Colleen F. McGillivray

Secondary Health Complications in an Aging Canadian Spinal Cord Injury Sample

Hitzig SL, Tonack M, Campbell KA, McGillivray CF, Boschen KA, Richards K, Craven BC: Secondary health complications in an aging Canadian spinal cord injury sample. Am J Phys Med Rehabil 2008;87:545–555. Objectives:This study describes self-reported incidence of secondary health complications (SHCs) and their associations with age, years postinjury (YPI), and impairment among a Canadian spinal cord-injured (SCI) cohort. Design:Cross-sectional telephone survey methods were used to collect data on (1) sociodemographics, (2) impairment, (3) health status, and (4) self-reported SHCs on 781 adults ≥1 yr post-SCI living in Ontario, Canada. Results:Logistic regression analyses were used to determine associations between self-reported incidences of SHCs with the following covariates: (1) age, (2) YPI, and (3) impairment. The odds ratios for cardiac complications, high blood pressure (HBP), and respiratory complications increased per year with age, whereas autonomic dysreflexia (AD), bladder infections, heterotopic ossification, psychological distress, and drug addiction decreased. The odds ratios for pressure ulcers, AD, and heterotopic ossification increased per YPI, whereas HBP, bowel problems, psychological distress, and depression decreased. Complete injuries were associated with bladder infections, pressure ulcers, and AD. Paraplegia was associated with HBP and bowel problems, and tetraplegia was associated with AD. Conclusions:The findings provide some clarification on factors associated with the occurrence of SHCs after SCI and are useful for informing health-promotion planners, clinicians, and stakeholders regarding the odds of SHCs with aging or among specific impairment groups.

Functional Electrical Stimulation Therapy of Voluntary Grasping Versus Only Conventional Rehabilitation for Patients With Subacute Incomplete Tetraplegia A Randomized Clinical Trial

Background. Functional electrical stimulation therapy (FET) has a potential to improve voluntary grasping among individuals with tetraplegia secondary to traumatic spinal cord injury (SCI). Objective. This single-site, randomized controlled trial examined the efficacy of 40 hours of FET with conventional occupational therapy (COT) compared with COT alone to improve grasping. Methods. Twenty-four subjects with subacute traumatic incomplete SCI (C4-C7, AIS B-D) consented to participate in 40 hours of therapy over 8 weeks, beyond the conventional rehabilitation program. Subjects were randomized to receive FET + COT (n = 9) or COT (n = 12). The key outcomes were changes in Functional Independence Measure (FIM) self-care subscores, Spinal Cord Independence Measure (SCIM) self-care subscores, and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) performed at baseline and follow-up. Results. At the end of the treatments, the change in mean FIM self-care subscore for the FET + COT group was 20.1 versus 10 (P = .015) for the COT group. Subjects randomized to FET + COT also had greater improvements in the SCIM and TRI-HFT. No longer term follow-up was feasible. Conclusion. FET significantly reduced disability and improved voluntary grasping beyond the effects of considerable conventional upper extremity therapy in individuals with tetraplegia.

The use of bioelectric impedance analysis to measure fluid compartments in subjects with chronic paraplegia

OBJECTIVES To determine the sensitivity and specificity of body mass index (BMI) as a surrogate marker of obesity in individuals with chronic paraplegia and to validate bioelectric impedance analysis (BIA) as a method of measuring body composition in this group. DESIGN Cross-sectional study. SETTING University hospital. PARTICIPANTS Convenience sample of 31 subjects with paraplegia (19 men, 12 women; mean age, 34.2+/-8.8y) and 62 able-bodied control subjects (30 men, 32 women; mean age, 28.6+/-7.2y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Total-body water (TBW) by deuterium dilution; extracellular water (ECW) by corrected bromide space. Fat-free mass (FFM)=TBW/.732; fat mass (FM)=weight-FFM. Single-frequency whole-body and segmental BIA, and multifrequency whole-body BIA. RESULTS BMI had 100% specificity and 20% sensitivity in distinguishing obese from nonobese subjects with paraplegia. TBW was predicted by using the equation: TBW (inL)=2.11-0.1age+3.45sex+.34wt+.28(ht(2)/R)-.086sex x wt(r(2)=.95, standard error of the estimate [SEE]=1.86L, P<.0001). This equation had 81.8% specificity and 68.4% sensitivity. ECW was predicted by using the equation: ECW (in L)=-.025+1.03sex+.187wt+.0041(ht(2)/X(c)) -.033sex x wt (r(2)=.75, SEE=1.62L, P<.0001). Multifrequency BIA offered no greater prediction of TBW or ECW than single-frequency BIA. CONCLUSIONS BMI has excellent specificity but poor sensitivity in distinguishing obese from nonobese individuals with paraplegia. TBW (and therefore FFM and FM) and ECW can be reasonably well predicted by using single-frequency BIA.

Traumatic Brain Injury in Patients With Traumatic Spinal Cord Injury: Clinical and Economic Consequences

OBJECTIVE To evaluate the clinical and economic burden of traumatic brain injury (TBI) in people with traumatic spinal cord injury (SCI). DESIGN Prospective, case-matched control study. SETTING Inpatient spinal cord rehabilitation program. PARTICIPANTS Patients (n=10) diagnosed with traumatic SCI and concomitant TBI matched to an SCI only control group. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Inpatient rehabilitation length of stay, health care costs (patient care hours), clinician resource allocation, behavioral and critical incidents, FIM, Personality Assessment Inventory, and neuropsychological assessment findings. RESULTS Prolonged loss of consciousness, increased rehabilitation costs, and greater demands on clinician recourses (trend) were found in the SCI with TBI group relative to the SCI-only group. Neuropsychological test performance was significantly worse in the SCI with TBI group, while the FIM cognition score did not discriminate because of ceiling effects. Greater evidence of psychopathology was observed in the SCI with TBI group. CONCLUSIONS The presence of TBI in SCI has a range of clinical and economic consequences. This dual diagnosis has the potential to affect SCI rehabilitation negatively, as well as quality of life and reintegration in the community. Specialized care appears to be needed to improve outcomes and to minimize clinical and economic burden, but further research is required.

Functional Electrical Stimulation Therapy for Grasping in Traumatic Incomplete Spinal Cord Injury: Randomized Control Trial

The purpose of this single-site randomized control trial was to assess the short-term and long-term efficacy of functional electrical stimulation (FES) therapy over conventional occupational therapy in improving voluntary hand function in incomplete C4-C7 spinal cord injury individuals. All 22 participants recruited in this randomized control trial received treatment for both the left and right upper extremities. Every participant, irrespective of group allocation, received one dose (60 min per day, 5 days per week for the duration of 8 weeks) of conventional occupational therapy for hand function. Of the 22 participants, 12 individuals received an additional dose of conventional occupational therapy, while the remaining 10 participants received a dose of FES hand therapy. The primary outcome measure was Functional Independence Measure (FIM) self-care subscore. The secondary outcome measures were Spinal Cord Independence Measure (SCIM) self-care subscore and Toronto Rehabilitation Institute Hand Function Test (TRI-HFT). The participants who received FES therapy showed significantly greater improvements in hand function at discharge, and were able to maintain their gains at long-term follow-up as assessed using FIM self-care subscore, SCIM self-care subscore, and TRI-HFT. The FES therapy effectively increased independence and thereby improved quality of life of individuals with tetraplegia when compared with conventional occupational therapy.

Evaluating Knowledge of Autonomic Dysreflexia Among Individuals With Spinal Cord Injury and Their Families

Abstract Background/Objective: Autonomic dysreflexia (AD) is a potentially life-threatening complication of spinal cord injury (SCI) characterized by episodic paroxysmal hypertension and bradycardia in response to a noxious stimulus below the level of injury. Recognition of AD is crucial for individuals with SCI and their family members to facilitate timely and appropriate management. The objectives of this study were to (a) evaluate knowledge of AD among SCI consumers and their family members and (b) identify the preferred format and timing of education regarding AD recognition and management for these stakeholders. Methods: Cross-sectional descriptive study on a cohort of community-dwelling individuals with chronic SCI (N = 100) and their family members (N = 16) by self-report mail survey. Frequency distributions were used to tabulate survey responses on AD knowledge level and to characterize learning preferences and 2 × 2 χ2 analyses were conducted to determine whether there were factors (ie, impairment) associated with AD knowledge (ie, how to treat AD). Results: Individuals with SCI and their family members have gaps in their knowledge of AD. Traumatic SCI etiology (vs nontrauma) was associated with greater knowledge about treating AD. Although the SCI sample was a high-risk group, 41 % had not heard of AD. More concerning was that 22% of individuals with SCI reported symptoms consistent with unrecognized AD. Respondents indicated that AD education would be best delivered during rehabilitation by a healthcare professional. Conclusions: Further work is needed to promote knowledge about recognizing and managing AD. This may help reduce risk of cardiac and cerebrovascular disease in the SCI population.

Exploring the associations between arterial stiffness and spinal cord impairment: A cross-sectional study.

Abstract Background/Objective Elevated aortic arterial stiffness (aortic pulse wave velocity: aPWV) is an independent coronary artery disease predictor among the general population. The purpose of this study was to: (1) report aPWV values in a representative cohort of patients with spinal cord injury (SCI); (2) to compare aPWV values in people with SCI based on neurological level of injury; and (3) to contrast the reported aPWV values with available normal values for the general population. Methods Adults with chronic SCI (n = 87) were divided into two groups (TETRA group, n = 37 and PARA group, n = 50). aPWV and potential confounders of aPWV were assessed. Analysis of covariance was used for comparisons between groups and adjusted for the confounders. Subjects’ aPWV values were contrasted with reference values for general population determined by “The Reference value for arterial stiffness’ collaboration” and prevalence of abnormal aPWV defined as greater than or equal to the age-specific 90th percentile was reported. Results Prevalence of abnormal aPWV in the cohort was 25.3%. After adjusting for covariates, the mean aPWV values were significantly different between two groups (TETRA: 8.0 (95% confidence interval (CI): 7.5–8.6) m/second, PARA: 9.0 (95% CI: 8.5–9.4) m/second, P = 0.010). The prevalence of abnormal aPWV was significantly higher in the PARA group (36%) compared to the TETRA group (11%) (P = 0.012). Conclusions One-quarter of the total cohort had an abnormal aPWV. Subjects with paraplegia had higher aPWV values and a higher frequency of abnormal aPWV than subjects with tetraplegia. Elevated aPWV in people with SCI, particularly those with paraplegia, may impart significant adverse cardiovascular consequences.

A study of the utility and equivalency of 2 methods of wound measurement: digitized tracing versus digital photography.

OBJECTIVE: To examine agreement between digitized tracing and digital photography methods in measuring wound area and healing rate, and to compare and contrast the 2 methods on feasibility and utility in patient care and research settings. SETTING: Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada. PARTICIPANTS: A total of 20 subjects aged 18 years or older with a spinal cord injury and pressure ulcers that were Stage II or higher, and who had received in- or outpatient wound care at the hospital for at least 3 consecutive weeks. METHODS: Wound area was measured at weekly intervals. One assessor calculated wound area from a digitized tracing. A second assessor calculated wound area using a wound photograph. Both assessors used Image-J software. The 2 methods were compared for differences in weekly wound area and weekly healing rate. RESULTS: Methods were different for wound area (P < .0001), whereas there was no difference between methods in weekly healing rate (P = .9429). CONCLUSIONS: The 2 methods are in agreement on the important parameter of healing rate. Both methods are feasible in clinical settings. Wound photography may be more useful than digitized tracings because it simultaneously captures wound appearance.

Identifying and classifying quality-of-life tools for assessing pressure ulcers after spinal cord injury

Abstract Context Although pressure ulcers may negatively influence quality of life (QoL) post-spinal cord injury (SCI), our understanding of how to assess their impact is confounded by conceptual and measurement issues. To ensure that descriptions of pressure ulcer impact are appropriately characterized, measures should be selected according to the domains that they evaluate and the population and pathologies for which they are designed. Objective To conduct a systematic literature review to identify and classify outcome measures used to assess the impact of pressure ulcers on QoL after SCI. Methods Electronic databases (Medline/PubMed, CINAHL, and PsycInfo) were searched for studies published between 1975 and 2011. Identified outcome measures were classified as being either subjective or objective using a QoL model. Results Fourteen studies were identified. The majority of tools identified in these studies did not have psychometric evidence supporting their use in the SCI population with the exception of two objective measures, the Short-Form 36 and the Craig Handicap Assessment and Reporting Technique, and two subjective measures, the Life Situation Questionnaire-Revised and the Ferrans and Powers Quality of Life Index SCI-Version. Conclusion Many QoL outcome tools showed promise in being sensitive to the presence of pressure ulcers, but few of them have been validated for use with SCI. Prospective studies should employ more rigorous methods for collecting data on pressure ulcer severity and location to improve the quality of findings with regard to their impact on QoL. The Cardiff Wound Impact Schedule is a potential tool for assessing impact of pressure ulcers-post SCI.