Rita Hamilton

Identifying predictors of resilience at inpatient and 3-month post-spinal cord injury

Objectives: To identify (1) changes in psychosocial factors, (2) relationships between psychosocial factors, and (3) significant predictors of resilience in adults with spinal cord injury (SCI) during inpatient rehabilitation and at 3-month post-discharge. Design: Cross sectional with convenience sample based on inclusion/exclusion criteria. Setting: Inpatient rehabilitation hospital and community-based follow-up. Participants: Individuals with a SCI. Interventions: Not applicable. Outcome measures: Demographic, resilience, self-efficacy for managing a chronic health issue, depression, social roles/activity limitations, and pain. Results: The final sample consisted of 44 respondents (16 women and 28 men). Results of repeated measure analyses of variance indicated no significant changes in variables between inpatient and 3-month follow-up. Bivariate correlations revealed associations between resilience and self-efficacy at inpatient (r = 0.54, P < 0.001), and resilience and depression (r = −0.69, P < 0.001) and self-efficacy (r = 0.67, P < 0.001) at 3-month follow-up. Hierarchical regression analyses a significant model predicting resilience at inpatient stay (R = 0.61; adjusted R2 = 0.24, P = 0.023), and at 3-month follow-up (R = 0.83; adjusted R2 = 0.49, P = 0.022). Self-efficacy was the strongest predictor at inpatient stay (β = 0.46, P  =  0.006) and depression was strongest at 3-month follow-up (β = −0.80, P = 0.007). Conclusion: Results suggest that although resilience appears to be stable from inpatient to 3-month follow-up, different factors are stronger predictors of resilience across time. Based on current results, an assessment of self-efficacy during inpatient rehabilitation and an identification of depression at 3-month follow-up may be important factors to help identify those at risk of health issues overtime.

Utilization and access to healthcare services among community-dwelling people living with spinal cord injury

Objective: Describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI). Design: Cross sectional, in-person or telephonic survey, utilizing a convenience sample. Setting: Community. Participants: Individuals with SCI greater than 12-months post injury. Interventions: N/A. Outcome measures: Demographic, injury related, and 34-item questionnaire of healthcare utilization, accessibility, and satisfaction with services. Results: The final sample consisted of 142 participants (50 female, 92 male). Ninety-nine percent of respondents had a healthcare visit in the past 12-months with primary care physicians (79%), with SCI physiatrists (77%) and urologists (50%) being the most utilized. 43% of the sample reported an ER visit within the past 12-months, with 21% reporting multiple visits. People who visited the ER had completed significantly less secondary education (P = 0.0386) and had a lower estimate of socioeconomic status (P = 0.017). The majority of individuals (66%) were satisfied with their primary care physician and 100% were satisfied with their SCI physiatrist. Individuals who did not visit an SCI physiatrist were significantly more likely to live in a rural area (P = 0.0075), not have private insurance (P = 0.0001), and experience a greater decrease in income post injury (P = 0.010). Conclusion: The delivery of care for people with SCI with low socioeconomic status may be remodeled to include patient-centered medical homes where care is directed by an SCI physiatrist. Further increased telehealth efforts would allow for SCI physiatrists to monitor health conditions remotely and focus on preventative treatment.

Sacral examination in spinal cord injury: Is it really needed?

Objective: To determine if a self-report measure of S4-5 motor and sensory function in patients with chronic SCI accurately predicts sacral examination results. Design: Prospective, single-blinded self-report survey compared with sacral exam. Setting: Outpatient SCI clinic. Participants: 116 patients aged 18+ with chronic SCI > 6 months who have undergone sacral exam. Interventions: The survey included demographic/clinical and sacral function information such as light tough (LT), pinprick sensation (PP), deep anal pressure (DAP) and voluntary anal contraction (VAC). Survey results and sacral exam were compared and stratified by the patient’s American Spinal Cord Injury Association Impairment Scale (AIS) category. Outcome Measures: Sacral self-report survey, AIS examination. Results: Mean age was 41.3 ± 14.4 years with majority male (69%) and Caucasian (71.6%). Overall, Positive Predictive Value (PPV) ranged between 48% (VAC) to 73% (DAP) and Negative Predictive Value (NPV) between 92% (VAC) to 100% (LT). AIS-A had NPV of 100% across all categories, and AIS-D had PPV of 100% across all categories. Conclusion: Patient report of sacral sparing can predict negative sensation in patients with AIS-A and predict positive sensation in persons with AIS-D. Overall, the self-report of sacral sparing of motor and sensory function is not predictive enough to rely on for accurate classification.

Healthcare utilization following spinal cord injury: Objective findings from a regional hospital registry

Objective: The purpose was to describe the prevalence and characteristics of healthcare utilization among individuals with spinal cord injury (SCI) from a Level I trauma center. Design: Retrospective data analysis utilizing a local acute trauma registry for initial hospitalization and merged with the Dallas-Fort Worth Hospital Council registry to obtain subsequent health care utilization in the first post-injury year. Setting: Dallas, TX, USA. Participants: Six hundred and sixty four patients were admitted with an acute traumatic SCI from January 2003 through June 2014 to a Level I trauma center. Fifty five patients that expired during initial hospitalization and 18 patients with unspecified SCI (defined by ICD-9 with no etiology or level of injury specified) were not included in the analysis, leaving a final sample of 591. Outcome Measures: Data included demographic and clinical characteristics, charges, and healthcare utilization. Results: Mean age was 46.1 years (±18.9 years), the majority of patients were male (74%), and Caucasian (58%). Of the 591 patients, 345 (58%) had additional inpatient or emergency healthcare utilization accounting for 769 additional visits (median of 3 visits per person). Of the 769 encounters, 534 (69%) were inpatient and 235 (31%) were emergency visits not resulting in an admission. The most prevalent ICD-9 codes listed were pressure ulcer, neurogenic bowel, neurogenic bladder, urinary tract infection, fluid electrolyte imbalance, hypertension, and tobacco use. Conclusion: Individuals with SCI experience high levels of healthcare utilization which are costly and may be preventable. Increasing our understanding of the prevalence and causes for healthcare utilization after acute SCI is important to target preventive strategies.

Inconsistencies with Screening for Traumatic Brain Injury in Spinal Cord Injury across the Continuum of Care

Abstract Objective: Explore how traumatic brain injury (TBI) is screened among spinal cord injury (SCI) patients across the continuum of care. Design: Retrospective chart review Setting: Emergency department, trauma, inpatient rehabilitation Participants: 325 patients with SCI from inpatient rehabilitation facility (IRF) between March 1, 2011 and December 31, 2014 were screened. 49 eligible subjects had traumatic SCI and received care in adjoining acute care (AC) hospital. Outcome Measures: Demographic characteristics and variables that capture diagnosis of TBI/SCI included documentation from ambulance, emergency department, AC, and IRF including ICD-9 codes, altered mental status, loss of consciousness (LOC), Glasgow Coma Score, Post Traumatic Amnesia (PTA), neuroimaging, and cognitive assessments. Results: Participants were male (81%), white (55%), privately insured (49%), and aged 39.3±18.0 years with 51% paraplegic and 49% tetraplegic. Mechanisms of injury were gunshot wound (31%), fall (29%), and motor vehicle accident (20%). TBI occurred in 65% of SCI individuals, however documentation of identification of TBI, LOC, and CT imaging results varied in H&P, discharge notes, and ICD-9 codes across the continuum. Cognitive assessments were performed on 16% of subjects. Conclusions: Documentation showed variability between AC and IRF and among disciplines. Imaging and GCS were more consistently documented than LOC and PTA. It is necessary to standardize screening processes between AC and IRF to identify dual diagnosis.

Poster 271 Differences in Outcomes between Patients Who Did and Did Not Go to Inpatient Rehabilitation 3 Months Post Injury

Objective: To evaluate prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery; to evaluate methods of exercise teaching; to assess postsurgical seroma formation. Design: Pilot study Setting: Academic medical center Participants: 60 breast cancer patients were randomly assigned to either personal exercise instruction, group 1, n1⁄436, or video only instruction, group 2, n1⁄424. Interventions: Shoulder exercises were assigned to both groups 1 month prior to surgery at an outpatient visit. Group 1 received personal instruction on exercises, plus written exercise instruction, and a link to access an online video. Group 2 received only written exercise instruction and a link to access the online video. Main Outcome Measures: Exercise compliance, pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma. Results or Clinical Course: 76% of study patients chose to exercise. There was no difference in exercise compliance between personal instruction versus video teaching. (75%, 24/32 in-person vs. 77%, 10/ 13 video only, OR1⁄41.03). 66% of patients (20/30) lost greater than 10 degrees shoulder abduction ROM at 1 month post surgery. 29% of patients (9/31) had worse shoulder pain at one month post surgery than at baseline (24%, 6/25 exercisers, and 50%, 3/6 non-exercisers). 15% of patients (4/27) had worse shoulder pain at 3 months post surgery than at baseline (8%, 2/25 exercisers, and 100%, 2/2 nonexercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (21%, 7/33 exercisers vs. 22%, 2/9 nonexercisers OR1⁄4.94). Conclusion: In-person teaching does not appear superior to video teaching for prehabilitation exercises in breast cancer. A high quality randomized controlled trial is necessary to assess efficacy of prehabilitation for improving post surgical outcomes. Prehabilitation exercises do not appear to increase risk of seroma formation in breast cancer surgery.

Analysis of Registry Healthcare Utilization Data for Spinal Cord Injury Patients Over Ten Years

Main Outcome Measures: Revised FIM score, the NIH Toolbox, adverse reactions. Results or Clinical Course: 498 patients were screened of which 61 were enrolled and followed per protocol. 38% had low T levels (< 260ng/dl) at screening and were randomized into placebo (n1⁄410) or physiologic T gel therapy (n1⁄413). No significant differences were found among the two low T and normal groups in the rate of improvement on the FIM over six weeks (intercepts t 1⁄4 -0.31, p1⁄4.7593, slopes t1⁄4 0.61, p 1⁄4 .5472). The low T treatment group demonstrated greater absolute FIM improvement than placebo or normal T groups (Normal T 1⁄4 17.5, Placebo 1⁄4 19.5, Treatment 1⁄4 30). A similar pattern was found for grip strength. There was no difference in adverse events per patient between groups. Percentage of time with agitated and aggressive behaviors was highest in the Placebo group. Conclusion: Although there was no difference in recovery rate, the Treatment group had greater functional improvement than the Placebo and the Normal T groups. Testosterone-supplemented patients had less frequent agitated and aggressive behavior than the Placebo group. Testosterone replacement to low normal levels was safe and well tolerated. Small sample size limited the study’s power.