Brad E. Dicianno

Rehabilitation and medical management of the adult with spina bifida

Dicianno BE, Kurowski BG, Yang JMJ, Chancellor MB, Bejjani GK, Fairman AD, Lewis N, Sotirake J: Rehabilitation and medical management of the adult with spina bifida. Am J Phys Med Rehabil 2008;87:1026–1050. As the life expectancy of individuals with spina bifida increases, a lifelong need for management of many health issues in a rehabilitation setting has emerged in recent years. Physiatrists, in consultation with a variety of adult specialists, are particularly well suited to manage the common musculoskeletal, skin, bowel, bladder, renal, neurological, and other issues that arise in the adult population. This article reviews the last 20 yrs of literature pertinent to the rehabilitative care of this population, summarizes current evidence-based practice, and identifies key areas in which scientific evidence is lacking and future research is needed.

Shoulder magnetic resonance imaging abnormalities, wheelchair propulsion, and gender.

OBJECTIVE To investigate the relationship between pushrim forces and the progression of shoulder injuries in manual wheelchair users. DESIGN Longitudinal case series. SETTING Biomechanics laboratory and magnetic resonance imaging (MRI) facility at a Veterans Health Administration medical center and university hospital, respectively. PARTICIPANTS Fourteen individuals with spinal cord injury (8 men, 6 women) who used manual wheelchairs. INTERVENTION Subjects propelled their own wheelchairs on a dynamometer at 0.9 and 1.8m/s. Bilateral biomechanical data were obtained by using force and moment sensing pushrims at time 1. Bilateral shoulder MR images were also completed on 2 occasions, at time 1 and, approximately 2 years later, at time 2. MAIN OUTCOME MEASURES The peak pushrim forces in a pushrim coordinate system were calculated, weight normalized and averaged over 5 strokes (presented as % body weight). MRI abnormalities were graded by using a summated scale. Differences between scores between times 1 and 2 were calculated. RESULTS Subjects were divided into 2 groups based on change in MRI score. Seven subjects were in the group with worsening scores (MRI+; mean, 8.14 points; range, 5-16), and 7 were in the group with improving or unchanging scores (MRI-; mean, -1.00 point; range, -5 to 1). There was no significant difference between groups with respect to age, body mass index, or years from injury. There were significantly more women in the MRI+ group (6 women, 1 man) than in the MRI- group (7 men) (P=.001). The MRI+ group used significantly greater weight-normalized radial force, or force directed toward the axle at time 1, to propel their wheelchairs at each speed (P<.01): MRI+ at 0.9m/s (mean radial force +/- standard deviation, 5.2%+/-1.0%) and MRI- at 0.9m/s (mean radial force, 3.2%+/-1.7%) (P=.028); and MRI+ at 1.8m/s (mean radial force, 6.6%+/-1.2%) (P=.023) and MRI- at 1.8m/s (mean radial force, 4.1%+/-2.2%). In a separate analysis, women were found to propel with a significantly higher radial force. A logistic regression found a significant relationship between radial force at time 1 and increased risk of progression of MRI findings over time. CONCLUSION Individuals who propel with a greater percentage of force directed toward the axle were at increased risk of progression of MRI findings over time. Most people in this group were women. Clinicians should instruct wheelchair users in effective propulsion techniques and should pay particular attention to women who use wheelchairs. Reducing forces during wheelchair propulsion may minimize the likelihood of developing shoulder injuries.

RESNA Position on the Application of Tilt, Recline, and Elevating Legrests for Wheelchairs

ABSTRACT This document, approved by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) Board of Directors on April 23, 2008, describes typical clinical applications and provides evidence from the literature supporting the application of tilt, recline, and elevating legrests for wheelchairs.

Investigating Neck pain in Wheelchair users

Boninger ML, Cooper RA, Fitzgerald SG, Lin J, Cooper R, Dicianno B, Liu B: Investigating neck pain in wheelchair users. Am J Phys Med Rehabil 2003;82:197–202. Objective Despite the fact that wheelchair users are exposed to risk factors for neck and upper back pain (NP), little is known about the impact and possible diagnoses associated with NP. The purpose of this study was to examine the significance of NP in wheelchair users and to determine if a portion of the NP may be myofascial in origin. Design Cross-sectional cohort study using questionnaires and physical exams to evaluate NP in a convenience sample of wheelchair users from the National Veteran’s Wheelchair Games. Main outcome measures included reported NP, visual analog scale of neck complaints, Neck Disability Index, and physical examination findings of trigger points. Results Sixty-six percent of subjects reported NP since becoming a wheelchair user and, 60% reported pain during the past month. Neither age nor length of time in a wheelchair was significantly different between those subjects who did and those subjects who did not report pain. Of those respondents who reported NP, 60% visited the doctor about the pain and 40% limited their daily activities due to the pain. Trigger-point palpation reproduced pain in 54% of those respondents who experienced pain in the past month (n = 34). Conclusion This study provides a first step in defining the prevalence and significance of NP among wheelchair users. Clinicians who work with this population need to ask subjects about symptoms and consider a myofascial origin for that pain when considering treatment.

Hospitalizations of adults with spina bifida and congenital spinal cord anomalies.

OBJECTIVE To examine hospital admission records from a large cohort of persons with spina bifida (SB) with a variety of insurers to provide descriptive detail about adult hospital use for persons with SB and associated disorders in terms of primary diagnosis for hospitalization, age, sex, payer source, lengths of stay, and total charges. DESIGN Retrospective secondary data analysis from the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project for 2004 and 2005 of hospitalizations for adults with SB or associated spinal cord anomalies. SETTING Records from U.S. inpatient hospital admissions. PARTICIPANTS Persons with SB age 18 years and older. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Diagnoses associated with hospitalizations and death. RESULTS The most common primary diagnosis for hospitalization was urinary tract infection, followed by complications from devices/grafts/implants and skin wounds. Sepsis accounted for the most deaths. Approximately one third of hospitalizations were for primary diagnoses of potentially preventable conditions. Hospitalizations associated with a primary diagnosis of a potentially preventable condition occurred most often in those less than 51 years of age and in rural or urban nonteaching hospitals. CONCLUSIONS Reducing the number of secondary medical conditions with proactive and preventative approaches to health care could reduce the morbidity, mortality, and cost for health care for this group.

Psychosocial impact of participation in the National Veterans Wheelchair Games and Winter Sports Clinic

Purpose. The purpose of this study was to determine the characteristics of individuals who participate in the National Veterans Wheelchair Games (NVWG) and the Winter Sports Clinic (WSC) for veterans with disabilities. In addition, it was of interest to determine how these events had impacted their lives. Method. Participants were recruited at the 20th Winter Sports Clinic, held in Snowmass Colorado and the 26th National Veterans Wheelchair Games held in Anchorage, Alaska. Data of interest included demographic, sport participation information, community integration, self-esteem, and quality of life. A secondary data analysis was completed to determine how comparable individuals who attended the NVWG/WSC were to individuals who did not participate in these events. Results. The 132 participants were a mean age of 47.4 + 13.4 and lived with a disability for an average of 13.4 + 12.1. Participants felt that the NVWG/WSC increased their knowledge of sports equipment (92%), learning sports (89%), mobility skills (84%), and acceptance of disability (84%). The majority of participants stated that the NVWG/WSC improved their life. Of those who participated at the NVWG/WSC, they tended to be more mobile, but have increased physical and cognitive limitations as measured by the CHART when compared to the non-attendees. Conclusions. Recommending veterans participate in events such as the NVWG and WSC can provide psychosocial benefits to veterans with disabilities.

A perspective on intelligent devices and environments in medical rehabilitation

Globally, the number of people older than 65 years is anticipated to double between 1997 and 2025, while at the same time the number of people with disabilities is growing at a similar rate, which makes technical advances and social policies critical to attain, prolong, and preserve quality of life. Recent advancements in technology, including computation, robotics, machine learning, communication, and miniaturization of sensors have been used primarily in manufacturing, military, space exploration, and entertainment. However, few efforts have been made to utilize these technologies to enhance the quality of life of people with disabilities. This article offers a perspective of future development in seven emerging areas: translation of research into clinical practice, pervasive assistive technology, cognitive assistive technologies, rehabilitation monitoring and coaching technologies, robotic assisted therapy, and personal mobility and manipulation technology.

Correlates of Depressive and Anxiety Symptoms in Young Adults with Spina Bifida

Objective Based on social ecological theory, this study was designed to examine the unique relationships between multi-level ecological factors and psychological symptoms in young adults with spina bifida (SB). Method A sample of 61 individuals with SB, 18–25 years of age, completed standardized self-report measures of attitude toward SB, satisfaction with family functioning, Chronic Care Model (CCM) services, and depressive and anxiety symptoms. A chart review yielded SB clinical data. Results High rates of depressive and anxiety symptoms were found. Hierarchical regression analysis identified the proximal individual (attitude toward SB) and family (satisfaction with family functioning) factors as more strongly related to depressive symptoms than the distal healthcare system factor (CCM services). Self-reported pain was the only ecological factor associated with anxiety symptoms. Conclusions Study findings provide a potential foundation for multi-factor screening of young adults with SB at risk for psychological symptoms.

iMHere: A Novel mHealth System for Supporting Self-Care in Management of Complex and Chronic Conditions

Background Individuals with chronic conditions are vulnerable to secondary complications that can be prevented with adherence to self-care routines. They benefit most from receiving effective treatments beyond acute care, usually in the form of regular follow-up and self-care support in their living environments. One such population is individuals with spina bifida (SB), the most common permanently disabling birth defect in the United States. A Wellness Program at the University of Pittsburgh in which wellness coordinators supervise the care of individuals with chronic disease has produced remarkably improved outcomes. However, time constraints and travel costs have limited its scale. Mobile telehealth service delivery is a potential solution for improving access to care for a larger population. Objective The project’s goal was to develop and implement a novel mHealth system to support complex self-care tasks, continuous adherence to regimens, monitoring of adherence, and secure two-way communications between patients and clinicians. Methods We developed and implemented a novel architecture of mHealth system called iMHere (iMobile Health and Rehabilitation) consisting of smartphone apps, a clinician portal, and a two-way communication protocol connecting the two. The process of implementing iMHere consisted of: (1) requirement analysis to identify clinically important functions that need to be supported, (2) design and development of the apps and the clinician portal, (3) development of efficient real-time bi-directional data exchange between the apps and the clinician portal, (4) usability studies on patients, and (5) implementation of the mHealth system in a clinical service delivery. Results There were 9 app features identified as relevant, and 5 apps were considered priority. There were 5 app features designed and developed to address the following issues: medication, skin care, bladder self-catheterization, bowel management, and mental health. The apps were designed to support a patient’s self-care tasks, send adherence data to the clinician portal, and receive personalized regimens from the portal. The Web-based portal was designed for clinicians to monitor patients’ conditions and to support self-care regimens. The two-way communication protocol was developed to facilitate secure and efficient data exchange between the apps and the portal. The 3 phases of usability study discovered usability issues in the areas of self-care workflow, navigation and interface, and communications between the apps and the portal. The system was used by 14 patients in the first 6 months of the clinical implementation, with 1 drop out due to having a poor wireless connection. The apps have been highly utilized consistently by patients, even those addressing complex issues such as medication and skincare. The patterns of utilization showed an increase in use in the first month, followed by a plateau. Conclusions The system was capable of supporting self-care and adherence to regimen, monitoring adherence, supporting clinician engagement with patients, and has been highly utilized.

Perspectives on the Evolution of Mobile (mHealth) Technologies and Application to Rehabilitation

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often require complex habilitative and rehabilitative services to prevent and treat these complications. This perspective article reviews the evolution of mHealth technologies and presents insights as to how this evolution informed our development of a novel mHealth system, iMHere (interactive mobile health and rehabilitation), and other technologies, including those used by the Veterans Administration. This article will explain the novel applications of mHealth for rehabilitation and specifically physical therapy. Perspectives on the roles of rehabilitation professionals in the delivery of health care using mHealth systems are included. Challenges to mHealth, including regulatory and funding issues, are discussed. This article also describes how mHealth can be used to improve patient satisfaction and delivery of care and to promote health and wellness.