Vulnerable Groups Living with Spinal Cord Injury

Exploring Post-acute Care Challenges and Opportunities in Spinal Cord Injuries: Perspectives from 3 Distinct Countries: Canada, the United States, and Mexico

This article describes the differences and similarities in post-acute care for patients with spinal cord injuries in Canada, the United States, and Mexico. It provides a comprehensive description of the current state of spinal cord injury post-acute care in each country, including the prevalent practices, rehabilitation continuum of care, as well as challenges and opportunities related to clinical services, psychosocial factors, economic considerations, and cultural influences.

Predicting inpatient rehabilitation length of stay for adults with traumatic spinal cord injury

INTRODUCTION

Most post-injury traumatic spinal cord injury (TSCI) care occurs in the inpatient rehabilitation setting. The inpatient rehabilitation length of stay (R-LOS) has been shown to be a significant predictor of motor function restoration in persons with TSCI. Due to the complexity, and heterogeneity of individuals with TSCI, the R-LOS is challenging to predict at admission.

PURPOSE

To identify the main predictors of R-LOS and derive an equation to estimate R-LOS in persons with TSCI.

METHODS

This is a retrospective analysis of data from adults with TSCI from The Rick Hansen Spinal Cord Injury Registry in Alberta, Canada, who received rehabilitation care between May 10, 2005, and January 28, 2020. Multiple linear regression analysis was used to determine significant relationships between R-LOS and measures of participant demographics, length of stay, impairment and injury classification, and comorbidities.

RESULTS

The analysis included 736 adults with TSCI from an eligible cohort of 1365. The median R-LOS was 65 days (IQR 39-99 days), ranging from 1 to 469 days. Multivariate linear regression analysis identified two significant predictors of R-LOS, total FIM score and the injury classification. This model was used to derive a R-LOS prediction equation, which explained 34% of the variance in R-LOS.

CONCLUSION

We developed a simple equation to predict R-LOS based on the level of impairment and total FIM scores in persons with TSCI. These data have implications for health system planning, improvement, and innovation, and provide insights to support further research into the predictors of R-LOS, identification of higher-risk individuals.

Strengths, gaps, and future directions on the landscape of ethics-related research for spinal cord injury

Spinal cord injury (SCI) affects between 250,000-500,000 people globally each year. While the medical aspects of SCI have received considerable attention in the academic literature, discourse pertaining to its ethical implications is more limited. The experience of SCI is shaped by intersecting demographic and identity factors such as gender, race, and culture that necessitate an intersectional and value-based approach to ethics-related research that is properly situated in context. Given this background, we conducted a content analysis of academic studies exploring the perspectives and priorities of individuals with SCI published in peer-reviewed journals in the decade between 2012-2021. Terms pertaining to SCI and ethics were combined in a search of two major publication databases. We documented overall publication patterns, recruitment and research methods, reporting of demographic variables, and ethics-related discourse. Seventy (70) papers met inclusion criteria and were categorized by their major foci. Findings reveal a gap in reporting of participant demographics, particularly with respect to race and ethnicity, geographic background, and household income. We discuss these person-centered themes and gaps that must be closed in the reporting and supporting of SCI research.

Spine Injuries in Household Environments: A Comprehensive Analysis

Introduction Recognizing the concerns posed by spine injuries within homes, stemming from falls, interactions with furnishings, and daily activities, it is imperative to consider preventive strategies. Our analysis of spine injuries utilizing the National Electronic Injury Surveillance System (NEISS) data sheds light on falls, furnishings, age-specific risks, recreation, technology, and socioeconomic disparities as contributing elements, accentuating the need for targeted interventions. This study aims to provide insights into the prevalence of spine injuries in different household locations, associated products, age groups, and gender, thus informing injury prevention strategies for safer living environments. Methods This is a retrospective, cross-sectional study utilizing data between 2013 to 2022 from the National Electronic Injury Surveillance System database. Specific household product codes and demographic data, such as age and gender, were analyzed. Statistical analysis in R (R Foundation for Statistical Computing, Vienna, Austria) involved descriptive statistics and multivariate logistic regressions. Results In analyzing 44,267 spine injuries, the study revealed location-specific variations in spine injuries within households. Living rooms and bedrooms had the highest injury rates at 34.17% and 21.65%, respectively. Significant differences in injury rates between males and females across various home locations. Females accounted for 51.78% of injuries in the living room and 59.99% in the bedroom. In the kitchen, females experienced 53.21% of injuries, while males accounted for 46.79% of cases. Notably, overall spine injuries exhibited a significant difference between males and females, with females having a higher total likelihood of injuries (AOR = 1.21, 95% CI: 1.14-1.77, p < 0.001). Regarding age, individuals between 51-60 years were most vulnerable to spine injuries, accounting for 17.98% of total cases. Notably, the age group of 61-70 years exhibited a substantial proportion of injuries at 17.12%, while the age group of 71-80 years accounted for 14.39%. The age group of 41-50 years also displayed a notable injury rate of 14.12%. The youngest age group, 0-10 years, demonstrated the lowest percentage of injuries at 4.79%. This age-based analysis provides valuable insights into the distribution of spine injuries across different demographic segments. Regarding age, individuals between 51-60 years were most vulnerable to spine injuries, comprising 17.98% of total cases. Age groups of 41-50 and 61-70 years also showed substantial proportions of injuries, accounting for 14.12% and 17.12%, respectively. The youngest age group, 0-10, exhibited the lowest percentage of injuries at 4.79%. Conclusion The study focuses on the occurrence of spinal injuries in common sites of injury in the household, such as the living room, bedroom, kitchen, and stairs. There is increased prevalence amongst females and increased risk vulnerability amongst people 51 to 60 years of age. Our research emphasizes the necessity of implementing specific injury prevention measures tailored to different demographic groups within their home setting. This approach should involve collaborative decision-making with patients while prioritizing patient education to create a safer living environment and reduce the likelihood of spine injuries.

Social and Structural Determinants of Health: Exploring Occupational Therapy's Structural (In)competence

Background: In high-income countries, such as Canada, 50% of health outcomes are attributable to social determinants. Occupational opportunities are also structurally determined, yet these inequities are obscured by the White, Western assumptions and ableist neoliberal ideology in which the profession is deeply rooted. Purpose. To highlight the impact of structural injustices and other social determinants of health and occupation; explore the occupational therapy profession's structural competence; and build on existing knowledge to advance an agenda for action on injustice and inequity for the occupational therapy profession. Key issues. Occupational therapy's failure to prioritize education, research and action on systemic injustices and other social determinants of health and occupation reflects a lack of commitment to achieving the World Federation of Occupational Therapists' Minimal Standards. Implications. If occupational therapy is to advance knowledge and practices that address inequities in the social and structural determinants of health and occupation, we must strive towards structural competence.

Differences in functional improvement based on history of substance abuse and pain severity following spinal cord injury

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η² = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64-10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

A Primary Care Provider's Guide to Social Justice, the Right to Care, and the Barriers to Access After Spinal Cord Injury

People living with spinal cord injury (SCI) face numerous barriers to primary care. This article identifies these barriers as social justice issues to emphasize their significance and the inequality of primary care received by people with SCI. Primary care providers have a responsibility to provide equal and accessible care to all patients and to remediate any obstacles to care. Understanding the well-documented barriers of competence, physical, policy and procedural, communication, and attitudes impacting primary care for people with SCI will bring much-needed awareness and opportunity for meaningful change. This article is a call to action for social justice within primary care and provides helpful recommendations for removing and addressing barriers. Better health care outcomes for people with SCI are possible if primary care physicians and providers become social justice advocates for their patients with SCI.

Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers

Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia. Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health. Setting: Urban and rural areas of Mongolia. Participants: A purposive sample of 16 persons with traumatic SCI. Interventions: Not applicable. Outcome Measures: Not applicable. Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life. Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.

Barriers to colorectal cancer screening for people with spinal cord injuries and/or disorders: A qualitative study

BACKGROUND

Limited research has shown people with spinal cord injuries and/or disorders (SCID) are less likely to be up to date with colorectal cancer (CRC) screening and therefore more likely to be diagnosed with advanced stage CRC compared to people without SCID.

OBJECTIVE

The aims of this study were to assess knowledge about CRC, CRC screening, and self-reported barriers to CRC screening for people with SCID.

METHODS

Interviews with 30 individuals with SCID were conducted using a semi-structured interview guide, audio recorded, and transcribed. Coding was performed using a hybrid approach of inductive and deductive analysis. Thematic analysis was used to identify, review, and modify themes and sub-themes.

RESULTS

Themes identified included barriers to CRC screening, such as socioeconomic, health system, transportation, psychological, and environmental or accessibility barriers. While most respondents were able to describe one CRC screening method (usually colonoscopy), knowledge of other screening modalities was limited. Low CRC literacy and misinformation about CRC screening appeared to increase respondent association between CRC screening and colonoscopy. While most respondents associated CRC screening with colonoscopy, almost half reported the colonoscopy preparation was the most substantial barrier to screening.

CONCLUSIONS

In addition to addressing identified barriers such as accessibility and transportation, communication, and prevention interventions should be specifically targeted to ensure all people with SCID are informed about appropriate and various modalities and the benefits of screening. Specific, evidence-based guidelines on the use of stool specimens first with follow up direct visualization, if needed, should be developed for this population.

Spinal Cord Injury Veterans' Disability Benefits, Outcomes, and Health Care Utilization Patterns: Protocol for a Qualitative Study

BACKGROUND

An estimated 42,000 people currently living with chronic spinal cord injury (SCI) are veterans. SCI was a common combat-related injury in the World Wars and Vietnam era and now affects more than 11% of military personnel injured in Operation Iraqi Freedom and Operation Enduring Freedom. The Veterans Benefits Administration primarily offers financial compensation for disabilities sustained or re-aggravated during military service, called service-connected disability compensation. With the overwhelming cost of living with an SCI, this monthly financial compensation can provide service-connected veterans and their families with access to additional supportive resources (eg, assistive devices and personal aide) and maintain their quality of life (QOL). Little is known about personal, health, functional, and QOL outcomes associated with service-connected and nonservice-connected status for veterans living with an SCI.

OBJECTIVE

The aim of this study is to compare the ways in which Veterans Affairs' (VA) service-connected and nonservice-connected status may be associated with health and functional outcomes, choice of health care provider, and overall QOL for veterans living with an SCI and their caregivers.

METHODS

This cross-sectional qualitative study will gather data using retrospective chart reviews, semistructured interviews, and focus groups. After obtaining institutional review board (IRB) approval, purposeful sampling techniques will be used to recruit and enroll the following key stakeholders: veterans living with an SCI, family caregivers, and SCI health care providers. Concurrent data collection will take place at 2 sites: Veterans Administration New Jersey Healthcare System and Northern New Jersey Spinal Cord Injury System.

RESULTS

This study was funded in July 2015. IRB approval was obtained by November 2016 at both sites. Enrollment and data collection for phase 1 to phase 4 are complete. A total of 69 veterans, 18 caregivers, and 19 SCI clinicians enrolled in the study. Data analyses for these phases are underway. In phase 5, the follow-up focus group activities are scheduled. The final results are expected by the end of 2019.

CONCLUSIONS

The factors that contribute to veterans living with SCI seeking and not seeking VA disability compensation benefits are not well understood in rehabilitation research. Triangulation of these data sources will allow us to compare, contrast, and integrate the results, which can be used to develop clinical guidelines, caregiver training, and patient education programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14039.

SCI and depression: Does inflammation commandeer the brain?

The incidence of depression is almost twice as high in the spinally injured population compared to the general population. While this incidence has long been attributed to the psychological, economic, and social burdens that accompany spinal cord injury (SCI), data from animal studies indicate that the biology of SCI may play an important role in the development of depression. Inflammation has been shown to impact stress response in rodents and humans, and inflammatory cytokines have been associated with depression for decades. The inflammation inherent to SCI may disrupt necessary mechanisms of mental homeostasis, such as serotonin production, dopamine production, and the hypothalamic pituitary adrenal axis. Additionally, gut dysbiosis that occurs after SCI can exacerbate inflammation and may cause further mood and behavior changes. These mediators combined may significantly contribute to the rise in depression seen after SCI. Currently, there are no therapies specific to depression after SCI. Elucidation of the molecular pathways that contribute to SCI-specific depression is crucial for the understanding of this disease and its potential treatments.

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.

Relationships Between Community Reintegration and Clinical and Psychosocial Attributes in Individuals With Spinal Cord Injury in a Nigerian City

Background: The bio-psychosocial model for comprehensive understanding of community reintegration among individuals with spinal cord injury (SCI) varies across communities. Yet, information about community reintegration in Nigeria is not available. Objective: To investigate the association between community reintegration and clinical and psychosocial attributes among Nigerians with SCI. Methods: Fifty individuals (31 females; 19 males) with SCI aged 38.6 ± 11.1 years participated in this longitudinal survey. Pain, functional ability, and severity of injury were assessed at discharge and at 1, 2, and 3 months post-discharge from inpatient care using the Visual Analogue Scale (VAS), FIM^®, and American Spinal Injury Association Impairment Scale (AIS), respectively. Self-esteem (SE), social support (SS), and depression were also assessed using the Self-Esteem Questionnaire, Social Support Questionnaire, and Beck Depression Inventory, respectively. CR was assessed at 1, 2, and 3 months post-discharge using the Reintegration to Normal Living Index (RNLI). Data were analyzed using Spearman's rho correlation and Friedman test. Results: The psychosocial and clinical attributes were significantly different from baseline and across the 3 months post-discharge (p < .0001), except for SS. CR significantly correlated with level of injury, function ability, SE, and depression across the 3 months post-discharge (p < .01). CR was significantly correlated with SS only at 1 month post-discharge (p = .027). Conclusion: Individuals with SCI had significant improvement in clinical and psychosocial attributes from discharge to 3 months post-discharge. Improvements in these variables were associated with better reintegration into the community.

Attachment and Employment Outcomes for People With Spinal Cord Injury

The purpose of this article is to evaluate the mediation effect of hope on the relationship between attachment and full-time employment for people with spinal cord injury (SCI). Quantitative descriptive research design using logistic regression, multiple regression, and correlational techniques were used. Eighty-four persons with SCI were recruited from several SCI advocacy organizations in Canada, the United Kingdom, and the United States. The results show that secure attachment, anxious attachment, and hope were significantly related to employment. Hope was found to be a significant mediator of the relationship between attachment and full-time employment. Results provide support for the use of hope-based interventions by vocational rehabilitation counselors working with individuals with SCI.

Differences in the Community Built Environment Influence Poor Perceived Health Among Persons With Spinal Cord Injury

OBJECTIVE

To assess the association between characteristics of the built environment and differences in perceived health among persons with spinal cord injury (SCI) using objective measures of the local community derived from Geographic Information Systems data.

DESIGN

Secondary analysis of cross-sectional survey data.

SETTING

Community.

PARTICIPANTS

Persons with chronic SCI enrolled in the Spinal Cord Injury Model Systems database (N=503). All cases were residents of New Jersey, completed an interview during the years 2000 through 2012, had a complete residential address, and were community living at the time of follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Perceived health.

RESULTS

Bivariate tests indicated that persons with SCI residing in communities with more (vs less) mixed land use and small (vs large) amounts of open space were more likely to report poor perceived health. No associations were found between perceived health and differences in the residential or destination density of the community. Adjusting for variation in demographic, impairment, quality of life, and community socioeconomic characteristics accounted for the gap in the odds of reporting poor health between persons living in areas with large versus small amounts of open space (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.28-1.02). However, even after accounting for individual background differences, persons living in communities characterized by more heterogeneous land use were twice as likely to report poor health compared with persons living in less mixed areas (OR, 2.14; 95% CI, 1.12-4.08).

CONCLUSIONS

Differences in the built characteristics of communities may be important to the long-term health and well-being of persons with SCI who may have greater exposure to the features of their local area because of limited mobility. The results of this study suggest living in a community with more heterogeneous land use was not beneficial to the perceived health of persons with chronic SCI living in New Jersey. Further investigation is needed to assess if the relationships observed in this analysis are influenced by differences in infrastructure and resources across communities. Further research is also needed to investigate the role built environment plays in the long-term health and well-being of persons with SCI in other geographic locales.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.