Central Recruitment: A process for engaging and recruiting individuals with spinal cord injury/disease in research at Toronto Rehabilitation Institute

Urban-Rural Disparities in Community Participation after Spinal Cord Injury in Ontario

BACKGROUND

Personal, social, and environmental factors may influence self-efficacy and social reintegration among people living with spinal cord injury or disease (SCI/D) in urban and rural areas. Novel data collection methods have the potential to characterize community participation (CP) in diverse settings.

OBJECTIVES

The objectives were (1) to describe and compare self-reported community participation (Reintegration to Normal Living Index (RNLI) and Moorong Self-Efficacy Scale (MSES)) levels of individuals with SCI/D living in urban or rural Ontario, Canada; and (2) to determine the accuracy of an artificial intelligence (AI) optical mark recognition tool for extracting data from CP surveys conducted among participants after transitioning from inpatient rehabilitation to home and residing in the community.

METHODS

We partnered with SCI Ontario staff to collect MSES and RNLI survey data from adults with motor complete (e.g., AIS A-B) and incomplete (AIS C-D) SCI/D living in urban or rural Ontario, Canada, between January and October 2022. The Rurality Index of Ontario (RIO) from the postal code determined urban or rural residency. Optical mark recognition (OMR) software was used for survey data extraction. A Research Associate validated the extracted survey responses. Descriptive statistics, correlation analysis, and non-parametric statistics were used to describe the participants, their impairments, and their reported CP levels across urban and rural settings.

RESULTS

Eighty-five individuals with SCI/D (mean age 53.7 years, 36.5% female) completed the survey. Most of the participants resided in major urban areas (69.4%) and had traumatic injuries (64.7%). The mean total MSES score for Ontarians with SCI/D was 87.96 (95% confidence interval [CI]: 84.45, 91.47), while the mean total RNLI score for the same individuals was 75.61 (95% CI: 71.85, 79.37). Among the MSES domains, the lowest score was observed in response to sexual satisfaction (mean: 4.012, 95% CI: 3.527, 4.497), while the lowest RNLI domain item score was associated with the ability to travel out of town (mean: 5.965, 95% CI: 5.252, 6.678). Individuals with incomplete injuries in rural areas reported lower MSES and RNLI scores than those with complete motor injuries, whereas no significant differences were found in MSES and RNLI scores among urban residents based on impairment. These findings suggest that, depending on the environmental context (e.g., rural vs. urban areas), AIS categories may influence the perception of CP among people living with SCI/D. The OMR tool had 97.4% accuracy in extracting data from the surveys.

CONCLUSIONS

The CP (MSES and RNLI) scores reported by individuals with SCI/D differ based on their living setting. In rural Ontario, individuals with greater functional ability reported lower CP than their counterparts living in urban settings. Although CP remains a challenge, the needs of individuals with motor incomplete SCI/D and heterogeneous levels of mobility residing in rural areas require exploration and targeted interventions. The OMR tool facilitates accurate data extraction from surveys across settings.

The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study

PURPOSE

To understand the circumstances, causes and consequences of falls experienced by individuals with subacute SCI, and to explore their perspectives on how falls/fall risk impacted their transition to community living.

MATERIALS AND METHODS

Sixty adults with subacute SCI participated. A sequential explanatory mixed methods design was adopted. In Phase I, falls were monitored for six months post-inpatient rehabilitation discharge through a survey. In Phase II, a qualitative focus group (n = 5) was held to discuss participants' perspectives on Phase I results and falls/fall risk. Descriptive statistics and thematic analysis were used to analyze Phase I and II data, respectively.

RESULTS

Falls commonly occurred in the daytime, at home and about half resulted in minor injury. Three themes reflecting participants' perspectives were identified in Phase II. 1) Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation. 2) Adjusting to increased fall risk following discharge from inpatient rehabilitation. 3) Psychological impact of the transition to living at home with an increased fall risk.

CONCLUSIONS

The findings highlight the need for fall prevention initiatives during subacute SCI, when individuals are learning to manage their increased fall risk.

Communicating Standing and Walking Data after Spinal Cord Injury: A Patient-Engaged, Qualitative Study

Background

The Standing and Walking Assessment Tool has been implemented by physical therapists across Canada, but there is no standardized communication tool to inform inpatients living with spinal cord injury (SCI) about their standing and walking ability.

Objectives

To identify how inpatients with SCI are currently receiving feedback on their standing and walking ability, and to determine if and how they would like to receive information on their standing and walking.

Methods

Ontario's Patient Engagement Framework informed study protocol development. Inpatients with SCI were recruited from a rehabilitation centre in Canada. Purposeful sampling considering severity of SCI and sex was adopted. Three to four months following discharge from inpatient rehabilitation, a semi-structured interview was conducted to explore participants'experiences and preferences regarding feedback on standing and walking ability during inpatient SCI rehabilitation. Interviews were audio-recorded and transcribed verbatim. A conventional content analysis was completed.

Results

Fifteen individuals with SCI (5 female, 10 male) participated. Four themes emerged from the transcripts: (1) motivation for standing and walking, (2) current standing and walking practice, (3) participant preferences for feedback on standing and walking ability, and (4) perceptions of preexisting tools.

Conclusion

Information on standing and walking ability was shared with inpatients with SCI in a variety of ways. Participants identified various preferences for the nature, format, and frequency of feedback concerning standing and walking ability during inpatient rehabilitation, which suggests the need for an individualized approach to communicating this information.

Interrater reliability of the Standing and Walking Assessment Tool for spinal cord injury

STUDY DESIGN

Psychometric study.

OBJECTIVES

The Standing and Walking Assessment Tool (SWAT) is a standardized approach to the evaluation of standing and walking capacity following traumatic spinal cord injury (tSCI) in Canada. The SWAT classifies individuals with a tSCI into 12 stages of standing and walking capacity that are paired with well-established outcome measures, such as the Berg Balance Scale and 10-m Walk Test. Prior research has demonstrated the validity and responsiveness of the SWAT stages; however, the reliability remains unknown. The objective of this study was to evaluate the interrater reliability of the SWAT stages.

SETTING

Inpatient units of two Canadian rehabilitation hospitals.

METHODS

Adults with sub-acute tSCI were recruited. SWAT stage was evaluated for each participant by two physical therapists separately. The two therapists aimed to complete the evaluations within one day of each other. To evaluate interrater reliability, the percentage agreement between the SWAT stages rated by the two physical therapists was calculated, along with a linear weighted kappa statistic with a 95% CI.

RESULTS

Forty-five individuals with sub-acute tSCI (36 males, 9 females, mean (SD) age of 54.8 (17.9) years) participated. The percentage agreement in SWAT stages between the two physical therapists was 75.6%. A kappa statistic of 0.93 with a 95% CI, 0.81-1.05 was obtained. In cases where therapists disagreed (18% of participants), therapists differed by 1-2 stages only.

CONCLUSIONS

The SWAT stages have high interrater reliability, providing further support for the use of the SWAT in rehabilitation practice in Canada.

Clinical Trials Targeting Secondary Damage after Traumatic Spinal Cord Injury

Spinal cord injury (SCI) often causes loss of sensory and motor function resulting in a significant reduction in quality of life for patients. Currently, no therapies are available that can repair spinal cord tissue. After the primary SCI, an acute inflammatory response induces further tissue damage in a process known as secondary injury. Targeting secondary injury to prevent additional tissue damage during the acute and subacute phases of SCI represents a promising strategy to improve patient outcomes. Here, we review clinical trials of neuroprotective therapeutics expected to mitigate secondary injury, focusing primarily on those in the last decade. The strategies discussed are broadly categorized as acute-phase procedural/surgical interventions, systemically delivered pharmacological agents, and cell-based therapies. In addition, we summarize the potential for combinatorial therapies and considerations.

Protocol for a single group, mixed methods study investigating the efficacy of photovoice to improve self-efficacy related to balance and falls for spinal cord injury

INTRODUCTION

Many individuals living with spinal cord injury (SCI) experience falls and a fear of falling, both of which can impact participation in daily activities and quality of life. A single group, convergent mixed methods study will be conducted to examine the effects of a photovoice intervention on falls self-efficacy among individuals living with chronic SCI. Secondary objectives include examining the effects of photovoice on fear of falling, participation and quality of life and exploring participants' experiences and perceptions of the photovoice intervention through qualitative interviews.

METHODS AND ANALYSIS

Adults with SCI (n=40) will be divided into groups according to their mobility status (ie, those who ambulate and those who primarily use a wheelchair). The study will be conducted virtually over three consecutive phases, totalling 30 weeks. Each group will self-report falls for 12 weeks prior to and following the intervention (phases 1 and 3, respectively). The 6-week photovoice intervention (phase 2) will be comprised of two photo assignments, two individual interviews with a researcher and a peer mentor, and four group meetings. Participants will discuss these photos at the interviews and group meetings. Standardised questionnaires of falls self-efficacy, fear of falling, participation and life satisfaction will be administered at four time points (ie, beginning of each phase and the end of phase 3). Questionnaire scores will be examined over time using repeated-measures analysis of variance. A semistructured interview will be completed at the end of phase 3 to gain feedback on the photovoice intervention. Qualitative data will be analysed using reflexive thematic analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained prior to study enrolment. Findings will be shared through peer-reviewed scientific publications and participant-directed knowledge translation activities.

TRIAL REGISTRATION NUMBER

NCT04864262.

Impact of Falls and Fear of Falling on Participation, Autonomy and Life Satisfaction in the First Year After Spinal Cord Injury

Introduction

Individuals with spinal cord injury (SCI) experience reduced participation in meaningful activities, leading to reduced social engagement and negative psychological impact. Two factors that may affect participation post-SCI are fall status (e.g., having experienced a fall) and having a fear of falling. Our objective was to examine if and how fall status and fear of falling impact participation, autonomy and life satisfaction in the first year post-injury.

Methods

Adult inpatients of a SCI rehabilitation hospital were recruited. Following discharge, falls were tracked for 6 months and participants who fell at least once were categorized as “fallers”. At the end of the 6-month period, the Impact on Participation and Autonomy Questionnaire and Life Satisfaction Questionnaire 9 were administered, and participants were asked if they had a fear of falling (i.e., an ongoing concern about falling leading to the avoidance of activities they are capable of doing). Falls were reported using descriptive statistics. Ordinary least squares regression was used to evaluate the relationships between the independent variables (i.e., fall status and fear of falling) and each dependent variable (i.e., questionnaire scores).

Results

Seventy-one individuals were enrolled in the study; however, 11 participants were lost to follow-up. The included participants (n = 60) were 58.4 ± 14.6 years old and 99 ± 60.3 days post-injury. Over one third (38.3%) of participants fell over the 6-month tracking period. Twenty-seven participants (45%) reported a fear of falling and 14 (51.9%) of these participants were fallers. Fear of falling significantly predicted scores of autonomy indoors (β = 3.38, p = 0.04), autonomy outdoors (β = 2.62, p = 0.04) and family role (β = 3.52, p = 0.05).

Conclusion

Individuals with subacute SCI and a fear of falling experienced reduced participation and autonomy, but with no differences in life satisfaction compared to those without a fear of falling. In contrast, having experienced a fall did not impact participation, autonomy or life satisfaction. In the first year after SCI, rehabilitation programs should place specific attention on the presence of fear of falling to help individuals with SCI prepare for everyday mobility challenges.