James S. Krause

A prospective study of health and risk of mortality after spinal cord injury.

OBJECTIVE To test hypothesized relationships between multiple health parameters and mortality among persons with spinal cord injury (SCI) while controlling for variations in biographical and injury characteristics. DESIGN Prospective cohort study with health data collected in late 1997 and early 1998 and mortality status ascertained in December 2005. SETTING A large rehabilitation hospital in the Southeastern United States. PARTICIPANTS A total of 1389 adults with traumatic SCI, at least 1 year postinjury. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome was time from survey to mortality (or time of censoring). Mortality status was determined using the National Death Index and the Social Security Death Index. There were 225 deaths (16.2%) by December 31, 2005. RESULTS Cox proportional hazards modeling identified several significant health predictors of mortality status, while controlling for biographic and injury factors. Two sets of analyses were conducted--the first identifying the significance of a single variable of interest and the second analysis building a comprehensive model based on an optimal group of variables. Multiple types of health conditions were associated with mortality. The best set of health predictors included probable major depression, surgeries to repair pressure ulcers, fractures and/or amputations, symptoms of infections, and days hospitalized. Inclusion of these variables, along with a general health rating, improved prediction of survival compared with biographic and injury variables alone, because the pseudo R(2) increased from .12 to .18 and the concordance from .730 to .776. CONCLUSIONS In addition to secondary conditions that have been the traditional focus of prevention efforts (eg, pressure ulcers, urinary tract infections), amputations, fractures, and depressive symptoms were associated with higher risk for mortality; however, further research is needed to identify the association of specific conditions with causes of death and to determine whether interventions can modify these conditions and ultimately improve survival.

Falls in individuals with incomplete spinal cord injury

Study design:Mail survey of participants with incomplete spinal cord injury (SCI).Objective:To describe the incidence, circumstances, consequences, and perceived contributory factors associated with falls among ambulatory individuals with incomplete SCI.Setting:Southeast region of the United States.Methods:A survey instrument was developed largely from existing measures and mailed to individuals with incomplete SCI to collect self-reported information on participant characteristics and fall-related variables.Results:Seventy-five percent of study participants sustained at least one fall over the previous year. Even though most injuries were minor, 18% of fallers sustained a fracture and 45% reported reduced ability to get out into the community and engage in productive activity. Factors perceived to contribute to falls most often were decreased strength in the trunk and lower extremities, loss of balance, and hazards in the environment.Conclusions:Falls occur frequently and often have significant consequences among ambulatory individuals with SCI. These data may assist rehabilitation professionals to identify those at risk and implement fall prevention strategies.Sponsorship:This project was supported by a grant from the South Carolina Spinal Cord Injury Research Fund Grant # 0703.

A Longitudinal Study of Depression From 1 to 5 Years After Spinal Cord Injury

OBJECTIVE To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury. DESIGN Longitudinal cohort study. SETTING SCI Model System. PARTICIPANTS Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher. RESULTS Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found. CONCLUSION In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

Employment after spinal cord injury: Relation to selected participant characteristics

OBJECTIVE To investigate the relation between selected participant characteristics and employment outcomes after spinal cord injury (SCI). Previous studies produced conflicting results with widely varying employment rates due to differences in study participant characteristics. DESIGN A field study of the employment history of a large stratified sample of people with SCI. Participants were grouped into cohorts and then compared on several employment variables using the chi square statistic and analysis of variance. PARTICIPANTS Three hundred sixty-two persons with SCI, selected by stratified sampling according to gender, race, and age. Participants were further grouped into cohorts based on time since injury, injury severity, and years of education. MAIN OUTCOME MEASURES Multidimensional Adjustment Profile, a specially designed measure of multiple outcomes after SCI. RESULTS The most successful employment outcomes were obtained by Caucasian women, persons up to the age of 29 years at injury, participants with incomplete injuries, and participants who had completed at least 16 years of education. The least successful outcomes were observed in minority men, participants age 50 years or older at injury, persons with complete quadriplegia, and participants with fewer than 12 years of education. CONCLUSIONS Results point to the need for rehabilitation professionals to make special efforts to maximize employability after SCI among people with biographic characteristics that place them at greatest risk for unemployment.

Skin sores after spinal cord injury: relationship to life adjustment

Study design: A field study of the relationship between skin sores and life adjustment after spinal cord injury (SCI) was conducted by surveying a sample of more than 1000 participants with SCI. Objectives: The purpose of this study was to identify the relationship between the number of skin sores and days adversely impacted by skin sores with multiple indicators of life adjustment after SCI. Summary of background data: Most existing research on skin sores after SCI has been epidemiologic in nature, with limited investigation of the relationship between problems with skin sores and psychosocial adjustment. Methods: A total of 1017 participants completed the Life Situation Questionnaire-revised (LSQ-R), a measure of multiple long-term outcomes after SCI. Results: Just less than half of all respondents (46%) reported having at least one skin sore during the 2 year period prior to the study, but only 27% reported having to reduce their sitting time by at least 1 day during the same time period due to skin sores. Although biographic characteristics were generally unrelated to skin sores (eg, gender, race), both the number of skin sores and days adversely impacted by sores were correlated with poorer adjustment in nearly every area of life studied. Conclusions: Although the results are correlational and cannot be taken as evidence for causation, it is clear that prevention of skin sores is critical for people with SCI. There is a need for research to identify psychological and behavioral risk factors for skin problems after SCI.

Outcomes After Spinal Cord Injury: Comparisons as a Function of Gender and Race and Ethnicity

OBJECTIVE To identify gender and racial and ethnic differences in subjective well-being (SWB), participation, and general health ratings in participants with spinal cord injury (SCI). DESIGN A multisite, cross-sectional study that used stratified sampling to identify and maximize participation among groups of people traditionally underrepresented in SCI research. SETTING Four Model Spinal Cord Injury Systems participated in the data collection. The primary site was a large southeastern specialty hospital; the other 3 were in the western and mountain regions of the United States. PARTICIPANTS A total of 512 participants, 475 of whom were included in the analysis. This group included relatively equal portions of whites, African Americans, American Indians, and Hispanics. Approximately 40% of the sample was women. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome measures included 2 measures of SWB (Life Situation Questionnaire-Revised, Older Adult Health and Mood Questionnaire), 1 measure of participation (Craig Handicap Assessment and Reporting Technique), and several items from the Behavioral Risk Factor Surveillance System. RESULTS The majority of racial and ethnic differences in SWB related to specific life areas (eg, economics, employment), rather than more global outcomes (eg, engagement, health), with whites generally reporting the best outcomes, followed by African Americans. American Indians, and whites generally reported the highest participation scores, whereas limited differences were noted between the racial and ethnic groups on health indicators. Women reported lower satisfaction with health, more poor mental health days, and lower SWB related to home life, but higher SWB related to interpersonal relations. CONCLUSIONS There are racial and ethnic differences in outcomes after SCI focused primarily on subjective outcomes in areas in which racial and ethnic minorities have traditionally been disadvantaged. The results of this study direct rehabilitation professionals to the outcomes that need to be targeted for intervention to eliminate inequities in outcomes for all persons with SCI.

Longitudinal changes in adjustment after spinal cord injury: A 15-year study

Research on changes in adjustment after spinal cord injury (SCI) has produced mixed results. Whereas cross-sectional research has suggested that adjustment declines with increasing age, but improves with greater time since injury, longitudinal research has suggested that some limited positive changes in adjustment occur over an 11-year period. The purpose of the current study was to identify the stability of adjustment over a 15-year period after SCI. One hundred thirty-five participants with SCI completed Life Situation Questionnaires (LSQ) in both 1974 and 1989. T-test comparisons were made on five adjustment scales and 15 individual items. The results suggested several positive changes in adjustment during the 15 years including increased sitting tolerance, more years of education, greater satisfaction with finances and employment, and a higher percentage of persons working. Decreases were noted in the number of hospitalizations and the number of days hospitalized. Given the average number of years since injury (9.3 years in 1974; 24.3 years in 1989), the results suggest that adjustment will at worst be stable, and at best will improve significantly with time.

Oxidative stress, DNA damage, and the telomeric complex as therapeutic targets in acute neurodegeneration

Oxidative stress has been identified as an important contributor to neurodegeneration associated with acute CNS injuries and diseases such as spinal cord injury (SCI), traumatic brain injury (TBI), and ischemic stroke. In this review, we briefly detail the damaging effects of oxidative stress (lipid peroxidation, protein oxidation, etc.) with a particular emphasis on DNA damage. Evidence for DNA damage in acute CNS injuries is presented along with its downstream effects on neuronal viability. In particular, unchecked oxidative DNA damage initiates a series of signaling events (e.g. activation of p53 and PARP-1, cell cycle re-activation) which have been shown to promote neuronal loss following CNS injury. These findings suggest that preventing DNA damage might be an effective way to promote neuronal survival and enhance neurological recovery in these conditions. Finally, we identify the telomere and telomere-associated proteins (e.g. telomerase) as novel therapeutic targets in the treatment of neurodegeneration due to their ability to modulate the neuronal response to both oxidative stress and DNA damage.

Spinal cord injury and aging challenges and recommendations for future research

ABSTRACTPopulation aging, caused by reductions in fertility and increasing longevity, varies by country and is anticipated to continue and to reach global proportions during the 21st century. Although the effects of population aging have been well documented for decades, the impact of aging on people with spinal cord injury (SCI) has not received similar attention. It is reasonable to expect that population aging features such as the increasing mean age of the population, share of the population in the oldest age groups, and life expectancy would be reflected in SCI population demographics. Although the mean age and share of the SCI population older than 65 yrs are increasing, data from the National Spinal Cord Injury Statistical Center suggest that life expectancy increases in the SCI population have not kept the same pace as those without SCI in the last 15 yrs. The reasons for this disparity are likely multifactorial and include the changing demographics of the SCI population with more older people being injured; susceptibility of people with SCI to numerous medical conditions that impart a health hazard; risky behaviors leading to a disproportionate percentage of deaths as a result of preventable causes, including septicemia; changes in the delivery of health services during the first year after injury when the greatest resources are available; and other unknown factors. The purposes of this paper are (1) to define and differentiate general population aging and aging in people with SCI, (2) to briefly present the state of the science on health conditions in those aging with SCI, and finally, (3) to present recommendations for future research in the area of aging with SCI.

Risk of Mortality After Spinal Cord Injury: An 8-Year Prospective Study

UNLABELLED Krause JS, Zhai Y, Saunders LL, Carter RE. Risk of mortality after spinal cord injury: an 8-year prospective study. OBJECTIVE To evaluate a theoretical model for mortality after spinal cord injury (SCI) by sequentially analyzing 4 sets of risk factors in relation to mortality (ie, adding 1 set of factors to the regression equation at a time). DESIGN Prospective cohort study of data collected in late 1997 and early 1998 with mortality status ascertained in December 2005. We evaluated the significance of 4 successive sets of predictors (biographic and injury, psychologic and environmental, behavioral, health and secondary conditions) using Cox proportional hazards modeling and built a full model based on the optimal predictors. SETTING A specialty hospital. PARTICIPANTS Adults (N=1386) with traumatic SCI, at least 1 year postinjury, participated. There were 224 deaths. After eliminating cases with missing data, there were 1209 participants, with 179 deceased at follow-up. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Mortality status was determined using the National Death Index and the Social Security Death Index. RESULTS The final model included 1 environmental variable (poverty), 2 behavioral factors (prescription medication use, binge drinking), and 4 health factors or secondary conditions (hospitalizations, fractures/amputations, surgeries for pressure ulcers, probable major depression). CONCLUSIONS The results supported the major premise of the theoretical model that risk factors are more important the more proximal they are in a theoretical chain of events leading to mortality. According to this model, mortality results from declining health, precipitated by high-risk behaviors. These findings may be used to target those who are at high risk for early mortality as well as to direct interventions to the particular risk factor.