Michelle A. Meade

Incidence and outcomes of spinal cord injury clinical syndromes.

Abstract Background/Objective: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). Design: Retrospective review. Setting: Tertiary care, level 1 trauma center inpatient rehabilitation unit. Participants: Eight hundred thirty-nine consecutive admissions with acute SCIs. Main Outcomes Measures: Functional independence measure (FIM), FIM subgroups (motor, self-care, sphincter control), length of stay (LOS), and discharge disposition. Results: One hundred seventy-five patients (20.9%) were diagnosed with SCI clinical syndromes. CCS was the most common (44.0%), followed by CES (25.1%) and BSS (17.1%). Significant differences (P < 0.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant differences (P < 0.01) with respect to age (39.7 vs 53.2 years) and a trend toward significance (P < 0.05) with regard to self-care admission and discharge FIM. No significant differences (P < 0.01) were found when comparing CMS to CES. Conclusions: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation, with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Patients with cervical BSS seem to achieve higher functional improvement by discharge compared with patients with CCS. Patients with CMS and CES exhibit similar functional outcomes. Patients with ACS and PCS show functional gains with inpatient rehabilitation, with patients with ACS displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI.

Traumatic brain injury and substance abuse: A review and analysis of the literature

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Accidents are a major cause of brain injury, and many accidents are alcohol or drug related. Evidence indicates that a vast majority of victims test positive for alcohol or illicit drugs at the time of hospital admission. Research also suggests that a majority of TBI survivors were moderate to heavy drinkers pre-injury. This manuscript reviews literature on pre- and post-injury substance use patterns, abuse risk factors, and dangers of post-injury use. Assessment is discussed in detail with information provided on the need for quantitative assessment, records review, corroboration, and long-term monitoring. Information is also provided on critical features of treatment, prevention, and education, and on the role of psychologists in substance abuse assessment and treatment. The manuscript concludes with a section addressing issues, questions, and concerns commonly encountered by clinicians.

A Structured Approach to Family Intervention After Brain Injury

Objective:Given the limitations of the literature, a structured approach to helping families after brain injury is clearly needed. Main Outcome Measures:On the basis of considerable clinical experience and research review, this article describes the Brain Injury Family Intervention (BIFI), developed to address common issues, concerns, and challenges. The foundation of the BIFI is a curriculum that includes 16 intervention topics, self-evaluation tools, and treatment strategies. Conclusions:Despite individual differences, families often encounter similar problems in their attempts to resume normal lives. A structured approach to family intervention can help mitigate commonly encountered problems.

Psychological Well-Being and Intensity of Employment in Individuals with a Spinal Cord Injury

This article describes a retrospective cross-sectional study that examined the relationship of varying levels of employment and psychological well-being (as characterized by satisfaction with life, societal participation, and depressive symptoms). Data from 2,875 individuals enrolled in the National Model SCI System are analyzed. Results support the value of employment in sustaining and improving psychological well-being among persons with a spinal cord injury. Part-time employment provided significant psychological advantages over unemployment status. Although greater exploration of the issue is necessary, the findings in this study suggest that there may be little difference between part-time and full-time employment with regard to the psychological benefits. Key words: employment, psychological well-being, spinal cord injury, work intensity

Incidence, etiology, and risk factors for fever following acute spinal cord injury.

Abstract Objective: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI). Design: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2- year period was performed. Setting: The study was performed at a tertiary care, Level I trauma center. Participants: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study. Main Outcome Measures: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured. Results: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5°F vs 101.1°F on acute and 101.5°F vs 100.7°F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4°F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation). Conclusions: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost- efficient fever workup in individuals with SCI.

Disparities in access to health care among adults with physical disabilities: Analysis of a representative national sample for a ten-year period

BACKGROUND People with physical disabilities are the largest underserved subpopulation in the U.S. However, disparities in access to health care and how these have changed over time have not been fully explored. OBJECTIVE To examine national trends in disparities in access to health care and to identify the impact of physical disability and the personal factors that are associated with unmet health care needs, defined as self-reported ability to get medical care, dental care or prescription medications, among working age adults within the United States. METHODS Logistic regression analysis of a nationally representative sample of adults ages 25-64 (n = 163,220) with and without physical disabilities, using pooled data from the 2002-2011 Medical Expenditure Panel Survey. RESULTS Individuals with physical disabilities have 75% (p < 0.0001), 57% (p < 0.0001), and 85% (p < 0.000) higher odds of having unmet medical, dental, and prescription medication needs, respectively. Sociodemographic and health factors were related to unmet needs in all three measures of access to care. In particular, being female, living at or near the poverty level, and lacking health insurance increased the odds of unmet health care needs. Predicted probabilities of unmet health care needs from 2002 to 2011 show persistent gaps between individuals with and without physical disabilities, with a growing gap in unmet dental care (p = 0.004). CONCLUSION Having physical disabilities increase the odds of unmet health care needs. This study has important policy and community program implications. The Affordable Care Act could significantly reduce unmet health care needs, especially among individuals with physical disabilities.

Marital Status, Marital Transitions, Well-Being and Spinal Cord Injury: An Examination of the Effects of Sex and Time

OBJECTIVE To examine the applicability of marital resource (marriage has substantial benefits for well-being over not being married) or marital crisis (marital dissolution leads to poorer well-being) models to the spinal cord injury (SCI) population by studying the effects of sex, marital status, and marital transitions on well-being. DESIGN Prospective cohort study from the SCI Model Systems National Database. SETTING Community. PARTICIPANTS Men (n=4864) and women (n=1277) who sustained traumatic SCI and completed a minimum of 1 follow-up interview beginning at 1 year through 15 years postinjury. INTERVENTIONS None. MAIN OUTCOMES MEASURES Life satisfaction, depressive symptoms, and self-perceived health status by using linear mixed models for longitudinal data. RESULTS In general, well-being improved over time since injury. Hypothesis testing supported the marital crisis model, as marital loss through being or becoming separated or divorced and being or becoming widowed, had the most consistent and negative impact across well-being outcomes, whereas being or becoming married had an advantage for only lower depression symptoms over time. However, marital dissolution or loss did not have a uniformly adverse impact on well-being outcomes, and this effect often was moderated by sex, such that widows had higher depressive symptoms and poorer self-perceived health than widowers, but separated or divorced women had higher life satisfaction and self-perceived health than men. Irrespective of sex, being separated or divorced versus being single was associated with higher depressive symptoms over time. CONCLUSIONS Results support the marital crisis model and that women and men can experience marital dissolution differently. All marital loss does not result in compromised well-being and all marriage does not enhance well-being, highlighting complex dynamics worthy of further investigation in this population.

Mechanical Ventilation, Health, and Quality of Life Following Spinal Cord Injury

OBJECTIVE To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not. DESIGN Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database. SETTING Community. PARTICIPANTS People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status. RESULTS Significant differences were found between the ventilator-user (VU) group and non-ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status. CONCLUSIONS People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.

The intersection of disability and healthcare disparities: a conceptual framework

Abstract Purpose: This article provides a conceptual framework for understanding healthcare disparities experienced by individuals with disabilities. While health disparities are the result of factors deeply rooted in culture, life style, socioeconomic status, and accessibility of resources, healthcare disparities are a subset of health disparities that reflect differences in access to and quality of healthcare and can be viewed as the inability of the healthcare system to adequately address the needs of specific population groups. Methods: This article uses a narrative method to identify and critique the main conceptual frameworks that have been used in analyzing disparities in healthcare access and quality, and evaluating those frameworks in the context of healthcare for individuals with disabilities. Specific models that are examined include the Aday and Anderson Model, the Grossman Utility Model, the Institute of Medicine (IOM)’s models of Access to Healthcare Services and Healthcare Disparities, and the Cultural Competency model. Results: While existing frameworks advance understandings of disparities in healthcare access and quality, they fall short when applied to individuals with disabilities. Specific deficits include a lack of attention to cultural and contextual factors (Aday and Andersen framework), unrealistic assumptions regarding equal access to resources (Grossman’s utility model), lack of recognition or inclusion of concepts of structural accessibility (IOM model of Healthcare Disparities) and exclusive emphasis on supply side of the healthcare equation to improve healthcare disparities (Cultural Competency model). In response to identified gaps in the literature and short-comings of current conceptualizations, an integrated model of disability and healthcare disparities is put forth. Conclusion: We analyzed models of access to care and disparities in healthcare to be able to have an integrated and cohesive conceptual framework that could potentially address issues related to access to healthcare among individuals with disabilities. The Model of Healthcare Disparities and Disability (MHDD) provides a framework for conceptualizing how healthcare disparities impact disability and specifically, how a mismatch between personal and environmental factors may result in reduced healthcare access and quality, which in turn may lead to reduced functioning, activity and participation among individuals with impairments and chronic health conditions. Researchers, health providers, policy makers and community advocate groups who are engaged in devising interventions aimed at reducing healthcare disparities would benefit from the discussions. Implications for Rehabilitation Evaluates the main models of healthcare disparity and disability to create an integrated framework. Provides a comprehensive conceptual model of healthcare disparity that specifically targets issues related to individuals with disabilities. Conceptualizes how personal and environmental factors interact to produce disparities in access to healthcare and healthcare quality. Recognizes and targets modifiable factors to reduce disparities between and within individuals with disabilities.

The Influence of Secondary Conditions on Job Acquisition and Retention in Adults With Spinal Cord Injury

OBJECTIVE To examine the associations of job acquisition and job retention to secondary conditions, hospitalizations, and nursing home stays for adults with spinal cord injury (SCI). DESIGN Retrospective analysis of longitudinal data from multicenter study. SETTING Community setting. PARTICIPANTS Two samples of adults participating in the SCI Model Systems; the first sample consisted of persons who reported being unemployed at follow-up (n=9501); the second sample consisted of those who reported working at follow-up (n=5,150). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Job acquisition (change from not working at 1 anniversary of injury to working at the following data collection) and job retention (maintenance of work between 2 assessment periods). RESULTS Discrete time hazard modeling was used to assess how secondary conditions affect job acquisition. After controlling for the effects of demographic and injury characteristics, hospitalizations within the last 12 months were associated with decreased chance of having obtained employment. Hierarchic logistic regression analyses were used to examine job retention. Hospitalizations and the presence of PUs were associated with lower odds of job retention once demographic and injury characteristics were controlled. Secondary conditions from the previous assessment period were not significantly related to either job acquisition or job retention after the variance from demographic and injury characteristics and current secondary conditions were controlled. CONCLUSIONS Hospitalization, as well as a limited number of secondary conditions, were associated with reduced odds of both job acquisition and job retention among adults with SCI. Interventions that can prevent secondary conditions and reduce the need for hospitalizations may be beneficial in improving employment for this population.