The Spinal Cord Injury Pressure Ulcer Scale (SCIPUS): an assessment of validity using Rasch analysis

STUDY DESIGN

Secondary analysis of retrospective data.

OBJECTIVE

The aim of this study was to further validate the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) using Rasch analysis.

SETTING

Two rehabilitation centers in Canada.

METHOD

Data were collected as part of the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) initiative. The SCIPUS was completed within 72 h of inpatient admission. Persons admitted for initial rehabilitation in two inpatient spinal cord rehabilitation programs were included in the project.

RESULTS

Data from 886 participants were analyzed, approximately 60% of whom were males. Rasch analyses demonstrated that the SCIPUS, in its current format did not meet criteria required for true measurement. A transformed version of the SCIPUS obtained by deletion of misfitting items and modification of the response scales improved fit to the model and showed preliminary evidence of unidimensionality. The person separation index, however indicated that the scale requires further adjustments of its scoring options.

CONCLUSIONS

In its original form, the SCIPUS does not meet the requirements of the Rasch model and its total score should be used cautiously. However, following some adjustments to the items such as addressing DIF between sites to insure a standardized assessment across sites and adding response options to some of the items, interval-scale measurement should be possible.

Determining Pressure Injury Risk on Admission to Inpatient Spinal Cord Injury Rehabilitation: A Comparison of the FIM, Spinal Cord Injury Pressure Ulcer Scale, and Braden Scale

OBJECTIVE

Assess the utility of the admission Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), Braden Scale, and the FIM for identifying individuals at risk for developing pressure injury during inpatient spinal cord injury (SCI) rehabilitation.

DESIGN

Retrospective cohort.

SETTING

Two tertiary rehabilitation centers.

PARTICIPANTS

Individuals (N=754) participating in inpatient SCI rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Logistic regression analysis was performed to determine the utility of the SCIPUS, Braden Scale, and FIM for identifying individuals at risk for developing pressure injury (PI) during inpatient SCI rehabilitation. Sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, odds ratio, likelihood ratio, and area under the curve (AUC) are reported.

RESULTS

The SCIPUS total score and its individual items did not demonstrate acceptable accuracy (AUC≥0.7) whereas the Braden Scale (0.73) and the FIM score (0.74) did. Once items were dichotomized into high and low risk categories, 1 Braden item (friction and shear), 5 FIM items (bathing, toileting, bed/chair transfer, tub/shower transfer, toilet transfer), the FIM transfers subscale, FIM Motor subscale, and the FIM instrument as a whole, maintained AUCs ≥0.7 and negative predictive values ≥0.95. The FIM bed/chair transfer score demonstrated the highest likelihood ratio (2.62) and overall was the most promising measure for determining PI risk.

CONCLUSION

Study findings suggest that a simple measure of mobility, admission FIM bed/chair transfer score of 1 (total assist), can identify at-risk individuals with greater accuracy than both an SCI specific instrument (SCIPUS) and a PI specific instrument (Braden). The FIM bed/chair transfer score can be readily determined at rehabilitation admission with minimal administrative and clinical burden.

Neurogenic bowel after spinal cord injury from the perspective of support providers: a phenomenological study

OBJECTIVE

To gain greater insight into the experience of support providers who assist and support individuals with spinal cord injury (SCI) for the performance of bowel care.

DESIGN

Qualitative (phenomenological) interviews and analysis.

SETTING

Community.

PARTICIPANTS

Ten support providers of individuals with SCI.

MAIN OUTCOME MEASUREMENTS

Themes related to supporting bowel care for individuals with SCI.

RESULTS

Support providers identified concerns and challenges as well as sources of satisfaction related to the provision of bowel care to individuals with SCI. Traits and characteristics of effective support providers also emerged.

CONCLUSIONS

Individuals with SCI often require emotional, logistical, and/or physical assistance to complete bowel care. Exploration of neurogenic bowel care from the perspective of support providers identified concerns and challenges, sources of satisfaction, and important traits and characteristics of support providers. This information can facilitate the identification of effective support providers and the provision of enhanced training and support. Interventions of this nature can improve the experience for individuals with SCI and their supports.

The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program

OBJECTIVES

To implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks.

DESIGN

Quality improvement.

SETTING

SCI Rehabilitation Center.

PARTICIPANTS

Inpatients admitted January 2012 to July 2013.

INTERVENTIONS

Implementation of two PU best practices were targeted: (1) completing a comprehensive PU risk assessment and individualized interprofessional PU prevention plan (PUPP); and (2) providing patient education for PU prevention; as part of the pan-Canadian SCI Knowledge Mobilization Network. At our center, the SCI Pressure Ulcer Scale replaced the Braden risk assessment scale and an interprofessional PUPP form was implemented. Comprehensive educational programing existed, so efforts focused on improving documentation. Implementation science frameworks provided structure for a systematic approach to best practice implementation (BPI): (1) site implementation team, (2) implementation drivers, (3) stages of implementation, and (4) improvement cycles. Strategies were developed to address key implementation drivers (staff competency, organizational supports, and leadership) through the four stages of implementation: exploration, installation, initial implementation, and full implementation. Improvement cycles were used to address BPI challenges.

OUTCOME MEASURES

Implementation processes (e.g. staff training) and BPI outcomes (completion rates).

RESULTS

Following BPI, risk assessment completion rates improved from 29 to 82%. The PUPP completion rate was 89%. PU education was documented for 45% of patients (vs. 21% pre-implementation).

CONCLUSION

Implementation science provided a framework and effective tools for successful pressure ulcer BPI in SCI rehabilitation. Ongoing improvement cycles will target timeliness of tool completion and documentation of patient education.

Phenomenological study of neurogenic bowel from the perspective of individuals living with spinal cord injury

OBJECTIVE

To gain greater insight into the lived experience of individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction (NBD).

DESIGN

Qualitative (phenomenologic) interviews and analysis.

SETTING

Community.

PARTICIPANTS

Individuals with SCI and NBD (N=19) residing in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Concerns related to living with NBD after SCI.

RESULTS

Challenges related to living with SCI and NBD included costs and requirements, emotional impact, diet, education and employment, intimacy and interpersonal relations, social participation, spontaneity and daily schedule, travel, lack of appropriate and consistent assistance, loss of autonomy (independence, privacy), lack of predictability and fear of incontinence, medical complications, pain or discomfort, physical effort of the bowel routine, physical experience, and time requirements.

CONCLUSIONS

Living with NBD presents many challenges. When categorized according to the International Classification of Functioning, Disability and Health, identified domains include body functions and structures, activity, participation, environmental factors, and personal factors. Identified issues have implications for improving clinical management and should be assessed when determining the impact and efficacy of interventions.

Evaluation of an interdisciplinary program for chronic pain after spinal cord injury

OBJECTIVE

To assess efficacy of an interdisciplinary pain program adapted for persons with spinal cord injury (SCI) and chronic pain.

DESIGN

Prospective cohort.

SETTING

University-affiliated rehabilitation hospital.

PARTICIPANTS

Twenty-two persons with traumatic or nontraumatic SCI and chronic pain of at least 6 months' duration.

METHODS

Subjects participated in an interdisciplinary pain program consisting of biweekly group sessions for 10 consecutive weeks. Sessions incorporated patient education on chronic pain and associated pain mechanisms, cognitive behavioral therapy, self-management strategies (eg, energy conservation, ergonomics, goal setting, stress management, anger management, and coping skills), group discussions and activities, and either exercise or guided relaxation at the end of each session.

MAIN OUTCOME MEASURES

Multidimensional Pain Inventory SCI, Coping Inventory of Stressful Situations, Pain Stages of Change Questionnaire, and Life Satisfaction Questionnaire.

RESULTS

After participation in an interdisciplinary pain program, persons with SCI and chronic neuropathic pain demonstrated increased involvement in learning and maintenance of coping strategies for chronic pain. Participation also led to less pain interference in daily life and a greater sense of control over one's life.

CONCLUSIONS

Participation in an interdisciplinary pain program does not reduce pain severity, but it can help persons with SCI and chronic neuropathic pain cope with pain, lessen interference of pain, and improve their sense of control.

Subjective experiences of men with and without spinal cord injury: tolerability of the juvent and WAVE whole body vibration plates

BACKGROUND

Device tolerability is an important determinant of subject adherence and intervention effectiveness. Although popular in rehabilitation settings, the tolerability of whole-body vibration (WBV) among patients with spinal cord injury (SCI) is unknown.

OBJECTIVE

To assess feedback from SCI and non-SCI subjects on the usability of passive standing and WBV devices (Juvent [Juvent Medical, Somerset, NJ] and WAVE [WAVE Manufacturing, Windsor, Ontario, Canada]) using a priori specified knee postures, plate amplitudes, and frequencies.

DESIGN

A matched groups design with repeated measures.

SETTING

A tertiary SCI rehabilitation center.

SUBJECTS

Eight men with chronic SCI (C4-L2, American Spinal Injury Association Impairment Scale A-D) and 10 men without SCI of similar height, weight, and body mass index.

INTERVENTION

Subjects (N = 18; 8 with SCI) underwent intermittent WBV during passive standing (EasyStand 5000 [Altimate Medical, Morton, MN]) for 45 minutes using the optimized WAVE and Juvent plates. WBV parameters were sequentially altered every 2 minutes and included parameter combinations of (1) postures of 140°, 160°, and 180° knee extension (180° with Juvent only); (2) amplitudes of 0.7 mm and 1.1 mm (WAVE only); and (3) frequencies of 25 Hz, 35 Hz, and 45 Hz. Outcome assessments were completed at 4-minute intervals throughout WBV exposure.

MAIN OUTCOME MEASURES

Qualitative, semistructured interviews were used to generate neutral, positive, and negative descriptors of the subjects' overall experience and device preference.

RESULTS

SCI subjects reported a greater frequency of positive descriptors than non-SCI subjects during WBV, regardless of plate, posture, amplitude, or frequency, with the exception of 1 combination of parameters (WAVE plate at 140°, 1.1 mm, and 25 Hz). Non-SCI subjects reported the highest frequency of negative effects with the WAVE plate at 160°, 1.1 mm, 25 Hz, and 35 Hz. Non-SCI subjects preferred the Juvent, whereas SCI subjects preferred the WAVE plate.

CONCLUSIONS

SCI and non-SCI subjects reported differing frequencies of positive and negative descriptors and indicated divergent device preferences. SCI subjects preferred the WAVE plate and vibration at high frequency. Future research will determine the therapeutic potential and adverse events associated with the device and WBV parameters tolerable for persons with SCI.

The Reproducibility and Convergent Validity of the Walking Index for Spinal Cord Injury (WISCI) in Chronic Spinal Cord Injury

Background. The Walking Index for Spinal Cord Injury II (WISCI II) is a hierarchical scale that measures improvements in walking following spinal cord injury (SCI). The WISCI II has good face validity, concurrent validity, and reliability following acute SCI; however, psychometric properties need to be determined for chronic SCI. Because prior studies have demonstrated a relationship between lower-extremity motor scores (LEMS) and walking, outcome measures for walking should demonstrate a linkage between the underlying impairment (weakness) and walking—convergent validity. Objective. To determine convergent validity and reproducibility of the WISCI II. Methods. Self-selected and maximum WISCI levels were assessed for 76 patients with chronic SCI (34 paraplegia, 42 tetraplegia); 10-m walking speeds were calculated. Convergent validity was assessed by correlating WISCI II levels to LEMS and walking speed. Reproducibility was assessed with the intraclass correlation coefficient (ICC) and the smallest real difference (SRD). Results. Convergent validity of the self-selected and maximum WISCI II with LEMS was moderate for paraplegia (ρ = 0.479 and ρ = 0.533) and strong for tetraplegia (ρ = 0.852 and ρ = 0.816). Tetraplegia, but not paraplegia, demonstrated convergent validity of walking speed at the self-selected and maximum WISCI levels with LEMS (ρ = 0.752 and ρ = 0.813). WISCI reproducibility was excellent (self-selected ICC = 0.994; maximum ICC = 0.995), resulting in SRDs of 0.785 (self-selected) and 0.597 (maximum), suggesting that a change of one WISCI level can be interpreted as real in a chronic patient. Conclusions. Results suggest that the WISCI II should be a very useful outcome measure for detecting changes in walking function following chronic SCI.

BRIEF EXPOSURES TO THETA-BURST MAGNETIC FIELDS IMPAIR THE CONSOLIDATION OF FOOD-INDUCED CONDITIONED PLACE PREFERENCE

Theta-burst magnetic fields (1 microT) designed to mimic electrical stimuli employed in vitro to affect long-term potentiation have been previously shown to impair the acquisition of conditioned fear. In the current study, the authors were interested in investigating whether similar magnetic fields could affect the consolidation of food-induced conditioned place preference. Fourteen male Wistar rats were exposed to a theta-burst magnetic field (1 s pulse of 5 trains of an LTP-evoking pattern) continuously or with either a 5 s or 10 s interstimulus interval for 15 min immediately following 6 daily conditioning trials (15 min/day) in a place preference apparatus. Testing demonstrated the durations in the food-paired chamber was significantly shorter for all of the magnetic field-exposed groups compared to the sham-exposed group (they remained for longer periods in the food-paired chamber, typical of normal rats). In addition, the group exposed continuously to the LTP-magnetic field (1-ms interstimulus duration) displayed the least time in the food-paired chamber. The treatments explained 80% of the variance in durations within the experimental setting. These results suggest that exposures to theta-burst magnetic fields elicit amnesic effects for contextual stimuli.