Who wants to walk? Preferences for recovery after SCI: a longitudinal and cross-sectional study

STUDY DESIGN

Cross-sectional and longitudinal direct observation of a constrained consensus-building process in nine consumer panels and three rehabilitation professional panels.

OBJECTIVES

To illustrate differences among consumer and clinician preferences for the restoration of walking function based on severity of injury, time of injury and age of the individual.

SETTING

Regional Spinal Cord Center in Philadelphia, USA.

METHODS

Twelve panels (consumer and clinical) came to independent consensus using the features-resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) at different stages of recovery.

RESULTS

Walking is given priority early in the game by eight out of nine consumer panels and by two out of three professional panels. The exception consumer panel (ISCI<50) moved walking later in the game, whereas the exception professional panel (rehRx) moved wheelchair early but walking much delayed. Bowel and Bladder was given primary importance in all panels.

CONCLUSIONS

Walking is a high priority for recovery among consumers with spinal cord injury irrespective of severity of injury, time of injury and age at time of injury. Among professional staff, walking is also of high priority except in rehabilitation professionals.

Cross-cultural differences in preference for recovery of mobility among spinal cord injury rehabilitation professionals

STUDY DESIGN

Direct observation of a constrained consensus-building process in three culturally independent five-person panels of rehabilitation professionals from the US, Italy and Canada.

OBJECTIVES

To illustrate cultural differences in belief among rehabilitation professionals about the relative importance of alternative functional goals during spinal cord injury (SCI) rehabilitation.

SETTING

Spinal Cord Injury Units in Philadelphia-USA, Rome-Italy and Vancouver-Canada.

METHODS

Each of the three panels came to independent consensus about recovery priorities in SCI utilizing the features resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) assuming different stages of recovery.

RESULTS

Sphincter management was of primary importance to all three groups. The Italian and Canadian rehabilitation professionals, however, showed preference for walking over wheelchair mobility at lower stages of assumed recovery, whereas the US professionals set wheelchair independence at a higher priority than walking.

CONCLUSIONS

These preliminary results suggest cross-cultural recovery priority differences among SCI rehabilitation professionals. These dissimilarities in preference may reflect disparities in values, cultural expectations and health care policies.

Research on physical activity and health among people with disabilities: a consensus statement

Research is required to advance the understanding of issues related to the effect of physical activity on health and disease prevention among people with disabilities. This report is the result of a consensus process using selected experts in health and exercise. The purpose of the consensus conference was to identify research priorities for physical activity and health among people with disabilities. Priorities were established by 30 participants, who were selected by the principal investigators to achieve balance in the areas of engineering, epidemiology, medicine, nutrition, exercise physiology, and psychology. Experts summarized relevant data from their research and from comprehensive review of the scientific literature on the topic areas chosen for the conference. Public commentary was provided by participants in the 1996 Paralympic Congress. Panel members discussed openly all material presented to them in executive session. Commentary from open discussion periods were recorded and transcribed. Selected panelists prepared first drafts of the consensus statements for each research priority question. All of these drafts were distributed to the panelists and pertinent experts. The documents were edited by the drafting committee to obtain consensus. This research priority setting process revealed that greater emphasis must be placed on determining the risks and benefits of exercise among people with disabilities. Exercise must be studied from the perspective of disease prevention while mitigating risk for injury. Five areas were identified as focal points for future work: epidemiological studies; effects of nutrition on health and ability to exercise; cardiovascular and pulmonary health; children with disabilities; and accessibility and safety of exercise programs. As people with disabilities live longer, the need for addressing long-term health issues and risk for secondary disability must receive greater attention. As a consequence of the consensus process, specific recommendations for future research regarding the impact of exercise on the health and quality of life of persons with disabilities were defined.

The road to developing standards for the diagnosis and treatment of venous leg ulcers

In early 1996 the Venous Leg Ulcer Guideline was developed for the diagnosis and treatment of venous leg ulcers. In order to discuss the development of standards in general, and the Venous Leg Ulcer Guideline in particular, we first need to understand the difference between the following terms: Critical pathway, consensus statement, guideline, and standard. There are advantages and disadvantages to the use of guidelines. In the development of a guideline, endorsement by a respected colleague is important. Development of the Venous Leg Ulcer Guideline began with a consensus statement and then underwent review by a national advisory panel and national peer review through publication. A revised guideline has now been developed which will be tested in a pilot study for clinical efficacy, effect on cost, and impact on quality of life. Validation will require implementation in a prospective clinical trial. Diagnostic and Treatment Algorithm forms for the diagnosis and treatment of venous leg ulcers were developed as part of the preliminary testing of the guideline. Although guidelines do not substitute for good clinical judgement, they can encourage clinical judgement and help reduce fragmented care and the costs associated with inappropriate treatments.

Multiple sclerosis and rehabilitation outcome

This paper reviewed the outcome for people with severe multiple sclerosis admitted to an inpatient rehabilitation center. Data was gathered on admission, at discharge, and at three months postdischarge. Over a four-year period 28 patients received care comprising a total of 33 patient admissions. Seventy-three percent of the cases were women, ages 23 to 69. Sixty-one percent were admitted from acute care medical services. On admission, 18% ambulated independently, by discharge 76% could do so. Fifteen cases changed from dependent to independent status in stair climbing by discharge. Less dramatic improvements were noted for activities of daily living categories. In general, individuals who stayed at the center longer were initially more dependent and made greater relative gains. More patients with multiple admissions were married, and they tended either to be employed or to have at least partial homemaking responsibilities.