Associations between health behaviour, secondary health conditions and quality of life in people with spinal cord injury

The influence of pain on community reintegration after spinal cord injury

BACKGROUND

Community reintegration is an important goal for people living with a spinal cord injury (SCI), and pain is suspected to limit reintegration due to its limitations in daily functioning, mood, and sleep.

OBJECTIVES

To determine the influence of pain on community reintegration in manual wheelchair users with SCI.

METHODS

The Reintegration to Normal Living Index was used to determine community reintegration, while the DN4 and the Wheelchair User's Shoulder Pain Index were used to determine the presence of neuropathic and shoulder pain respectively. Associations and differences between the pain variables and participants with and without pain were analyzed with Spearman correlations and Mann-Whitney U-tests using SPSS v27 at 0.05 significance level and 95% confidence interval.

RESULTS

Of the 122 participants, 85.2% reported current pain, with a 77.7% median for community reintegration. Neuropathic pain (53.3%) was more common and severe than nociceptive shoulder pain (14.8%). There was no significant difference in community reintegration between participants with and without pain, nor any correlation between the overall presence of pain and community reintegration. The severity of pain, particularly shoulder pain, was negatively associated with taking trips out of town (p < 0.01), and overall community reintegration (p < 0.05).

CONCLUSION

It is not the mere presence of pain that influences community reintegration, but rather the severity and the location of pain. Shoulder care and pain management need to be included in the rehabilitation program, as these are important considerations when rehabilitating people with SCI back into their communities.

Evidence based clinical practice guideline for follow-up care in persons with spinal cord injury

Introduction

While it is well-established that follow-up care programs play a crucial role in preventing and early detecting secondary health conditions (SHCs) in persons with spinal cord injury [SCI, including spina bifida (SB)], the availability of evidence-based follow-up care programs remains limited. Under the leadership of the German-speaking Medical Society for Paraplegiology (DMGP), we have developed an evidence based clinical practice guideline for follow-up care of SHCs in persons with SCI and identify research gaps.

Methods

This guideline was developed in accordance with the regulations of the Association of the Scientific Medical Societies in Germany (AWMF e.V.). To ensure an evidence-based guidance, we utilized the International Classification of Functioning, Disability and Health (ICF) generic core set and ICF Core Set for individuals with SCI in long-term context as our foundational framework. We conducted a comprehensive literature review to identify existing recommendations for follow-up care and graded the level of evidence according to relevant instruments. Subsequently, we formulated recommendations and achieved consensus through a structured nominal group process involving defined steps and neutral moderation, while adhering to the criteria outlined in the German guideline development instrument (DELBI).

Results

Although there is a fair number of literatures describing prevalence and severity of SHCs after SCI, the amount of literature including recommendations was low (19 for SCI and 6 for SB). Based on the current evidence on prevalence and severity of SHCs and available recommendations, a clinical practice guideline on follow-up care of most relevant SHCs was defined. The recommendations for follow-up care are described in the following chapters: (1) Nervous system; (2) (Neuropathic) pain; (3) Cardiovascular diseases; (4) Respiratory System; (5) Immunological system, vaccination and allergies; (6) Gastrointestinal tract and function; (7) Endocrinological system and nutrition; (8) Urogenital system; (9) Contraception, pregnancy, birth and postpartum care; (10) Musculoskeletal system; (11) Pressure injuries; (12) Psychological health; (13) Medication and polypharmacy.

Conclusion

We could successfully establish an evidence based clinical practice guideline for follow-up care of SHCs in individuals with SCI. There is however a notable lack of high-quality recommendations for SCI follow-up care.

Impact of secondary health conditions on the quality of life and wellbeing of Canadians living with spinal cord injury: A comparison of preference-weighted index scores derived from generic standardized instruments

CONTEXT/OBJECTIVES

To compare the assessment of the impact of secondary health conditions (SHCs) on the quality of life and wellbeing of Canadians living with spinal cord injury (SCI) using four preference-based outcome measures.

DESIGN

Secondary analysis of data from a cross-sectional, online survey.

SETTING

Community.

PARTICIPANTS

Community-dwelling adults (n = 364) living with traumatic or non-traumatic spinal cord injury at least one year post-injury (70% at least 10 years post-injury).

OUTCOME MEASURES

A modified version of the Spinal Cord Injury Secondary Conditions Scale (SCI-SCS); three health-related instruments (EQ-5D-5L, Health Utilities Index Mark 3 (HUI3), and the Assessment of Quality of Life 8-dimension questionnaire (AQoL-8D)) and a capability wellbeing instrument (ICEpop CAPability measure for Adults (ICECAP-A)).

RESULTS

Across unadjusted and controlled analyses (i.e. controlling for associations between index scores and sociodemographic and impairment characteristics), trends were observed that identified lower levels of quality of life/wellbeing with higher problem ratings for each of the SHCs. Despite the trends, there was considerable variation in mean index scores across instruments, with HUI3 scores the lowest of the health-related instruments and ICECAP-A scores the highest overall. Respiratory problems, depression/mood problems, pressure sores, and autonomic dysreflexia were associated with the lowest levels of quality of life and wellbeing.

CONCLUSIONS

Higher problem ratings for SHCs are negatively associated with scores derived from preference-based quality of life and wellbeing instruments. Variation in index scores across instruments - including across the health-related instruments alone - highlights the critical importance of assessing the relative merits of preference-based instruments when using (or considering using) these instruments/estimates in comparative effectiveness research and economic evaluation.

Exploring the Experience of Living with Pain after Spinal Cord Injury: A Qualitative Study

A spinal cord injury is a life-changing experience that results in functional limitations and an increased risk of secondary health conditions. People with spinal cord injury identify pain as the most devastating health problem following their injury that not only affects their social life but their mental well-being as well. This study is aimed at exploring the lived experience of living with pain by community-dwelling manual wheelchair users with spinal cord injuries. An explorative qualitative design was used to explore their experiences. In-depth interviews were recorded and transcribed, and the data were analysed using inductive thematic content analysis in the MAXQDA v2020. Fifteen manual wheelchair users with paraplegia participated in this study, and four themes were identified from their experience of living with pain: pain constantly lurks, pain is worse than the direct consequences of the SCI, pain is restrictive, and life continues despite the pain. Categories and subcategories included the participants being one with the pain; pain interfering with sleep; feelings of anger, isolation, and suicidal ideation; and uncertainties about what the future holds living with pain. Living with pain after SCI is a challenging feat, and effective management of pain is necessary to improve not only functioning and mobility but also mental health and life satisfaction.

Pain medication misuse in the South African spinal cord injury context

Background

Pain after spinal cord injury (SCI) is debilitating and has been reported to be difficult to treat, despite pharmacological interventions. Pain medication misuse (PMM) and associated individual factors among people with spinal cord injury (PWSCI) are scarce.

Aim

To determine PMM and the associated factors in PWSCI.

Setting

Homes of community-dwelling manual wheelchair users with SCI in South Africa.

Methods

Community-dwelling PWSCI (n = 122) were consecutively sampled and the Pain Medication Questionnaire (PMQ) was used to determine PMM. Descriptive statistics, Fisher's exact test, independent t-tests, and simple linear regression tests were performed using SPSS v27. Testing was conducted at the 0.05 level of significance.

Results

Eighty-five per cent of the participants reported the presence of pain and 48.1% of them used pain medication. Forty-four percent of people who used pain medication scored ≥ 30, indicative of serious aberrant drug-taking behaviours. Opioids were mainly used for neuropathic pain and in combination with other types of medications such as anticonvulsants and non-steroidal anti-inflammatories (44.0%). Pain severity and the type of pain medication were found to be predictors of PMM (p < 0.01 respectively).

Conclusion

Pain relief after SCI remains difficult to achieve, with an evident high risk of PMM, which may lead to long-lasting side effects, dependency, or overdose.

Contribution

This study has shown the need for the assessment of the potential risk of dependency before prescribing pain medication, particularly opioids to PWSCI.

Effects of Adaptations in an Interdisciplinary Follow-Up Clinic for People with Spinal Cord Injury in the Chronic Phase: A Prospective Cohort Study

People with spinal cord injury (SCI) often experience secondary health conditions (SHCs), which are addressed during interdisciplinary follow-up clinics. We adapted the design of our clinic, by introducing a questionnaire concerning functioning and SHCs, additional measurements of blood pressure and saturation, and participants were seen by either a specialized nurse or rehabilitation physician. In this study, we investigated the effects of these adaptations and the experienced satisfaction of the participants. The results showed an increased number of recommendations in the adapted design, compared to the initial design. Further, the nature of the recommendations shifted from somatic issues to recommendations regarding psychosocial functioning and regarding (the use of) devices. The added measurements revealed an average high systolic blood pressure, which led to more referrals to the general practitioner. The clinical weight and pulmonary functions stayed stable over time. The current adaptations in design expanded and optimized the number and nature of recommendations regarding SHCs to participants. The questionnaire helps the participant to prepare for the clinic and the professionals to tailor their recommendations, resulting in highly satisfied participants.

Development of a pain self-management intervention framework for people with spinal cord injury

BACKGROUND

 Pain is the most common reason for medical visits to primary health care practitioners. Pain self-management interventions are encouraged and there is no known self-management intervention framework available that clinicians and people with spinal cord injury (PWSCI) can use to guide treatment selection.

AIM

 This study aimed to develop a pain self-management intervention framework for PWSCI.

SETTING

 Online and facilitated in Gauteng, South Africa.

METHODS

 A three-round modified e-Delphi method was used to reach an 80% consensus among a 21-expert panel. Fifty-nine interventions were distributed via REDCap and a final online audio meeting was held to either include or exclude interventions in the final framework. SPSS v27 was used to analyse descriptive data and content analysis was used for qualitative responses.

RESULTS

 The final developed pain self-management framework consists of 56 interventions and includes interventions from multiple health professions to encompass medical, psychological, therapeutic and social interventions. Interventions are also specified for nociceptive and/or neuropathic pain and grouped according to the biopsychosocial model.

CONCLUSION

 The interprofessional framework may be used as a guideline for PWSCI to alleviate pain, as well as assist health professionals in clinical decision-making, by providing them with the freedom to choose acceptable and adequate interventions that may be appropriate to treat the affected individual's pain.Contribution: Pain management is a basic need at the primary healthcare level and PWSCI need access to the broad range of interventions available to manage their pain. The framework highlights the variety of appropriate interventions to guide both health professionals and PWSCI with pain relief options.

Prevalence of secondary health conditions and mental status in persons with long-term spinal cord injury in South Africa: Comparison between public and private healthcare sectors

BACKGROUND

Spinal cord injuries typically result in a range of negative health outcomes and health states, which impacts overall functioning, health and well-being. It remains important to establish the prevalence (burden) of health outcomes to help with the development of optimal treatment strategies.

OBJECTIVES

To determine the prevalence and treatment rates of secondary health conditions (SHCs) and mental health states in persons with long-term spinal cord injury (SCI) receiving public compared with private healthcare services in South Africa.

METHODS

A cross-sectional survey included 200 community-dwelling persons with long-term SCI, 60% with paraplegia, 53% with complete injuries and 156 from the public and 44 from private healthcare sectors. The following modules of the International Spinal Cord Injury (InSCI) community survey were used: (i) demographic and injury characteristics; (ii) SHCs and treatment rates; and (iii) vitality and emotional well-being. All statistical analyses were stratified according to healthcare sector.

RESULTS

Pain (47% v. 57), sexual dysfunction (59% v. 41%) and muscle spasms (54% v. 43%) were the most common SHCs in both cohorts, and the period prevalence was significantly higher for sleeping problems (41% v. 25%), sexual dysfunction (59% v. 41%) and contractures (42% v. 20%) in the public compared with the private cohort. Persons with SCI in the private cohort received treatment more often for sleeping problems (100% v. 45%), autonomic dysreflexia (75% v. 27%) and pain (56% v. 33%) than their counterparts with public insurance. Negative mental health states were prevalent in both groups.

CONCLUSION

SHCs and negative mental health were common in persons with SCI in South Africa, while those with public insurance reporter a higher occurrence of sleep problems and contractures, as well as lower treatment rates. Overall, a need exists to better support persons with SCI in the long-term context to facilitate improved functioning and wellbeing.

The prevalence and profile of spinal cord injury in public healthcare rehabilitation units in Gauteng, South Africa

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

To determine the prevalence and describe the profile of person with SCI (PWSCI) admitted in the public healthcare sector in Gauteng, South Africa.

SETTING

Specialized public healthcare rehabilitation units in Gauteng, South Africa.

METHODS

Medical records of PWSCI admitted to public healthcare rehabilitation units between 01 January 2018 and 31 December 2019 were perused. Data were collected anonymously and then summarised using descriptive and inferential statistics. Significance was set at p < 0.05.

RESULTS

386 of 998 participants (38.7%) were admitted following SCI and the mean age was 36.9 years. Most participants were male (69.9%), with females significantly more likely to sustain a NTSCI (p < 0.001), which was the least common cause of SCI (34.9%). Those sustaining a TSCI were found to be significantly younger than their NTSCI counterparts (p < 0.001). Assault was the leading cause of injury (35.2%), and a positive HIV status with the presence of comorbidities were found to be significant risk factors for developing a NTSCI (p < 0.001). Most injuries were between T7-T12 (39.9%) and were complete (56.9%). The rehabilitation length of stay 85.6 days, with a mortality rate of 6.48%.

CONCLUSIONS

Gauteng has among the highest global proportion of TSCI due to assault. Of interest, more females sustained a NTSCI than their male counterparts. There is a need to strengthen SCI prevention strategies, particularly targeting assault in young males and infectious causes in females and older populations. Further epidemiological and outcomes-based research is required for PWSCI.

Robotic locomotor training for spasticity, pain, and quality of life in individuals with chronic SCI: A pilot randomized controlled trial

Objective

The prevention and treatment of secondary complications is a key priority for people with spinal cord injury and a fundamental goal of rehabilitation. Activity-based Training (ABT) and Robotic Locomotor Training (RLT) demonstrate promising results for reducing secondary complications associated with SCI. However, there is a need for increased evidence through randomized controlled trials. Therefore, we aimed to investigate the effect of RLT and ABT interventions on pain, spasticity, and quality of life in individuals with spinal cord injuries.

Methods

Participants with chronic motor incomplete tetraplegia (n = 16) were recruited. Each intervention involved 60-minute sessions, 3× per week, over 24-weeks. RLT involved walking in an Ekso GT exoskeleton. ABT involved a combination of resistance, cardiovascular and weight-bearing exercise. Outcomes of interest included the Modified Ashworth Scale, the International SCI Pain Basic Data Set Version 2, and the International SCI Quality of Life Basic Data Set.

Results

Neither intervention altered symptoms of spasticity. Pain intensity increased from pre-post intervention for both groups, with a mean increase of 1.55 [-0.82, 3.92] (p = 0.03) and 1.56 [-0.43, 3.55] (p = 0.02) points for the RLT and ABT group, respectively. The ABT group had an increase in pain interference scores of 100%, 50%, and 109% for the daily activity, mood, and sleep domain, respectively. The RLT group had an increase in pain interference scores of 86% and 69% for the daily activity and mood domain respectively, but no change in the sleep domain. The RLT group had increased perceptions of quality of life with changes of 2.37 [0.32, 4.41], 2.00 [0.43, 3.56] and 0.25 [-1.63, 2.13] points, p = 0.03, for the general, physical, and psychological domains, respectively. The ABT group had increased perceptions of general, physical and psychological quality of life with changes of 0.75 [-1.38, 2.88], 0.62 [-1.83, 3.07] and 0.63 [-1.87, 3.13] points, respectively.

Conclusions

Despite increased pain ratings and no change in symptoms of spasticity, there was an increase in perceived quality of life for both groups over 24-weeks. This dichotomy warrants additional investigation in future large-scale randomized controlled trials.

Clinical and socio-demographic determinants of community reintegration in people with spinal cord injury in eThekwini Municipality, KwaZulu-Natal province

Background

Community reintegration is a major outcome of rehabilitation after the acute phase in people with spinal cord injury (PWSCI).

Objective

To investigated clinical and socio-demographic factors determining community participation in PWSCI, living in the greater eThekwini Municipality, KwaZulu-Natal province.

Method

Our quantitative, cross-sectional study had a convenient sample of 41 PWSCI. A trained interviewer obtained socio-demographic information using a structured questionnaire. Participants completed the Reintegration to Normal Living Index (RNLI). Descriptive statistics were used in summarising the data; inferential statistics, -a t-test and analysis of variance (ANOVA) assessed the association of clinical and socio-demographic factors with the extent of community reintegration. A multiple linear regression investigated the determinants of community reintegration with the alpha level set at p = 0.05.

Results

Mean age of the participants was 41 years (s.d.: 10, range 25–66), with the majority (n = 32, 78%) being male. The mean RNLI score was 68% (s.d.: 22, range 24–100). Participants scored higher on the RNLI if they were male (mean difference [MD] 18%, 95% confidence interval [CI]: 2–34), were employed (MD 16%, 95% CI: 0–32), had a salary (MD 19%, 95% CI: 5–32) and had no muscle spasms (MD 14%, 95% CI: 1–27. Muscle spasms (p = 0.012, 95% CI: 3.85–29.05) and being female PWSCI (p = 0.010, 95% CI: −35.75 to −5.18) were significant negative predictors of community reintegration.

Conclusion

Community reintegration may be influenced by socio-economic factors. Special interventions for muscle spasms and support for women living with spinal cord injuries may enhance community reintegration.

Clinical implication

Therapists need to focus on community reintegration with female PWSCI and on returning to PWSCI to work as this was improved community reintegration.

The presence of pain in community-dwelling South African manual wheelchair users with spinal cord injury

Background

Pain after spinal cord injury (SCI) is common and is likely to continue throughout life with varying levels of severity.

Objective

To determine the presence of pain, the sociodemographic and injury profile of community-dwelling manual wheelchair users.

Method

This quantitative correlational study used a sociodemographic and injury profile sheet and the Douleur Neuropathique 4 Questions (DN4) questionnaire to document demographic, SCI profiles as well as pain characteristics. Pain severity was determined using the Numeric Rating Scale. Data were analysed using the Statistical Package for the Social Sciences (SPSS) v27 at 0.05 level of significance.

Results

The pain rate was 104; 85% of 122 participants and mainly in those with complete SCI (77.9%). Neuropathic pain was more common (76; 62.5%) and significantly associated (p < 0.05) with higher pain severity. Pain was mainly in one area of the body (59; 48.4%) but occurring in up to five areas. The most painful area had a mean severity of 6.7/10; was more common in the lower limbs below the injury level (48; 39.4%); and was burning in nature (40; 32.7%).

Conclusions

Pain after SCI is as problematic in the South African context as it is globally. With the rising SCI prevalence in the country, understanding pain and its presentation is important for holistic management of a person with SCI.

Clinical implications

In-depth assessment of pain should be conducted and appropriate management interventions for specific pain types be prescribed to effectively reduce pain.

Exploring prevention and management of secondary health conditions in people with spinal cord injury in South Africa

Background/Aims

Preventative care for people with spinal cord injury is neglected, even though secondary health conditions are prevalent among this group. There is limited information on preventative care for secondary health conditions among people with spinal cord injury. This study aimed to explore how people with spinal cord injury prevent and manage secondary health conditions.

Methods

A total of 17 individuals with spinal cord injury attending an outpatients clinic at a public rehabilitation hospital were interviewed face to face. All the interviews were transcribed verbatim and analysed using thematic content analysis.

Results

The participants used different strategies to prevent and manage secondary health conditions, such as medication, assistive devices, self-management, resilience coping strategies and therapeutic approaches. The participants found prevention of secondary health conditions ‘challenging’ and some of the strategies were ineffective.

Conclusions

Although many strategies are used by people with spinal cord injury to prevent and manage secondary health conditions, the experience is difficult. To minimise the occurrence and the consequence of secondary health conditions among people with spinal cord injury, health professionals must promote and support preventative care for secondary health conditions.

Experiences of secondary health conditions amongst people with spinal cord injury in South Africa: A qualitative study

BACKGROUND

Secondary health conditions (SHCs) such as pain, pressure sores, sexual problems, bowel and bladder problems are prevalent throughout the lifespan of people with spinal cord injury (SCI). Studies have reported that SHCs decrease life expectancy and increase health care costs. Studies on the lived experience of SHCs are, however, limited.

OBJECTIVES

To explore the experiences of SHCs amongst people with SCI in a public rehabilitation hospital in South Africa.

METHOD

Face-to-face semi-structured interviews were conducted with people with SCI from August 2018 to July 2019. All interviews were transcribed verbatim and analysed using a content analysis approach.

RESULTS

Seventeen people with SCI were interviewed. Participants experienced a range of SHCs. The most common experienced SHC was pain (94%). The main theme that emerged from the analysis was 'the impact of secondary health conditions on health and well-being'. The categories linked to the impact were SHCs co-occurrence and how SHCs limit function, restrict participation, affect mental health and disrupt lives.

CONCLUSION

We found that SHCs were enormously impactful on our participants' lives and health, as illustrated by their stories of fear, embarrassment and shame. Understanding people with SCI experiences of SHCs can enhance communication between people with SCI and health professionals and may help develop prevention strategies.

CLINICAL IMPLICATIONS

To enhance patient-centred care, health professionals are encouraged to actively listen to patients' experiences of illness and the impact on health and wellbeing.

'I forget to do pressure relief': Personal factors influencing the prevention of secondary health conditions in people with spinal cord injury, South Africa

BACKGROUND

Across the lifespan, people with spinal cord injury (SCI) may experience preventable secondary health conditions (SHCs) such as pressures sores, muscle spasms and urinary tract infections (UTIs). Some factors influencing prevention of SHCs include social support, poor access to care and the prevention style of individuals. There is limited research on these factors.

OBJECTIVE

To explore personal factors influencing the prevention of SHCs in people with SCI.

METHOD

An explorative qualitative study included participants recruited in an outpatient department at a rehabilitation hospital. Semi-structured interviews were conducted with patients with SCI. Interviews were transcribed verbatim. Data analysis was conducted using content analysis.

RESULTS

Seventeen individuals with SCI were interviewed. From the interview analysis, six personal factors were identified, namely, socio-economic status; mental well-being (forgetfulness, beliefs, attitude); lack of knowledge of SHCs and prevention; lifestyle choices and practising prevention care; patient activation (self-management, problem-solving, resilience, self-awareness, help-seeking behaviour) and owning an appropriate assistive device.

CONCLUSION

Socio-economic status, mental well-being, knowledge of SHCs and prevention care, behaviour patterns, patient activation and owning an appropriate assistive device can influence prevention of SHCs. To enhance patient-oriented care, a model of care for people with SCI should consider these factors when developing prevention strategies. Future research could look into identifying environmental factors that influence the prevention of SHCs in people with SCI.

CLINICAL IMPLICATIONS

Tailored prevention strategies need to be developed, health professionals must ask patients about individual factors that may be barriers or facilitators to preventing secondary health conditions.

Pain and its impact on functioning and disability in manual wheelchair users with spinal cord injury: a protocol for a mixed-methods study

INTRODUCTION

Approximately 80% of people with spinal cord injury experience clinically significant chronic pain. Pain (whether musculoskeletal or neuropathic) is consistently rated as one of the most difficult problems to manage and negatively affects the individual's physical, psychological and social functioning and increases the risk of pain medication misuse and poor mental health. The aim of this study is to therefore determine the presence of pain and its impact on functioning and disability as well as to develop a framework for self-management of pain for South African manual wheelchair users with spinal cord injury.

METHODS AND ANALYSIS

Community-dwelling participants with spinal cord injury will be invited to participate in this three-phase study. Phase 1 will use a quantitative, correlational design to determine factors related to pain such as pectoralis minor length, scapular dyskinesis, wheelchair functioning, physical quality of life, community reintegration and pain medication misuse. Demographic determinants of pain such as age, gender, type of occupation, completeness of injury and neurological level of injury will also be investigated. Participants with pain identified in phase 1 will be invited to partake in a qualitative descriptive and contextually designed phase 2 to explore their lived experience of pain through in-depth interviews. The results of phases 1 and 2 will then be used with the assistance from experts to develop a framework for self-management of pain using a modified Delphi study. Data analysis will include descriptive and inferential statistics (quantitative data) and thematic content analysis (qualitative data).

ETHICS AND DISSEMINATION

Approval for this study is granted by the Faculty of Health Sciences Research Ethics Committee of the University of the Pretoria (approval number 125/2018). This study is registered with the South African National Health Research Database (reference GP201806005). This study's findings will be shared in academic conferences and published in scientific peer-reviewed journals.

Mortality and secondary complications four years after traumatic spinal cord injury in Cape Town, South Africa

STUDY DESIGN

A prospective, regional, population-based study.

OBJECTIVES

(1) Determine the mortality rate and factors associated with it 4 years after a TSCI and (2) The point prevalence of secondary medical complications of survivors at 4 years.

SETTING

Communities of the Cape metropolitan area, South Africa.

METHODS

All persons (n = 145) sustaining a TSCI from 15 September 2013 to 14 September 2014 were eligible for follow-up at 4 years. Participants were contacted after 4 years. The next of kin, via verbal autopsy, was used to establish cause of death. Those who were alive at 4 years were asked to indicate any secondary medical complications. Logistic regression techniques were used to identify independently associated risk indicators for death and development of secondary complications, respectively.

RESULTS

Of the initial 145 persons, 87 were included and accounted for. Of these, 21 (24%) had died, 55 (63%) were alive and completed the survey, and 11 (13%) were classified as alive but did not submit the survey. The main cause of death reported was septicaemia (n = 7; 33%), followed by unknown natural causes (n = 7; 33%), then pressure injuries (n = 5; 24%). Out of the 55 persons alive, 89% had at least one medical complication at the time of enquiry, while more than 50% experienced 6 or more complications. The most common complications were pain (80%), muscle spasms (76%), sleeping problems (56%), and bladder dysfunction (44%).

CONCLUSIONS

Almost one-quarter of persons with TSCI have died 4 years after injury. Also, secondary complications were found to be highly prevalent at 4 years. This information could be used to develop secondary complications prevention programmes to reduce premature deaths.

SPONSORSHIP

This study was funded by the Medical Research Council of South Africa within the Research Capacity Development Initiative.

Reliability and validity of the Readiness for Hospital Discharge Scale in patients with spinal cord injury

Background

Measuring rehabilitation outcomes in patients with spinal cord injury (PWSCI) requires measurement tools that are valid and reliable and have been psychometrically tested in the population with spinal cord injury (SCI). The Readiness for Hospital Discharge Scale (RHDS) has been found to be reliable and valid in adult surgical patients, post-partum mothers, parents of hospitalised children and geriatrics. However, the psychometric properties have not yet been tested in the population with SCI, furthermore, in a South African context.

Objectives

The purpose of this study was to psychometrically test the internal consistency and construct validity of the RHDS as a measure of discharge readiness in PWSCI prior to discharge from rehabilitation units in the Tshwane metropolitan area, South Africa.

Method

A cross-sectional study that included 50 PWSCI who were in their last week of rehabilitation was conducted. The RHDS item and scale statistics were calculated by using descriptive statistics and the scale reliability was measured for internal consistency by using Cronbach’s alpha coefficients. To determine construct validity, convergent and divergent validities were measured by using the RHDS items’ correlation coefficient dimensions. All data were tested at the 0.05 level of significance by using Statistics and Data (STATA) statistical software, version 14.

Results

Cronbach’s alpha of the RHDS was 0.904, indicating an excellent reliability coefficient. Convergent validity scores showed 81% correlation coefficients, although divergent validity scores showed 62% correlation coefficients.

Conclusion

The RHDS is a valid and reliable measure of readiness for discharge in a South African sample of PWSCI and can be used in SCI rehabilitation.

Clinical implications

Over and above using the RHDS to determine if PWSCI are ready for discharge in the clinical setting, the RHDS may also assist health care practitioners to assess the patient’s progress towards readiness and strategies for addressing shortcomings to meet short and long-term goals of the rehabilitation process.

Quality of life of persons with traumatic spinal cord injury in rural Kilimanjaro, Tanzania: a community survey

AIM

To describe the quality of life of persons with traumatic spinal cord injury (TSCI) in a rural area of a low-income country.

METHODS

This was a cross-sectional descriptive study in which snowballing was used to identify persons with TSCI in their homes. A Kiswahili version of the short version of the World Health Organization quality of life questionnaire was used for data collection. Data were analyzed descriptively and independent samples t-tests were used to calculate the difference in the mean scores between groups.

RESULTS

Eighty persons with TSCI with a mean age of 42.29 ± 11.4 years were identified, 68.8% of whom were males. The highest scoring domains were psychological (12.76 ± 2.55) and social relationships (12.62 ± 2.95). The lowest scores were for physical (11.48 ± 2.74) and environment (9.59 ± 2.68) domains. Significantly higher scores were associated with younger age in: physical (0.05), social relationships (0.01), and environment (0.02) domains (p value < 0.05).

CONCLUSIONS

Persons with TSCI in the Kilimanjaro rural area registered a relatively low quality of life in which the most affected domains are physical health and environment.Implications for rehabilitationQuality of life is the ultimate goal in the rehabilitation of persons with any irreversible disability such as spinal cord injury.It is important for rehabilitation professionals to know which domains of quality of life are most affected among persons with spinal cord injury.Rehabilitation professionals ought to understand and address physical health and environmental issues that affect persons with traumatic spinal cord injury in rural resource-constrained areas.Addressing physical health and environmental challenges for persons with spinal cord injury in resource-constrained rural areas require involvement of the family, rehabilitation personnel, policy makers, and the community.

[Expression of TLR4/MyD88/NF-κB pathway genes and its related inflammatory factors in secondary spinal cord injury]

OBJECTIVE

To investigate the expression of Toll-like receptor 4 (TLR4)/myeloid differentiation factor (MyD88)/nuclear factor-κB (NF-κB) pathway genes and related inflammatory factors tumor necrosis factor-α (TNF-α), interleukin (IL)-12, IL-6 in patients with secondary spinal cord injury (SSCI) and the correlations with prognosis.

METHODS

The clinical data of 105 SSCI patients and 40 healthy subjects were reviewed. According to Frankel's classification of spinal cord injury, the patients were divided into complete injury group and incomplete injury group, and according to the improvement of Japanese Orthopedic Association (JOA) scores, the patients were divided into good prognosis group and poor prognosis group. The expression of TLR4, MyD88, NF-κB in peripheral blood mononuclear cells (PBMC) and serum TNF-α, IL-12, IL-6 levels were compared between SSCI patients and healthy controls, between patients with complete and incomplete injury, between patients with poor and good prognosis. Logistic regression analysis was used to analyze the risk factors leading to poor prognosis of SSCI, and Pearson's correlation analysis was used to analyze the correlation between JOA score and the above indicators.

RESULTS

The expressions of TLR4, MyD88, NF-κB in PBMC and serum TNF-α, IL-12, IL-6 levels in SSCI patients were significantly higher than those in healthy subjects (all P<0.01), those in complete injury group were higher than those in incomplete injury group, and those in poor prognosis group were higher than those in good prognosis group (all P<0.01). The proportions of patients with Frankel grade A, spinal cord edema or hemorrhage, spinal cord injury length longer than 4 cm in poor prognosis group was significantly higher than those in good prognosis group (all P<0.01). Logistic regression analysis showed that Frankel grade, spinal cord edema or hemorrhage, length of spinal cord injury, relative expressions of TLR4, MyD88, NF-κB in PBMC, serum levels of TNF-α, IL-12 and IL-6 were risk factors for poor prognosis in SSCI patients (P<0.05 or P<0.01). Pearson's correlation analysis showed that JOA improvement rate was negatively correlated with the relative expressions of TLR4, MyD88, NF-κB mRNA in PBMC and serum TNF-α, IL-12, IL-6 levels (P<0.05 or P<0.01).

CONCLUSIONS

The activation of TLR4/MyD88/NF-κB pathway and the up-regulation of the expression of related inflammatory factors TNF-α, IL-12 and IL-6 are involved in the progression of SSCI, which are closely related to the neuroinflammatory injury, and can be used as reference indexes for evaluating prognosis in SSCI patients.