Frédéric S. Dumont

Spinal Cord Injury Community Survey: A National, Comprehensive Study to Portray the Lives of Canadians with Spinal Cord Injury

BACKGROUND To better understand service-related needs and the current situation of persons with spinal cord injury (SCI) living in the community, a more comprehensive approach for studying their interrelationships (needs vs community living outcomes) is greatly needed. OBJECTIVE To describe the development, design, and findings of a Canadian survey portraying the life situation of people with SCI. METHOD The SCI Community Survey covers demographics, health, SCI-specific needs, community participation, employment, quality of life, health care utilization, and overall health rating. A total of 1,549 persons with SCI completed the survey (Web or phone) between May 2011 and August 2012. RESULTS Some major expressed needs for services to support community living are met to a great extent for a substantial proportion of people with SCI. Complications remain highly prevalent for some health issues, including pain, sexual dysfunction, and musculoskeletal disorders. The extent of community participation based on values and preferences varies tremendously among daily activities and social roles. Some dimensions of quality of life are rated positively (eg, family life) while others are greatly disrupted (eg, sex life and physical health). Most of these findings vary significantly between people with traumatic and nontraumatic lesions. CONCLUSION This survey is the first in Canada and among the first worldwide to draw a comprehensive picture of major aspects of the lives of people with SCI including service needs. The results will help to determine the links between various aspects of community living and guide service providers and policy makers in focusing on major issues to enhance quality of life after SCI.

Impact of Pressure Ulcers on Individuals Living With a Spinal Cord Injury

OBJECTIVE To describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI). DESIGN Cross-sectional study. SETTING Nationwide survey. PARTICIPANTS Participants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%-36.3%) had a pressure ulcer over the last 12 months. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Measures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0. RESULTS Of the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05). CONCLUSIONS Pressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.

Hypercapnic ventilatory response of anesthetized female rats subjected to neonatal maternal separation: Insight into the origins of panic attacks?

Neonatal maternal separation (NMS) is a form of stress that interferes with the regulation of the stress response, an effect that predisposes to the emergence of panic and anxiety related disorders. We previously showed that at adulthood, awake female (but not male) rats subjected to NMS show a hypercapnic ventilatory response (HCVR; 5% CO2) that is 63% greater than controls (Genest et al., 2007). To understand the mechanisms underlying the sex-specific effects of NMS on the ventilatory response to CO2, we used two different anesthetized female rat preparations to assess central CO2 chemosensitivity and contribution of sensory afferents (stretch receptors and peripheral chemoreceptors) that influence the HCVR. Data show that anesthesia eliminated the respiratory phenotype observed previously in awake females and CO2 chemosensitivity did not differ between groups. Finally, the assessment of the ovarian hormone levels across the oestrus cycle failed to reveal significant differences between groups. Since anesthesia did not affect the manifestation of NMS-related respiratory dysfunction in males (including the hypercapnic ventilatory response) (Kinkead et al., 2005; Dumont and Kinkead, 2010), we propose that the panic or anxiety induced by CO2 during wakefulness is responsible for enhancement of the HCVR in NMS females.

Health Care Utilization in Persons with Traumatic Spinal Cord Injury: The Importance of Multimorbidity and the Impact on Patient Outcomes

BACKGROUND Persons with spinal cord injury (SCI) living in the community have high health care utilization (HCU). To date, the interrelationships among multiple secondary health conditions (multimorbidity due to comorbidities and complications) that drive HCU and their impact on patient outcomes are unknown. OBJECTIVE To determine the association among multimorbidity, HCU, health status, and quality of life. METHODS Community-dwelling persons with traumatic SCI participated in an online/phone SCI Community Survey. Participants were grouped using the 7-item HCU questionnaire (group 1 did not receive needed care and/or rehospitalized; group 2 received needed care but rehospitalized; group 3 received needed care and not rehospitalized). Personal, injury, and environmental factors; multimorbidity (presence/absence of 30 comorbidities/ complications); health status (Short Form-12); and quality of life measures (Life Satisfaction-11 first question and single-item quality of life measure) were collected. Associations among these variables were assessed using multivariate analysis. RESULTS The 1,137 survey participants were divided into 3 groups: group 1 (n = 292), group 2 (n = 194), and group 3 (n = 650). Group 1 had the greatest number of secondary health conditions (15.14 ± 3.86) followed by group 2 (13.60 ± 4.00) and group 3 (12.00 ± 4.16) (P < .05). Multimorbidity and HCU were significant risk factors for having a lower SF-12 Mental (P < .001) and Physical Component Score (P < .001). They in turn were associated with participants reporting a lower quality of life (P < .001, for both questions). CONCLUSIONS Multimorbidity and HCU are interrelated and associated with lower health status, which in turn is associated with lower quality of life. Future work will include the development of a screening tool to identify persons with SCI at risk of inappropriate HCU (eg, rehospitalization, not able to access care), which should lead to better patient outcomes and cost savings.

Self-report of one-year fracture incidence and osteoporosis prevalence in a community cohort of canadians with spinal cord injury.

BACKGROUND Sublesional declines in hip and knee region bone mass are a well-established consequence of motor complete spinal cord injury (SCI), placing individuals with SCI at risk for fragility fracture, hospitalization, and fracture-related morbidity and mortality. OBJECTIVES To describe the 1-year incidence of fracture and osteoporosis prevalence in a community cohort of Canadians with chronic SCI. METHODS As part of the SCI Community Survey, consenting adult participants with chronic SCI completed an online or telephone survey regarding their self-reported medical comorbidities, including fracture and osteoporosis, in the 12 months prior to survey conduct. Survey elements included sociodemographic and impairment descriptors and 4 identified risk factors for lower extremity fragility fracture: injury duration ≥ 10 years, motor complete and sensory complete (AIS A or A-B) paraplegia, and female gender. RESULTS Consenting participants included 1,137 adults, 70.9% were male, mean (SD) age was 48.3 (13.3) years, and mean (SD) time post injury was 18.5 (13.1) years. Eighty-four participants (7.4%) reported a fracture in the previous 12 months and 244 (21.5%) reported having osteoporosis in the same time period, with corresponding treatment rates of 84.5% and 64.8%, respectively. The variables most strongly associated with fracture were osteoporosis (odds ratio [OR], 4.3; 95% CI, 2.72-6.89) and having a sensory-complete injury (OR, 2.2; 95% CI, 1.38-3.50) or a motor complete injury (OR, 1.7; 95% CI, 1.10-2.72). CONCLUSIONS The discordance between fracture occurrence and treatment and the strength of the association between osteoporosis diagnosis and incident fractures necessitates improved bone health screening and treatment programs, particularly among persons with complete SCI.

Neonatal stress and attenuation of the hypercapnic ventilatory response in adult male rats: the role of carotid chemoreceptors and baroreceptors

Neonatal maternal separation (NMS) is a form of stress that disrupts respiratory control development. Awake adult male rats previously subjected to NMS show a ventilatory response to hypercapnia (HCVR; Fi(CO(2)) = 0.05) 47% lower than controls; however, the underlying mechanisms are unknown. To address this issue, we first tested the hypothesis that carotid bodies contribute to NMS-related attenuation of the HCVR by using carotid sinus nerve section or Fi(O(2)) manipulation to maintain Pa(O(2)) constant (iso-oxic) during hypercapnic hyperpnea. We then determined whether NMS-related augmentation of baroreflex sensitivity contributes to the reduced HCVR in NMS rats. Nitroprusside and phenylephrine injections were used to manipulate arterial blood pressure in both groups of rats. Pups subjected to NMS were separated from their mother 3 h/day from postnatal days 3 to 12. Control rats were undisturbed. At adulthood, rats were anesthetized [urethane (1g/kg) + isoflurane (0.5%)], and diaphragmatic electromyogram (dEMG) was measured under baseline and hypercapnic conditions (Pa(CO(2)): 10 Torr above baseline). The relative minute activity response to hypercapnia of anesthetized NMS rats was 34% lower than controls. Maintaining Pa(O(2)) constant during hypercapnia reversed this phenotype; the HCVR of NMS rats was 45% greater than controls. Although the decrease in breathing frequency during baroreflex activation was greater in NMS rats, the change observed within the range of pressure change observed during hypercapnia was minimal. We conclude that NMS-related changes in carotid body sensitivity to chemical stimuli and/or its central integration is a key mechanism in the attenuation of HCVR by NMS.

An Exploratory Analysis of the Potential Association Between SCI Secondary Health Conditions and Daily Activities

BACKGROUND Secondary health conditions (SHCs) are common following traumatic spinal cord injury (tSCI) and are believed to influence a persons ability to participate in daily activities (DAs). This association should be understood so that health care providers may target interventions with clarity and purpose to manage SHCs and facilitate DAs to maximal effect. OBJECTIVE To explore the association between SHCs and DAs expressed as the increased chance of not participating as much as wanted in a DA when an SHC is present. METHODS Community-dwelling persons with tSCI (n = 1,137) responded to the SCI Community Survey. The occurrence and frequency of 21 SHCs were determined. The extent of participation in 26 DAs was measured. The relative risk (RR) of not participating as much as wanted in a DA when a SHC is present was calculated. RESULTS When some SHC were present, the RR of not participating as much as wanted increased significantly (range, 15%-153%; P < .001). Certain SHCs (light-headedness/dizziness, fatigue, weight problems, constipation, shoulder problems) were associated with a greater chance of not participating in many DAs. No single SHC was associated with every DA and conversely not every DA was associated with an SHC. CONCLUSIONS Maximizing participation in DAs requires minimizing SHCs in every instance. Understanding the association between SHCs and DAs may facilitate targeted care resulting in less severe SHCs, greater participation in DAs, and benefits to both the individual and society.

Understanding Quality of Life in Adults with Spinal Cord Injury Via SCI-Related Needs and Secondary Complications.

BACKGROUND Understanding the factors that can predict greater quality of life (QoL) is important for adults with spinal cord injury (SCI), given that they report lower levels of QoL than the general population. OBJECTIVES To build a conceptual model linking SCI-related needs, secondary complications, and QoL in adults with SCI. Prior to testing the conceptual model, we aimed to develop and evaluate the factor structure for both SCI-related needs and secondary complications. METHODS Individuals with a traumatic SCI (N = 1,137) responded to an online survey measuring 13 SCI-related needs, 13 secondary complications, and the Life Satisfaction Questionnaire to assess QoL. The SCI-related needs and secondary complications were conceptualized into factors, tested with a confirmatory factor analysis, and subsequently evaluated in a structural equation model to predict QoL. RESULTS The confirmatory factor analysis supported a 2-factor model for SCI related needs, χ(2)(61, N = 1,137) = 250.40, P <.001, comparative fit index (CFI) = .93, root mean square error of approximation (RMSEA) = .05, standardized root mean square residual (SRMR) = .04, and for 11 of the 13 secondary complications, χ(2)(44, N = 1,137) = 305.67, P < .001, CFI = .91, RMSEA = .060, SRMR = .033. The final 2 secondary complications were kept as observed constructs. In the structural model, both vital and personal development unmet SCI-related needs (β = -.22 and -.20, P < .05, respectively) and the neuro-physiological systems factor (β = -.45, P < .05) were negatively related with QoL. CONCLUSIONS Identifying unmet SCI-related needs of individuals with SCI and preventing or managing secondary complications are essential to their QoL.

Spinal Cord Injury Community Survey: Understanding the Needs of Canadians with SCI

BACKGROUND There is a lack of literature regarding service needs of people with SCI living in the community. Better assessment of expressed and met and unmet needs would help in the development of effective service delivery. OBJECTIVE From a national SCI Community Survey in Canada, the aim was to identify the most critical service needs of people living in the community at least 1 year post discharge from rehabilitation and the support they received to meet their needs. METHOD Data were collected mainly through a secure Web site and encompassed demographics, personal and household income, an SCI severity measure, and an SCI community needs measure containing information on 13 SCI-related needs. RESULTS A total of 1,549 persons with SCI (traumatic lesion, n = 1,137; nontraumatic lesion, n = 412) across Canada completed the survey. Most critical needs for community integration were expressed by a substantial proportion of survey participants, but significantly more expressed and met needs were reported by persons with a traumatic than a nontraumatic lesion. Personal and environmental characteristics influenced the probability of expressing and meeting needs (eg, severity of injury and household income). Help and support to meet expressed needs were received from government agencies, community organizations, and friends or family. CONCLUSION Better assessment of expressed and met or unmet needs for services remains a challenge but will serve as a tool to optimize service delivery in the community. Environmental barriers to services, particularly the process of getting needs met and associated costs, remain an issue that requires a reconsideration of some aspects of access to services.

Neonatal stress and abnormal hypercapnic ventilatory response of adult male rats: the role of central chemodetection and pulmonary stretch receptors.

Neonatal maternal separation (NMS) is a form of stress that interferes with respiratory control development. At adulthood, the hypercapnic ventilatory response (HCVR) of male NMS rats is lower than controls both during wakefulness and anesthesia. To address the mechanisms underlying the respiratory phenotype of NMS rats, we first used phrenic nerve recording in anesthetised (urethane: 1.0 g/kg+isoflurane: 0.5%), vagotomised, and artificially ventilated (hyperoxic) animals, to test the hypothesis that the central chemodetection is altered by NMS. As no difference was observed between groups, we then tested the hypothesis that NMS affects respiratory modulation by pulmonary stretch receptors (PSRs). Experiments were performed on urethane/isoflurane anesthetised, spontaneously breathing rats (with vagi intact). The role of PSR and their implication was assessed during normo- and hypercapnia (+10 mm Hg above baseline) by the induction of a positive airway pressure (Paw). The slopes of the relationships between the ventilatory variables (frequency, amplitude, and minute activity) and the different levels of Paw in each group were compared between groups. During normocapnia, the decrease in breathing frequency induced by increasing Paw was greater in control than in NMS rats, thereby revealing that NMS reduces the Hering-Breuer reflex (HBR). During hypercapnia, however, the responses of control and NMS rats were similar indicating that the stimulation of chemoreceptors by CO(2) reduced the influence of stretch receptors on ventilation. These results indicate NMS does not affect central CO(2) chemosensitivity of this preparation but that differences in PSR function and/or signal integration contribute to the effects of NMS on respiratory regulation.