneic stem cell transplants and improved posttransplant care have led to an increase of individuals with chronic graft-versus-host disease (cGVHD). Although cGVHD leads to functional impairment for many, there is limited literature regarding the benefits of acute inpatient rehabilitation for patients with cGVHD.

OBJECTIVE

To assess Functional Independence Measure (FIM) outcomes of patients with cGVHD during acute inpatient rehabilitation and to compare inpatient rehabilitation outcomes with patients with burn injuries, a rehabilitation patient population with similar comorbidities.

DESIGN

Retrospective chart review.

SETTING

Acute rehabilitation center at a large academic medical center.

PATIENTS (OR PARTICIPANTS)

A total of 37 adult patients with cGVHD and 30 with burn injuries admitted to inpatient rehabilitation from 2010 to 2015.

METHODS OR INTERVENTIONS

Linear regression analysis to evaluate group (cGVHD versus burn) differences in functional gains. Effect size and minimal detectable change at the 90% confidence level (MDC90) were used to evaluate change in FIM outcomes.

MAIN OUTCOME MEASUREMENTS

Total FIM gain, motor FIM gain, and FIM efficiency.

RESULTS

Patients with cGVHD had statistically significant lower functional gains than patients with burn injuries, with an average of 11.66 fewer total FIM points (P ≤ .001), 10.54 fewer motor FIM points (P = .01), and 2.45 units less of FIM efficiency (P = .01). At the time of discharge, 7 (18%) patients with cGVHD exceeded the MDC90 values for total FIM gain versus 9 (30%) patients with burn injuries (P = .26). Eight (21%) patients with cGVHD exceeded the MDC90 for motor FIM gain versus 13 (43%) patients with burn injuries (P = .048). Effect sizes for patients with cGVHD and with burn injury were moderate to large, respectively, with patients with burn injuries having nearly twice the magnitude of gains as patients with cGVHD.

CONCLUSIONS

Despite achieving more modest functional gains than patients with burn injuries, patients with cGVHD improved in function after acute inpatient rehabilitation. If replicated in larger studies, patients with functional impairment from cGVHD can be considered for inpatient rehabilitation. Future work should also determine minimal clinically important differences in function gain from inpatient rehabilitation for patients with cGVHD.

LEVEL OF EVIDENCE

II.

The Effects of Local Anesthesia Administration on Pain Experience During Interventional Spine Procedures: A Prospective Controlled Trial

OBJECTIVE

It has been postulated that local anesthetic administration may be the most painful part of interventional spine procedures. Despite this, there is a lack of evidence supporting the commonly used traditional technique of anesthetic delivery as part of these procedures. This study tested three hypotheses: 1) alternative method of local anesthesia injection is superior to the traditional method; 2) using the traditional method of injection is not superior to using no local anesthetic; and 3) treatment needle size, anesthetic injection technique, and sedation are associated with pain experienced during procedures.

DESIGN

Prospective, multicenter clinical trial of 127 participants who underwent elective bilateral symmetric interventional spine procedures in outpatient spine clinics.

METHODS

Primary outcomes were pain scores during and after procedures to examine the influence of anesthetic injection method and treatment needle gauge on pain experience using linear mixed model regression analysis. A post-hoc comparison of estimated marginal mean pain scores was completed on both anesthetic injection method and treatment needle gauge.

CONCLUSIONS

The alternative method was superior (P < 0.05) to the traditional method on post procedural pain scores. Injecting local anesthetic with the traditional or alternative method was not superior to using no local anesthetic. Treatment needle size, pain at one inch of treatment needle insertion, and baseline pain were all significantly (P < 0.05) associated with overall procedural pain. Further studies are needed optimize and justify local anesthetic injections for these procedures.

Spinal cord injury-functional index: item banks to measure physical functioning in individuals with spinal cord injury

OBJECTIVES

To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning.

DESIGN

Cross-sectional.

SETTING

Inpatient and community.

PARTICIPANTS

Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Spinal Cord Injury-Functional Index (SCI-FI) measurement system.

RESULTS

Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models.

CONCLUSIONS

Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Abstract 3160: Tolerance to a Tilt Table Standing Protocol In an Acute Stroke-Unit Setting: A Pilot Study

Background: objective was set to describe and examine physiological and self-reported indices of tolerance of a standing tilt table protocol (STTP) among patients following an acute stroke.

Design: Prospective, observational pilot study of patients admitted to a stroke unit of a single academic medical center.

Methods: A clinical protocol for the use of the tilt table was developed and applied to subjects in the acute phase following a stroke. The protocol involved a step-wise process to gradually raise the subject into a standing position with lower extremities in a weight bearing position on the tilt table platform, at 10 degree intervals from 60 to 90 degrees. The STTP clinical indices of tolerance were operationally defined as: Systolic blood pressure (SBP) maintained within 20 mmHg of baseline, diastolic blood pressure (DBP) maintained within 10 mmHg of baseline, heart rate (HR) maintained within 10 beats per minute of baseline, oxygen saturation (SpO 2 ) maintained at 90% or above while on supplemental O 2 or room air, absence of pallor. Subjective indices of tolerance were operationally defined as: rating of perceived exertion (RPE) < 15 per Borg Rating of Perceived Exertion Scale, pain < 5 using a numerical pain rating scale ranging from 0 to 10, and absence of angina, dizziness, nausea, dyspnea, or request to discontinue the STTP. No single measure was considered to be of primary importance, and any value falling outside the predetermined parameter was considered indicative of intolerance. Overall, tolerance of the STTP was defined as the ability to sustain 60 degrees or greater of tilt table inclination (minimum of 87% total weight bearing) for a minimum 5 minutes, without signs or symptoms of intolerance. Specifically, frequencies of the highest angle achieved, the duration of standing time tolerated, and physiologic response were recorded.

Results: Thirty-six patients with ischemic or hemorrhagic stroke (22 females, 14 males) aged 24 to 87 years (62 + 16 years) enrolled. Fifty three percent of subjects (N = 19) attained 60 degrees or higher on the standing tilt table. Ten subjects were unable to achieve 45 degrees. Subjects tolerated a mean total standing time at or above 60 degrees of 8.9 + 7.2 minutes. All subjects met tolerance criteria for dyspnea, pain, pallor, perceived effort, and nausea at 60 degrees or higher. All subjects were tolerant by heart rate criteria at 70, 80 and 90 degrees; 96% were tolerant at 60 degrees. For diastolic blood pressure, tolerance ranged from 72% (80 degrees) to 90% (70 degrees). For systolic blood pressure, tolerance ranged from 84% (70 degrees) to 100% (90 degrees). Oxygen saturation tolerance was achieved in 100% of subjects at each angle.

Conclusion: This pilot study suggests that use of a tilt table is well tolerated among patients in the acute stroke phase, and may be an effective tool for introducing early mobilization to a medically fragile patient population.

Confirmatory factor analysis of the Patient Health Questionnaire-9: a study of the participants from the spinal cord injury model systems

OBJECTIVE

To examine the factor structure of the Patient Health Questionnaire-9, a measure of depression, in persons with spinal cord injury (SCI).

DESIGN

Cross-sectional, confirmatory factor analytic study.

SETTING

Community.

PARTICIPANTS

Data for 7296 persons with an SCI who had sustained their injury at least 1 year prior to assessment and who had complete Patient Health Questionnaire-9 data collected at a follow-up interview were drawn from the National Spinal Cord Injury Statistical Center Database.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Factor structure of the Patient Health Questionnaire-9.

RESULTS

Confirmatory factor analysis indicated a marginal fit for the single factor solution (root mean square error of approximation [RMSEA] = 0.086), whereas the solution with 5 somatic items and 4 nonsomatic items had the best fit (RMSEA = 0.054) among 2-factor models that used all 9 items. Of the models that used fewer than 9 items, the best fit was for the 6-item solution with 3 somatic items (sleep, appetite, and fatigue) and 3 nonsomatic items (feeling down, feeling bad about self, and suicidal ideation; RMSEA = 0.043). Similar results were found across the strata except for the Hispanic group (for whom no model fit well).

CONCLUSIONS

Given the results of this analysis that support a 2-factor structure of the Patient Health Questionnaire-9 in persons with SCI, the next step in this line of research is to validate each of these dimensions against other ways of measuring depression.