The relationship between prescription medication use and ability to ambulate distances after spinal cord injury

Prescribing patterns for treating common complications of spinal cord injury

OBJECTIVE

The purpose of this study was to find the most and least commonly prescribed medications for treating secondary health complications associated with spinal cord injury (SCI); and determine overall polypharmacy rates and risk factors associated with it.

DESIGN

Observational design, cross-sectional analysis.

SETTING

Community; Canada.

PARTICIPANTS

Individuals with spinal cord injury (n = 108).

RESULTS

A total of 515 prescriptions were issued to the sample comprising 213 different medications to treat 10 SCI-related complications. Forty-five (45%) participants were prescribed >5 medications concurrently. No associations were found between the number of drugs taken and age, sex, level of injury, completeness of injury, time since injury, or cause of injury. The most commonly treated complications included pain (56.5%), muscle spasms (54%) and urinary tract infections (43%). Anti-convulsants (pregabalin, gabapentin), anti-spasmodics (baclofen, diazepam) and nitrofurantoins (Macrobid) were the most commonly prescribed medications to treat each of the three conditions, respectively. Thirty five percent of the total sample received a combination of two or more analgesics including fourth-line agents in the opiate class (hydromorphone, hydrocodone and morphine). Similarly, some participants were prescribed general muscle relaxants and cephalosporins for treatment of muscle spasms and urinary tract infections, respectively, that are generally not recommended in SCI patients. We compare these prescribing patterns with the available clinical practice guidelines and highlight areas where the prescriptions fall outside the recommended clinical practice while considering the complexity of medication management in SCI.

CONCLUSION

Medication management in SCI is complex. Tools are required that enable prescribers to choose evidence-based medical regimens and deprescribe potentially inappropriate medications for their patients with SCI.

Prescriptions pour les complications courantes des lésions de la moelle épinière

Objectif

Décrire les modèles de prescriptions dans le cas de 3 complications communes associées à une lésion de la moelle épinière (LME) et proposer aux médecins de famille des stratégies pour optimiser les soins aux patients atteints d’une LME.

Sources de l’information

Les résultats d’une enquête nationale sur l’utilisation des médicaments d’ordonnance par des personnes atteintes d’une LME au Canada et d’une étude longitudinale des complications secondaires liées aux LME.

Message principal

Les fonctions neurologiques et cardiométaboliques altérées chez les patients atteints d’une LME compliquent le choix des régimes pharmacologiques optimaux chez de tels patients. Trois problèmes courants observés en soins primaires chez des patients atteints d’une LME exigent une pharmacothérapie, soit la douleur (traitée chez 57 % des répondants à l’enquête), les spasmes musculaires (54 %) et les infections des voies urinaires récurrentes (43 %). Le contrôle de la douleur peut nécessiter plusieurs médicaments, selon la source ou la nature de la douleur. Certains médicaments d’ordonnance recommandés pour le traitement de la douleur pourraient être sous-utilisés dans cette population, comme l’amitriptyline, tandis que d’autres pourraient être surutilisés chez de tels patients, comme les antibiotiques pour les infections des voies urinaires. La spasticité est souvent liée à un problème sous-jacent, comme la douleur, et le traitement des problèmes concomitants peut donc aussi réduire la spasticité. Il a été observé que des benzodiazépines à courte durée d’action ont été prescrites pour la spasticité à des taux étonnamment élevés, même si elles ne font pas partie du paradigme thérapeutique recommandé. L’étude longitudinale sur les complications secondaires associées aux LME a mené à l’élaboration de pépites exploitables, un outil novateur de transmission des connaissances à l’intention des professionnels des soins primaires.

Conclusion

Dans le but de prodiguer un traitement optimal des patients souffrant d’une LME, les médecins de famille sont encouragés à entamer des communications franches au sujet des médicaments d’ordonnance, y compris sur les aspects liés aux coûts, à la polypharmacie et aux substituts thérapeutiques. Les médecins de famille devraient aussi explorer l’établissement d’une collaboration interprofessionnelle avec des spécialistes des LME et d’autres professionnels de la santé afin d’offrir aux patients des stratégies non pharmacologiques adaptées à leur degré d’activité et à leurs besoins nutritionnels. L’application mobile des pépites exploitables fournit aux médecins de famille des renseignements concis, pratiques et fondés sur des données probantes portant sur les 20 principales préoccupations liées à la santé causées par une LME.

Prescribing for common complications of spinal cord injury

OBJECTIVE

To describe prescribing patterns for 3 common complications associated with spinal cord injury (SCI) and to provide family doctors with strategies for optimizing the care of patients with SCI.

SOURCES OF INFORMATION

Results of a nationwide survey of prescription medication use among people with SCI in Canada and a longitudinal study of secondary complications associated with SCI.

MAIN MESSAGE

Altered neurologic and cardiometabolic function in patients with SCI make it difficult for family physicians to predict optimal medication regimens for these patients. Three common problems seen in primary care among patients with SCI that require pharmacologic treatment are pain (treated in 57% of survey respondents), muscle spasms (54%), and recurrent urinary tract infections (43%). Pain management may require multiple medications, depending on the source or nature of the pain. Some prescription medications recommended for treating pain may be underused in this population, such as amitriptyline, while others may be overused in this population, such as antibiotics for urinary tract infections. Spasticity is often related to an underlying problem such as pain, and treatment of concomitant conditions may also reduce spasticity. Short-acting benzodiazepines were found to have been prescribed for spasticity outside the recommended treatment paradigm at a surprisingly high rate. The longitudinal study of secondary complications associated with SCI led to the development of Actionable Nuggets, an innovative knowledge translation tool for primary care providers.

CONCLUSION

To provide optimal treatment to patients with SCI, family doctors are encouraged to engage in open communication with them about prescription medications, including aspects of cost, polypharmacy, and therapeutic substitutions. Family physicians should also explore interprofessional collaboration with SCI specialists and allied health providers to provide patients with nonpharmacologic strategies tailored to their activity levels and nutritional needs. The Actionable Nuggets mobile app provides family doctors with brief, actionable, evidence-based information on the top 20 health concerns associated with SCI.

Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

OBJECTIVE

To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

DESIGN/METHODS

Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

OUTCOME MEASURES

Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

RESULTS

Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4-24.2). Total motor score averaged 39.2 (95% CI 37.8-40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P = 0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

CONCLUSIONS

Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.

The risks of polypharmacy following spinal cord injury

OBJECTIVE

The purpose of this study was to examine the overall prevalence of polypharmacy within the spinal cord injury (SCI) population, the level of polypharmacy with respect to seven classes of high-risk drugs commonly used to treat secondary conditions in the SCI population, and the overall risks for drug-related problems (DRP) related to polypharmacy.

DESIGN

A retrospective case-control design.

SETTING

A commercially available claims dataset that included patient cases from 4800 hospitals in the USA between 2007 and 2009.

PARTICIPANTS

Individuals with tetraplegia, paraplegia, and those with SCI but not specified as either tetraplegia or paraplegia as well as a control population of randomly selected, age- and sex-matched individuals without a diagnosis of SCI.

OUTCOME MEASURES

The overall prevalence of polypharmacy, the prevalence of commonly prescribed high-risk medications, and the prevalence of reported DRPs.

RESULTS

Overall, the patients in the SCI population were prescribed significantly more medications than their control counterparts. There was a higher rate of individuals being prescribed medications from multiple high-risk classes (e.g. analgesic-narcotics, anticonvulsant, antidepressant, and skeletal muscle relaxer), as well as multiple medications within each class (e.g. multiple analgesic-narcotics). The SCI group had a higher incidence of DRPs.

CONCLUSION

Our results are some of the first to demonstrate the extent of polypharmacy in individuals with SCI, including commonly prescribed high-risk medications, leading to a higher rate of DPRs. The higher rate of polypharmacy and DRPs can impact rehabilitation goals and community integration following neurologic injury.

A qualitative exploration of living with chronic neuropathic pain after spinal cord injury: an Italian perspective

PURPOSE

The purpose of this study is to understand how people with spinal cord injury (SCI) in Italy experienced and managed chronic neuropathic pain (CNP), and their perspectives of Italian healthcare services.

METHOD

Nine people with SCI participated. Two focus groups (three and four individuals) and one semi-structured interview were audio-recorded and transcribed. One "virtual interview" was conducted via e-mail. A qualitative thematic analysis was undertaken.

RESULTS

Three main themes were identified. First, participants experienced pain as a powerful, intrusive and, at times, inescapable force, with the potential to overwhelm the sense of self, and place limits on enjoyable experiences. Second, participants recounted a strong desire to understand CNP, and, in the absence of expert guidance, used trial-and-error methods to find ways of relieving pain. Third, healthcare practice was perceived as pharmacologically focused and lacking specialist knowledge. Practitioners were described as reluctant to explore alternative therapies or participate in collaborative, patient-centred care.

CONCLUSIONS

This study reveals SCI-related CNP as a deeply troubling and psychologically distressing condition impacting widely on everyday life. Specialist, collaborative, individually tailored rehabilitation approaches that attend to patients' priorities and experiences, include education about CNP, and offer opportunities to explore complementary treatments, may be welcomed by people living with this condition in Italy. Implications for Rehabilitation People living in Italy with SCI-related CNP describe inadequate and ineffective pain relief. The impact of CNP on physical, psychological and social functioning is significant but may be an issue that continues to be underestimated by health professionals. Health professionals may better support patients living in Italy with SCI-related CNP by providing long-term, individualized, collaborative and specialist support. Ongoing, patient-led discussion forums where experiences, ideas and information can be shared may be useful to persons with SCI to help them cope with their pain over the long-term.

Medication-related problems in individuals with spinal cord injury in a primary care-based clinic

OBJECTIVE

To determine the frequency of medical problems, reason for referral/primary complaint, products used, medication-related problems, and polypharmacy in patients with spinal cord injury (SCI) seen at an interprofessional primary care mobility clinic.

DESIGN

Retrospective review of medical records of patients with SCI for patient visits between August 2012 and March 2013.

METHODS

Data were abstracted from medical records of patients with SCI.

RESULTS

Of 74 patients who presented to the clinic, 19 had an SCI. Mean age was 46.7 years and 74% were male. Most frequent medical problems were depression/anxiety (37%), osteoporosis/osteopenia (26%), hypertension (21%), dyslipidemia (21%), and osteoarthritis (21%). Most common presenting complaints were pain (23%) and bowel/bladder issues (13%). Most common medication-related problems were untreated conditions (41%), ineffective medications (21%), adverse drug reactions (18%), and under- and over-dosage (each 9%). Patients with SCI most frequently used products to treat pain (68%), constipation (42%), muscle spasm (42%), hypertension (42%), and depression (37%). When including natural health products, vitamins and minerals, polypharmacy was seen in 74% of patients with SCI (63% when limited to prescription and over-the-counter medications). For patients with SCI in whose care a pharmacist collaborated, a mean of 3.2 medication-related problems per patient were identified compared with 1 per patient when the pharmacist was not involved.

CONCLUSION

This study is the first to describe medication use, polypharmacy and medication-related problems in patients with SCI seen at an interprofessional primary care clinic. Use of high-risk medications, polypharmacy, and medication-related problems in patients with SCI suggest the need for collaborative interprofessional care that includes a pharmacist.

Risk of Pain Medication Misuse After Spinal Cord Injury: The Role of Substance Use, Personality, and Depression

Our purpose was to identify risk of pain medication misuse (PMM) among participants with spinal cord injury (SCI) by examining associations with multiple sets of risk factors including demographic and injury characteristics, pain experiences, frequency of pain medication use, substance use, personality, and depressive symptoms. Risk of PMM was defined by a cutoff score ≥30 measured using the Pain Medication Questionnaire (PMQ) and examined in 1,619 adults with traumatic SCI of at least 1 year duration who reported at least 1 painful condition and use of prescription pain medication using a cross-sectional design. Results indicated 17.6% of participants had scores of ≥30 on the PMQ. After controlling for demographic, injury, and pain characteristics, logistic regression analysis showed that being a current smoker, recently using cannabis (behavioral factors), and multiple psychological factors were associated with risk of PMM, as indicated by scores on the PMQ. These included elevated depressive symptomatology and exhibiting impulsive or anxious personality traits. Because risk of PMM is indicated in individuals with SCI, prescribers should assess and monitor multiple risk factors for PMM including substance use behaviors and psychological indicators.

PERSPECTIVE

This article identifies behavioral substance use and psychological factors associated with risk of PMM, measured using the PMQ, among those with SCI. Identification of these related variables will help health care professionals better prescribe and monitor pain medication use and/or misuse among individuals with SCI.

Pain medication misuse among participants with spinal cord injury

STUDY DESIGN

Self-reported survey.

OBJECTIVE

Our purpose was to identify the predictors of pain medication misuse (PMM) among participants with spinal cord injury (SCI).

SETTING

A medical university in the southeastern United States.

METHODS

A total of 919 adults with impairment from traumatic SCI of at least 1-year duration, who reported at least one painful condition and were taking prescription medication to treat pain, were included in this study. PMM was measured by the Pain Medication Questionnaire (PMQ).

RESULTS

The average PMQ score was 19.7, with 25.8% of participants scoring at or above the cutoff of 25, which is indicative of PMM. A three-stage logistic regression analysis was conducted by sequentially adding three sets of predictors to the equation: (1) demographic and injury characteristics; (2) pain characteristics and (3) frequency of pain medication use. Age and education level were protective of PMM, whereas pain intensity, pain interference and pain medication use were risk factors. Number of painful days was not significant in the final model.

CONCLUSION

PMM must be of concern after SCI, given its high prevalence among those with at least one painful condition and its relationship with pain indicators.

Divergent modulation of clinical measures of volitional and reflexive motor behaviors following serotonergic medications in human incomplete spinal cord injury

Incomplete spinal cord injury (SCI) can result in profound impairments in volitional strength and reflex excitability, which contribute to loss of function. Human and animal models suggest that disruption of endogenous monoaminergic input, particularly serotonin (5-HT), from supraspinal centers contributes to this impaired motor function following SCI. In the present study, we investigated the effects of 5-HT medications on motor function in individuals with chronic (>1 year) SCI. Clinical measures of strength, spasticity/spasms, and walking ability were assessed in 12 individuals with chronic incomplete SCI following acute administration of either 8 mg cyproheptadine, a 5-HT antagonist, or 10 mg escitalopram, a selective 5-HT reuptake inhibitor (SSRI), in a double-blinded, randomized, crossover fashion. Results indicated that 5-HT medications modulated both volitional and reflexive behaviors with little change in walking performance; 5-HT antagonist medications depressed clinical measures of strength and spasticity/spasms, whereas SSRIs augmented both strength and spasticity/spasms. These changes are consistent with the dysregulation of 5-HT sensitive spinal neurons following SCI. This understanding may augment clinicians' awareness of the motor consequences of 5-HT medications.

Ambulation and spinal cord injury

Walking is possible for many patients with a spinal cord injury. Avenues enabling walking include braces, robotics and FES. Among the benefits are improved musculoskeletal and mental health, however unrealistic expectations may lead to negative changes in quality of life. Use rigorous assessment standards to gauge the improvement of walking during the rehabilitation process, but also yearly. Continued walking after discharge may be limited by challenges, such as lack of accessibility in and outside the home, and complications, such as shoulder pain or injuries from falls. It is critical to determine the risks and benefits of walking for each patient.

Association between reliance on devices and people for walking and ability to walk community distances among persons with spinal cord injury

OBJECTIVE

To identify and describe the frequency of reliance on assistive devices and/or people for ambulating distances and stair climbing.

DESIGN

Survey.

SETTING

A total of 429 adults with traumatic spinal cord injury who were able to walk at least 10 m were identified through inpatient and outpatient hospital databases at a specialty hospital in the southeast United States.

OUTCOME MEASURE

Data were collected using a self-report questionnaire including items related to distances walked and devices used for ambulation.

RESULTS

Participants best able to ambulate community distances were those who were independent with ambulation and those who used one cane or crutch. Reliance on people or use of a walker was associated with walking shorter distances. Regression analysis indicated reliance on devices or people for walking predicted variation in ability to ambulate community distances after controlling for demographic and injury characteristics.

CONCLUSION

This study suggests that reliance on devices or a person for assistance is important to consider when assessing potential for achieving functional community ambulation.

Cutaneous inputs from the back abolish locomotor-like activity and reduce spastic-like activity in the adult cat following complete spinal cord injury

Spasticity is a condition that can include increased muscle tone, clonus, spasms, and hyperreflexia. In this study, we report the effect of manually stimulating the dorsal lumbosacral skin on spontaneous locomotor-like activity and on a variety of reflex responses in 5 decerebrate chronic spinal cats treated with clonidine. Cats were spinalized 1 month before the terminal experiment. Stretch reflexes were evoked by stretching the left triceps surae muscles. Crossed reflexes were elicited by electrically stimulating the right tibial or superficial peroneal nerves. Wind-up of reflex responses was evoked by electrically stimulating the left tibial or superficial peroneal nerves. We found that pinching the skin of the back abolished spontaneous locomotor-like activity. We also found that back pinch abolished the rhythmic activity observed during reflex testing without eliminating the reflex responses. Some of the rhythmic episodes of activity observed during reflex testing were consistent with clonus with an oscillation frequency greater than 3 Hz. Pinching the skin of the back effectively abolished rhythmic activity occurring spontaneously or evoked during reflex testing, irrespective of oscillation frequency. The results are consistent with the hypothesis that locomotion and clonus are produced by common central pattern-generators. Stimulating the skin of the back could prove helpful in managing undesired rhythmic activity in spinal cord-injured humans.

A report of anticipated benefits of functional electrical stimulation after spinal cord injury

BACKGROUND

Functional electrical stimulation (FES) has been regularly used to offset several negative body composition and metabolic adaptations following spinal cord injury (SCI). However, the outcomes of many FES trials appear to be controversial and incoherent.

OBJECTIVE

To document the potential consequences of several factors (e.g. pain, spasms, stress and lack of dietary control) that may have attenuated the effects on body composition and metabolic profile despite participation in 21 weeks of FES training.

PARTICIPANT

A 29-year-old man with T6 complete SCI participated in 21 weeks of FES, 4 days per week.

METHODS

Prior to and following training, the participant performed arm-crank-graded exercise testing to measure peak VO(2). Tests conducted included anthropometrics and dual energy X-ray absorptiometry body composition assessments, resting energy expenditure, plasma lipid profiles and intravenous glucose tolerance tests.

RESULTS

The participant frequently reported increasing pain, stress and poor eating habits. VO(2) peak decreased by 2.4 ml/kg/minute, body mass increased by 8.5 kg, and body mass index increased from 25 to 28 kg/m(2). Waist and abdominal circumferences increased by 2-4 cm, while %fat mass increased by 5.5%. Absolute increases in fat mass and fat-free mass of 8.4 and 1 kg, respectively, were reported. Fasting and peak plasma glucose increased by 12 and 14.5%, while lipid panel profiles were negatively impacted.

CONCLUSION

Failure to control for the listed negative emerging factors may obscure the expected body composition and metabolic profile adaptations anticipated from FES training.

Association of spasticity and life satisfaction after spinal cord injury

Objective

To identify the relationship between spasticity and life satisfaction as measured by 3 multi-item factor scales and a rating of overall quality of life among participants with spinal cord injury (SCI).

Study Design

Cross-sectional survey; secondary analysis of existing data by linear regression analysis between spasticity and quality of life.

Setting

Large specialty hospital in the Southeastern United States.

Methods

Participants included 1,549 adults with traumatic spinal cord injuries, at least 18 years of age and a minimum of 1 year post-injury at survey. Outcome measures included: (1) Home Life Satisfaction, (2) Global Satisfaction, (3) Vocational Satisfaction, (4) Overall Quality of Life and (5) three subscales from the Patient Reported Impact of Spasticity Measure.

Results

Three aspects of spasticity (Daily Activities, Positive Impact, and spasticity at its worst) all were negatively correlated with Home Life Satisfaction, Global Satisfaction, and Overall Quality of Life. Only the Daily Activities scale and the spasticity at its worst rating had a significant negative correlation with Vocational Satisfaction.

Conclusion

Spasticity is negatively associated with quality of life after SCI. These negative outcomes need to be considered in an individual’s rehabilitation and treatment methods.