Presentation abstracts

1. 40 YEARS OF SCI RESEARCH ESSIE MORGAN LECTURESHIP

James S. Krause

College of Health Professions, Medical University of South Carolina, Charleston, SC, USA

Background: Psychological, socio-environmental, and behavioral factors are integrally related to health, quality of life (QOL), and longevity after spinal cord injury (SCI). A quarter of a century ago, our research team began the search for a better understanding of how psychological and QOL variables are related to mortality. Early research validated what most psychologists, social workers, and other rehabilitation professionals firmly believed—improving psychosocial and vocational outcomes ultimately results in better health and even enhances longevity. We have come a long way, now using prospective cohort studies to understand factors beyond basic demographic and injury characteristics and the strength of their relationships with mortality and life expectancy.

Purpose: To present the recent progress in understanding the role of specific health behaviors and economic factors as related to all-cause mortality after SCI. The Theoretical Risk and Prevention Model will be discussed, along with research to help individuals use the model in preventing secondary health conditions and mortality from an interdisciplinary perspective.

Significance: Although rehabilitation programs have moved beyond use of a pure medical model, they remain largely focused on traditional and enhanced therapies to promote health, with particular emphasis on exercise. Research on mortality clearly indicates promoting longevity requires the elimination of core risk behaviors including smoking, alcohol misuse, drug misuse, risktaking, and overuse of prescription medications. Many of these behaviors are intricately related to personality and fully within the realm of psychology. Other leading risk factors for mortality are related to unemployment and poverty, which again speak to the importance of the psychologist, social worker, and counselor whose goals are to enhance participation, employment opportunities, and QOL.

Conclusion: We must move beyond the study of all-cause mortality to investigate specific relationships of different psychological, socio-environmental, behavioral, and health factors with specific causes of mortality which may then be targeted for intervention. If we are to be successful, we also must address core issues of those facing the greatest obstacles of unemployment, poverty, poor QOL, and clinical depression. Researchers working with interdisciplinary rehabilitation professionals show promise for promoting health, QOL, and longevity after SCI.

2. ADDRESSING CHRONIC PAIN IN SCI WITH USE OF ELECTRO-ACUPUNCTURE

Chestin Jones, Bridgett Bennett, Itala Wickremasinghe

Dallas VA Medical Center, Dallas, TX, USA

Problem statement: Chronic Pain is a common complication affecting approximately 80% of people with spinal cord injury and disorders (SCI/D). Often a combination of medications and other non-pharmacologic treatments are used to manage pain in veterans with SCI/D. While pharmacologic therapy remains a mainstay of treatment, non-pharmacological therapies such as Acupuncture have been proven to reduce chronic pain in the general population. More specifically, percutaneous nerve stimulation (PENs) has been shown to be highly effective in decreasing chronic musculoskeletal pain as well as neuropathic in the general population. There have been no such studies within the SCI/D population.

Objective: To test the efficacy of a 4-week pain intervention using a Classical Upper Thoracic Cervical PENs protocol in veterans with SCI/D in the outpatient setting.

Methods: Patients were recruited using advertising throughout the SCI Outpatient Clinic and provider referrals. Inclusion criteria included: veterans with documented SCI, musculoskeletal or neuropathic pain lasting greater than 6 months & currently on no more than 2 narcotics. Patients presented for two 30 minute appointment for 4 weeks. Each week they completed a pain journal to track progress to determine efficacy of the intervention.

Data Analysis: Data was collected for 4 weeks at each scheduled visit. The data was analyzed to account for different variables and statistical significance.

Significance: Results of this intervention provided a safe, low-cost, time effective non-pharmacological treatment approach to managing chronic pain in the SCI population. Acupuncture, more specifically PENS Treatments, is being offered as a means of additional pain management therapy in SCI patients with chronic pain.

Conclusion: PENS is effective and is being used to manage chronic pain in the outpatient setting by activating the various innervations in the affected pain lesion.

3. ASSESSMENT OF THE RELATIONSHIP OF SPIRITUAL WELL-BEING TO DEPRESSION AND QUALITY OF LIFE

Catherine Wilson^1,2, Martin Forchheimer³, Ann Marie Warren⁴, Cheryl McCullumsmith⁵, PRISMS Investigators

¹James A. Haley Veterans Hospital, Tampa, FL, USA; ²Northwestern University, Chicago, IL, USA; ³University of Michigan, Ann Arbor, MI, USA; ⁴Baylor University Medical Center, Dallas, TX, USA; ⁵University of Alabama, Birmingham, AL, USA

Background/Objective: This study sought to describe the association between spiritual well-being, demographic characteristics, quality of life (QOL) and depressive symptoms following spinal cord injury (SCI). We hypothesized that levels of QOL and depressed mood would both be explained by extent of spiritual well-being, and that while meaning-focused spirituality would have a stronger impact than faith-focused spirituality, both would be significant predictors.

Methods: 210 individuals with SCI were screened as part of a subset of a randomized control trial of venlafaxine XR for major depressive disorder. Of those, 204 completed all study measures which included the Patient Health Questionniare-9 (PHQ-9) to assess depression, the FACIT-Sp to assess spiritual well-being, the PAW to assess quality of live, and the PANAS to assess affect. Demographic and injury characteristics were also collected.

Results: The mean age of the sample was 41.2 years (range 18 to 73), 52.0% of participants had paraplegia and the majority (72.1%) was male. Scores on the PHQ-9 showed that approximately 26% of the sample had likely MDD. Bivariate correlations of scores on the PAW and those from the PANAS and FACIT-Sp showed that all four scales on the latter two measures were strongly correlated with those on the PAW (P < 0.0005). As hypothesized, both the M&P and Faith scales of the FACIT-Sp were significant predictors of QOL (ß = 0.544; (P < 0.0005 and ß = 0.151; P = 0.004), with the M&P scale explaining significantly more of the variance in PAW scores, as is highlighted by the respective part correlations of the two FACITSp scales, 0.345 and 0.127.

Conclusion: The findings support our hypothesis that spirituality as measured by the FACIT-Sp would be strongly associated with self-reported QOL and lower levels of depression. Assessment of spirituality along with more traditional psychological measurements can provide valuable information to better inform treatment. When working with SCI, clinicians should consider spirituality a valid concept, as well as an important part of the therapeutic process as individuals adjust to injury.

4. AUTONOMIC DYSREFLEXIA: A MEDICAL EMERGENCY

Jennifer Wahl

Craig Hospital, Englewood, CO, USA

Objective: To enhance the knowledge of emergency healthcare providers in the Denver Metropolitan area regarding the recognition and initial treatment of autonomic dysreflexia (AD) for spinal cord injured persons.

Design: This study will employ the quasi-experimental design. This research study is mobile in nature with the presenter traveling to area emergency rooms, firehouses, and urgent care clinics to educate the emergency healthcare personnel on the topic of autonomic dysreflexia.

Participants/methods: Participants for this research study are emergency healthcare providers in the Denver Metropolitan area who have the potential of caring for spinal cord injured persons susceptible to autonomic dysreflexia (AD). This study is comprised of a pretest, an interactive lecture, and a posttest to measure knowledge enhancement. This design requires a collection of data from study participants' level of performance before the intervention took place (pre-), then the same data is collected after the intervention took place (post-). The participants will be given a detailed handout of the information contained in the educational presentation post lecture for care reference after the posttest has been collected.

Results: This research study is still in progress. Final data collection will occur on 3/6/15, final data analysis will occur in July of 2015, with final project results from the data analysis available August 2015. This study has provided education to over 100 participants to date, 30 subjects are anticipated for participation on 3/6/15.

Conclusion: This educational provision/research study has been well received and has a positive impact on the care of spinal cord injured persons who may be experiencing AD, according to participant responses. Consistent feedback reflects the information provided has enhanced the knowledge of participants regarding autonomic dysreflexia (AD).

Financial Support: Financial support for this research study is provided by Craig Hospital.

5. CARDIOVASCULAR RESPONSE TO AQUATIC THERAPY AND ROBOTIC-ASSISTED BODY WEIGHT-SUPPORTED LOCOMOTOR TRAINING IN INDIVIDUALS WITH CHRONIC MOTOR INCOMPLETE SPINAL CORD INJURY

Peter Gorman^1,2,3, Paula Geigle^1,2, Leslie VanHiel⁴, Keith Tansey^5,6, William Scott^1,3

¹University of Maryland Rehabilitation and Orthopedic Institute, Baltimore, MD, USA; ²University of Maryland School of Medicine, Baltimore, MD, USA; ³VA Maryland Healthcare System, Baltimore, MD, USA; ⁴Shepherd Center, Atlanta, GA, USA; ⁵Emory University School of Medicine, Atlanta, GA, USA; ⁶VA Medical Center, Atlanta, GA, USA

Objective: To determine the cardiovascular impact of a sequential 3 months of Aquatic Therapy (AT) and Robot Assisted Body Weight Supported Locomotor Training (RABWSLT) in chronic motor incomplete spinal cord injury (CMISCI).

Design: Randomized dual center crossover clinical trial.

Participants/methods: 32 individuals with CMISCI, C2-T12, AIS C and D, were studied. Participants were randomized to either initial AT or RABWSLT for 3 months, 3 days/week followed by an additional 3month period of the other intervention. Individualized sessions lasted 40–45 minutes and were performed at 6575 % heart rate reserve. Primary outcome measure was peak VO₂ obtained during arm cycle ergometry (pVO₂ACE) at baseline, crossover, and post intervention. Additional peak VO₂ assessments were obtained during robotic locomotor exercise (pVO2RLE) before and after the RABWSLT 3-month intervention period.

Results: The initial AT randomized group (n = 15) displayed an increase (7.4%, P = 0.14) in pVO₂ACE across the AT intervention. The initial RABWSLT randomized group (n = 17) displayed a decrease (–1.9%, P = 0.31) in pVO₂ACE across the RABWSLT intervention. There was in this group however a significant increase in pVO₂RLE (13.9%, P = 0.03). Similarly, when the groups crossed over to the alternative intervention, the initial RABWSLT randomized group experienced an increase (4.7%, P = 0.08) in pVO₂ACE after completing AT. The initial AT group experienced an increase in pVO₂ACE (2%, P = 0.68) and pVO₂RLE (9.6%, P = 0.47). Stratification into paraplegia and tetraplegia did not reveal any response differences across interventions.

Conclusions: pVO₂ACE did not improve after 3 months AT and RABWSLT interventions in patients with CMISCI. However a significant improvement in pVO₂RLE occurred in the RABWSLT randomized group, paralleling our previous findings of the impact of RABWSLT. While peak VO₂ improved as measured with both techniques in the AT-first randomized group after completing the crossover RBWSLT intervention, the gains were not significant. These results suggest two possibilities alone or in combination: 1) AT does not have the underlying capacity to produce measurable cardiovascular fitness improvement or 2) measurement of pVO₂ACE is not the proper method for accurately detecting cardiovascular fitness improvement under these circumstances. Matched training and assessment conditions might be necessary in future study designs. Additionally, the sequence of interventions may influence outcome.

Financial Support: Department of Defense CDMRP, SC090147 Clinical Trial Award, FY2009.

6. CAREGIVER CHARACTERISTICS AND YOUTH OUTCOMES IN PEDIATRIC SPINAL CORD INJURY

Erin H. Kelly^1,2, Anne L. Riordan¹, Sara Thorpe¹, Kathy Zebracki^1,3, Lawrence C. Vogel^1,4

¹Shriners Hospitals for Children, Chicago, IL, USA; ²Marquette University, Milwaukee, WI, USA; ³Loyola University, Chicago, IL, USA; ⁴Rush University, Chicago, IL, USA

Background: While past research has found relationships between the mental health of parental caregivers and their children with spinal cord injury (SCI), little is known about how other aspects of caregiver health and functioning impact youth quality of life (QOL).

Objective: To evaluate the importance of caregiver mental health, physical health, burden, and problem-solving skills in relation to child physical and psychosocial QOL.

Design: Survey research study.

Methods: Forty-one youth with SCI ages 7–17 years who had been injured for at least one year and their primary caregivers participated. Data were collected from youth and their primary caregivers as baseline data prior to a caregiver intervention that was taking place within a children's hospital. Youth completed the Pediatric Quality of Life Inventory; primary caregivers completed standardized measures of mental health (the Hospital Anxiety and Depression Scale) and physical health (the Pennebaker Inventory of Limbic Languidness), caregiver burden (the Caregiver Burden Interview), and problem solving (the Social Problem Solving Inventory-Revised). We evaluated two hierarchical linear regression models, predicting child physical and psychosocial QOL.

Results: The 41 youth were an average of 11.49 years (SD = 3.17), 63% were male, and 80% Caucasian. Youth had been injured an average of 6.88 years (SD = 3.87); 76% had paraplegia and 61% complete injuries. Caregivers included mothers (85%), fathers (7.5%), and other family members (7.5%). Sixty percent of caregivers were married, and 94% had at least some college education. Univariate analyses revealed caregiver problem solving alone was related to child physical QOL, and caregiver mental health, burden, and problem solving were related to child psychosocial QOL. Regression analyses controlling for child age and injury level revealed effective caregiver problem solving (P < 0.01) was significantly related to greater child physical (Model R2 = 0.440) and psychosocial (Model R2 = 0.544) QOL.

Conclusions: Caregiver problem solving emerged as more closely related to child physical and psychosocial QOL than caregiver mental health, physical health, or caregiver burden. Further research should explore relationships among larger samples, but results indicate caregiver problem solving is a reasonable target for intervention to improve QOL among youth with SCI.

Financial Support: Funded by the Craig H. Neilsen Foundation.

7. CARING FOR PERSONS WITH SPINAL CORD INJURY IN PRIMARY CARE PROGRAM EVALUATION

James Milligan^1,2,3, Craig Bauman^1,2

¹McMaster University Department of Family Medicine, Hamilton, ON, Canada; ²The Centre for Family Medicine, Kitchener, ON, Canada; ³Western University, London, ON, Canada

Objective: Individuals with spinal cord injury (SCI) face many barriers when seeking primary care. In addition to physical barriers, persons with spinal cord injuries report that family physicians typically lack the specific expertise necessary to provide them with optimal primary care. To address this concern the Caring for Persons with Spinal Cord Injury eLearning resource was developed. This resource was designed specifically for family physicians who care for, or are considering providing care for, persons with spinal cord injury in their practice. By sharing critical information in a convenient online format the resource aims to increase the comfort level and knowledge of family physicians who care for this unique population.

Design: Qualitative study involving survey and interviews

Participants/methods: A sub-sample of 34 resident physicians was selected to evaluate the effectiveness of the eLearning resource via survey and in-depth interviews were carried out with 10 learners. A thematic analysis of interview transcripts and survey responses was undertaken to identify perceptions of the utility of the eresource and to identify existing facilitators and barriers associated with tool use. Quantitative survey data was also analyzed to gauge learner satisfaction.

Results: Themes that emerged from residents it that they found the resource to be comprehensive, accessible, useful. They found it a bit challenging to navigate the resource for quick information. Resident physician feedback was helpful in identifying the tools strengths and limitations as well as contributes to research on supporting training in primary care with relation to treatment of SCI clients.

Conclusions: Knowledge of unique care requirements for individuals with SCI represents a formidable issue within primary care. Continued growth of the Caring for Persons with Spinal Cord Injury eLearning resource represents a promising avenue by which to facilitate continued learning.

Financial Support: Study supported by grant from the Ontario Neurotrauma Foundation.

8. CATHETER ASSOCIATED URINARY TRACT INFECTIONS FOLLOWING SCI DONALD MUNRO LECTURESHIP

Todd A. Linsenmeyer

Kessler Institute for Rehabilitation, West Orange, NJ, USA

Summary: Catheters have been described since Roman times. Advances in medical treatment have allowed even those with high levels of tetraplegia to survive their SCI and reintegrate into the community. Indwelling catheters have allowed increased independence in many people with higher level SCI injuries and have become an important part of bladder management for these individuals.

Of concern are catheter-associated urinary tract infections (CAUTIs). Guidelines have been established which are focused on preventing unnecessary catheterization of able bodied individuals in acute care hospitals and those in long term skilled nursing facilities. Unfortunately, these guidelines can have a negative impact on those with SCI.

This presentation is based on the Consortium for Spinal Cord Medicine Clinical Practice Guideline: Bladder Management for Adults with Spinal Cord Injury. The guidelines provide rationales for considering or not considering an indwelling catheter in a person with SCI. Important issues are the pathogenesis of biofilms, differences between colonization and symptomatic UTI, current prevention strategies and future directions at preventing CAUTIs.

9. CLINICAL OUTCOMES OF A GROUP SEXUALITY TELEHEALTH INTERVENTION PROGRAM FOR VETERANS WITH SPINAL CORD INJURIES OR DISORDERS (SCI/D)

Angela Kuemmel¹, Terra Sanderson¹, Alissa Kolb², Monique Washington¹

¹Louis Stokes VA, Cleveland, OH, USA; ²Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA

Objective: The purpose of the SCI Passion Multipoint Interactive Learning Opportunity (SCIPASSION MILO) project was to develop and evaluate an innovative web-based Telehealth sexuality intervention program.

Design: Participants received four 60-minute group intervention sessions, including: (1) an educational lecture; (2) a panel of veterans with spinal cord injuries or disorders (SCI/D) sharing their personal experiences with relationships and sexuality; (3) viewing and discussion of a film, The Sessions (which was streamed to program participants), and three other SCI sexuality videos; and (4) discussion of vignettes of commonly experienced barriers to sexuality after SCI/D.

Participants/Methods: Five patients completed the SCI-PASSION MILO pilot; including veterans of both genders. A mixed-methods approach was utilized to evaluate clinical and programmatic outcomes, using pre- and post-intervention questionnaires and a focus group was conducted with participants after program completion to capture qualitative feedback. Clinical outcome measures included the Multidimensional Sexual Self-Concept Questionnaire (MSSCQ) and ten Likert scale items developed by the authors to capture SCI/D specific aspects of sexuality.

Results: On the MSSCQ, group mean scores increased on the sexual satisfaction, esteem, self-efficacy, problem management, motivation, optimism, and assertiveness subscales, while group mean scores decreased on the sexual depression, fear of sex, and sexual anxiety subscales. On the Likert scale items, group mean scores increased with regard to self-confidence in the areas of finding a partner, having a relationship that meets one's needs and desires, maintaining a satisfying sexual relationship, potential rejection from partners, discussing sexuality with a partner, intimate sexual encounters, sexual abilities, relationship skills, and the ability to navigate common barriers to sexuality following SCI/D. Group mean scores decreased with regard to self-confidence in the area of communication skills. Qualitative results indicated that participants were generally satisfied with the program and themes of desiring more specific content and increased number of sessions emerged.

Conclusion: This pilot program contributes to positive patient outcomes in a small sample and that treatment delivery via Telehealth offers improved access for vets. The outcomes have been used to improve the program. SCI-PASSION MILO is now an integrated program for sexuality intervention at the Cleveland VA with ongoing enrollment of 5–10 patients and continued outcome evaluation.

10. CORRELATES AND PREDICTORS OF BURDEN IN CAREGIVERS OF PATIENTS WITH ALS

Monique Washington¹, Frances McClellan¹, Angela Kuemmel¹, Broderick Flynn¹, Stephen M. Selkirk^1,2

¹Louis Stokes Cleveland VA Medical Center, Spinal Cord Injury Division, Cleveland, OH, USA; ²Case Western Reserve Medical School, Department of Neurology, Cleveland, OH, USA

Problem Statement: Caregivers of patients with Amyotrophic Lateral Sclerosis (ALS) experience a multitude of strain and stressors, putting them at risk for high caregiver burden (CB). For example, it is estimated that ALS caregivers spend more than eleven hours daily providing care, even with assistance. CB is of great concern since it can also negatively impact the patient's physical and mental well-being.

Objective: To determine patient-level factors associated with CB, including survival time (survival), degree of functional impairment, and quality of life (QOL).

Methods: A cross-sectional analysis including patient-caregiver pairs (n = 31) receiving care from an interdisciplinary Spinal Cord Injury team. QOL was determined by McGill QOL, functional status by ALS Functional Rating Scale-Revised (ALSFRS-R), and CB by Zarit Caregiver Burden Interview Screen (Zarit). Assessments were completed at the same time point, and raters were trained on administration.

Data Analysis: Mean Zarit (0 = none to 16 = high burden), ALFRS-R (0 = maximum disability to 48 = normal), and QOL (0 = low to 10 = high) scores were calculated. Survival was calculated as diagnosis to assessment date. ALSFRS-R bulbar, motor, and respiratory sub-scales were created (0= maximum disability to 4 = normal). Spearman coefficient assessed correlation between variables, and multivariate linear regression determined significant predictors of CB at P = 0.05.

Significance: The mean Zarit was 5.26, and 23% were = 8 indicating high CB. Bulbar, motor, and respiratory subscales had good reliability (Cronbach a = 0.86, 0.90, and 0.75, respectively). Mean ALSFRS-R was 30.10 (SD = 0.98), survival time 2.55 years (SD = 2.84), and QOL 6.22 (SD = 0.87). The greatest disability was in motor function (1.94, SD = 1.22), then respiratory (2.84, SD = 0.94) and bulbar (3.33, SD = 0.98). CB had a moderate, negative correlation with total ALSFRS-R (r = –0.35, P = 0.05) and motor function (r = 0.37, P = 0.03). There was no correlation between CB and other factors. Regression results indicated motor function significantly predicted CB (ß = –0.38, P < 0.05), but only explained 14% of the variance (R2 = 0.14, F (1, 29) = 4.84, P < 0.05).

Conclusion: A decline in motor function may predict CB. However, other patient and caregiver level contributing factors need to be identified. This will facilitate effective, targeted interventions that will benefit both caregivers and patients with ALS.

11. FACTORS ASSOCIATED WITH FLOURISHING AND SUCCESSFUL ADJUSTMENT IN INDIVIDUALS WITH SPINAL CORD INJURY

Michelle Meade¹, Brad Trumpower¹, Colette Duggan², Lisa DiPonio¹, Catherine Wilson³

¹Department Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA; ²Rehabilitation Institute of Michigan, Detroit, MI, USA; ³James A. Haley Tampa Veterans Affairs Health System, Tampa, FL, USA

Objective: Too identify factors associated with Flourishing among individuals with spinal cord injury (SCI).

Design: Cross-sectional observational design

Participants / Methods: More than 1800 mail surveys were distributed to individuals identified as having a traumatic SCI; 551 individuals completed and returned the survey. Survey questions related to personal factors, current health and access to care as well as resilience, happiness and flourishing. Imbedded within the survey was the Flourishing Scale, an 8 item standardized measure of resilience created by Dienar and colleagues.

Results: Participants were primarily male, married, non-Hispanic White, and had not served in the military. Individuals were fairly evenly distributed between those with high-level Tetraplegia; low-level tetraplegia, and thoracic level paraplegia; 2% reported requiring a ventilator to breath. Average age was 53.7 years (SD = 16.6; range 18 to 93) and average time since injury was 15.73 years (SD = 13.26; range = 0 to 66 years).Scores on the Flourishing scale ranged from 8 to 56; average scores for this sample (Mean = 42.9, SD = 9.54) were somewhat lower than general population norms (Mean = 45, SD = 6.08). Total scores were not found to be related to gender, marital status or military background, nor were they related to time since injury or level of SCI. There was a significant relationship between Flourishing and both employment status and household income as well as a trend towards significance with age. Approximately one-third of respondents wrote in answers to the question, “Is there anything else you would like to tell us about your resilience or ability to “bounce back” when you face a challenge?” Responses reflect factors such as general outlook on life, the impact of physical health and functioning, the importance of social support and relationships and the role of religion and spirituality.

Conclusion: In general, our findings suggest that many individuals with SCI see themselves as doing well as report having a sense of meaning in their life. Factors associated with higher levels of flourishing and successful adjustment include family income and employment status.

Financial Support: Funding was provided through the proposal “Cognitions, Decisions, and Behaviors Related to Successful Adjustment among Individuals With SCI: A Qualitative Examination of Military and Nonmilitary personnel,” funded through the Department of Defense, Proposal Log Number SC110130, Award Number W81XWH-12-1-0589, HRPO Log Number A-17615.1a.

12. IMPLEMENTATION OF MEDICAL EARLY WARNING SYSTEM IN REHABILITATION – A TOOL TO REDUCE UNPLANNED TRANSFERS

Wesley Chay, Justine Sgrillo, Alberto Esquenazi

MossRehab, Elkins Park, PA, USA

Objective: To test the hypothesis that implementing a novel early warning monitoring system in an acute inpatient rehabilitation unit will decrease the unplanned transfer out to acute care rates.

Design: Retrospective study.

Participants/methods: Four hundred fifty-eight patients admitted to an acute inpatient rehabilitation unit from July 2013 through January 2015. A Medical Early Warning System (MEWS) Rehab monitoring system was implemented in February of 2014. Unplanned transfer out rate (UTR) was monitored and compared to prior rate.

Results: Prior to implementation of the MEWSRehab monitoring system, UTR on the SCI rehab unit (year to date October 2013) was 19.44% (national average, 11.69%, case mix adjusted). After implementation of MEWSRehab in February of 2014, UTR trended downward. Year to date May 2014, UTR was 16.96% (national average,13.69%, case mix adjusted). Year to date September 2014, UTR was 12.96% (national average, 14.03%, case mix adjusted). Year to date January 2015, UTR was 17.54% (national average, 14.16%, case mix adjusted).

Discussion: Medical monitoring systems have successfully been researched and implemented in the acute care hospital setting to alert clinicians to the declining medical status of patients. There has been limited implementation of such monitoring systems in the acute inpatient rehabilitation setting. As strong emphasis has been placed on quality metrics including minimizing hospital readmissions and reducing unplanned transfers, we introduced a modified medical early warning system in rehabilitation (MEWSRehab) based on the proven data used in some acute care facilities to predict transfer to higher intensity of care and mortality.

Conclusion: Variability of unplanned transfer out rates is noted but after implementation of MEWSRehab, there was a notable reduction of unplanned transfer out rate in the spinal cord injury inpatient unit.

13. INNOVATIVE TELEHEALTH PROGRAMS FOR PEOPLE LIVING WITH ADVANCED MULTIPLE SCLEROSIS (MS-AD)

Jacinta M. Seton^1,2, Monique Washington¹, Mia Allmond¹

¹Cleveland VAMC, Cleveland, OH, USA; ²APT Center, Cleveland, OH, USA

Problem Statement/Objective: Multiple Sclerosis (MS) is a chronic, progressive disease of the central nervous system. Advanced MS (MS-AD) affects the spinal cord, leading to conditions such as spasticity, chronic pain, and disability, which impacts quality of life (QOL). Care Coordination/Home Telehealth programs (CCHT) are designed to enhance healthcare delivery and patient-centered care by focusing on prevention, early detection, and access to care. The benefits of CCHT for patients with chronic, debilitating illnesses are well documented. However, little is known about its effectiveness in MS. The purpose of this pilot was to determine the impact of a 90-day multi-modal CCHT program on QOL in patients with MS-AD.

Methods/Design: MS-AD patients (n = 9) receiving care by a Spinal Cord Injury team participated. A MS disease management protocol delivered educational, self-management, and symptom related questions daily via data messaging device. Novel video-to-home technology was utilized to provide nurse visits via computer. Interventions included MS disease education, consultation with SCI providers, nurse case management, and referral to interdisciplinary team members. The MS QOL-54 was administered at baseline (prior to intervention) and after completion to determine changes in QOL.

Data Analysis/Results: Mean QOL scores (0 = poorest to 100 = highest) were calculated. MSQOL-54 components include a physical health composite (Physical function, Health perceptions, Energy/Fatigue, Role limitations—physical, Pain, Sexual function, Social function, and Health distress scales), mental health composite (health distress, overall QOL, emotional well-being, role limitations-emotional, and cognitive function scales), and single item measures (sexual function satisfaction and change in health).

Significance: Baseline, physical health (mean 43.3, SD = 20.0) was lower than mental health QOL (mean 73.3, SD = 26.1). After completion, QOL improved for all scales except Physical Role Limitations. The greatest improvements were Health Distress (mean 35.0, SD = 14.1 vs. mean 60.0, SD 14.1), Pain (mean 55.5, SD = 20.0 vs. mean 76.2, SD = 17.2), Change in Health (mean 36.1, SD = 28.2 vs. mean 58.3, SD = 27.9), and Health Perceptions (mean 52.5, SD = 18.4 vs. mean 63.7, SD = 29.5).

Conclusion: This innovative program provided insight into the QOL of individuals with MS-AD, and potential benefits of CCHT. These programs may increase access to specialty care, facilitate symptom management, and improve QOL. Further empirical investigation is warranted.

14. INPATIENT REHABILITATION OUTCOMES OF INFECTION-RELATED MYELOPATHY

Morgan Brubaker, Marianne Luetmer, Ronald Reeves

Mayo Clinic, Rochester, MN, USA

Objectives: To determine inpatient rehabilitation functional outcomes for patients with infection-related myelopathy.

Problem statement: There is little published literature regarding functional outcomes for infection-related myelopathy. Of the current literature, methods and results vary, making generalization of results difficult.

Methods: Retrospective chart review of patients with myelopathy discharged from a U.S. inpatient rehabilitation unit between January 1, 1995 and December 31, 2010. Patients were divided into 3 groups: infection-related myelopathy (IRM), other non-traumatic myelopathy (NTM) and traumatic myelopathy (TM). Demographic and outcome data were collected. Primary outcome measures were Functional Independence Measure (FIM) change and FIM change per day.

Data analysis: Means and standard deviations were calculated. Analysis of variance and pairwise comparisons were used to compare groups with statistically significant values set at P < 0.05 and P < 0.017, respectively.

Results: Of the 1601 patients, 40 (2.5%) had IRM. Infectious pathogens were bacterial (80%), viral (10%), tuberculous (7.5%), and parasitic (2.5%). Staphylococcus aureus was the most common bacterial etiology (66%). NTM had 1105 patients (69%) and TM had 456 patients (28.5%). IRM average age was 59 years (SD ± 16) with 73% male. The majority in each group had incomplete injuries (87% IRM, 95% NTM, 70% TM). IRM had significantly longer lengths of stay (mean 31 days, 95%CI:25–37, P < 0.0001), lower admission FIM scores (mean 51, 95%CI:44–57, P = 0.0005), lower discharge FIM scores (mean 75, 95%CI:67–83, P = 0.0048) and lower FIM change per day (mean 1.3, 95%CI:0.7–1.9, P = 0.0017) than NTM. Degree of functional improvement between groups was similar. The majority were discharged home in each group.

Significance: These findings show our patients with IRM experienced greater initial functional impairments, but achieved a similar degree of functional improvement as NTM during inpatient rehabilitation. There were no differences in outcomes between IRM and TM. Compared with prior studies, New also found significant functional improvements of IRM, but had no comparison group. Koo found IRM made greater functional improvements and McKinley and Zafonte found IRM made lower functional improvements, all compared with TM.

Conclusion: Infectious etiologies are a small proportion of NTM, but a unique entity with distinct recovery patterns and outcomes. These patients can achieve a similar degree of improvement as other NTM during inpatient rehabilitation, albeit, over a longer period of time.

15. INTEGRATED EMPLOYMENT SERVICES TO IMPROVE SCI OUTCOMES: RESEARCH TO PRACTICE

Sunil Sabharwal^1,2, Lisa Ottomanelli^3,4, Lance L. Goetz^5,6, Bridget A. Cotner³, Dan Edelston¹

¹VA Boston Healthcare System, Boston, MA, USA; ²Harvard Medical School, Boston, MA, USA; ³Center of Innovation on Disability and Rehabilitation Research (CINDRR) at the James A. Haley Veterans' Hospital, Tampa, FL, USA; ⁴Rehabilitation and Mental Health Counseling at the University of South Florida, Tampa, FL, USA; ⁵Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA; ⁶Virginia Commonwealth University (VCU), Richmond, VA, USA

Objective: This symposium focuses on integrating vocational services and medical rehabilitation improves employment and quality of life (QOL) for persons with spinal cord injury (SCI). A well-balanced panel will use quantitative and qualitative research data blended with clinical application to demonstrate how integrating evidence-based practice supported employment (EBP-SE) into medical rehabilitation provides a framework to focus a team's rehabilitation efforts toward improving community reintegration and QOL for persons with SCI. Finding effective methods for restoring employment is essential to comprehensive rehabilitation care. Vocational rehabilitation (VR) has traditionally been ancillary to medical rehabilitation and used a conventional VR model. With the advent of the first trial of EBP-SE in 2005, a new approach was introduced that integrated vocational services into clinical care to help persons with SCI obtain competitive employment in the community.

Theme: This symposium, moderated by Dr. Sunil Sabharwal, describes key findings from 10 years of interdisciplinary research applying EBP-SE in the Veterans Affairs (VA) SCI system of care to advance employment of persons with SCI. Included are Dr. Ottomanelli's outcome data from two multicenter trials of SE in SCI. In the first, 201 persons with SCI received 12 months of either SE or treatment as usual (TAU) The employment rate was 2.5 times higher with SE than TAU at intervention sites and 11.4 times higher at observation sites. Social participation, community mobility, and role productivity were significantly greater for employed participants. Preliminary data from a mixed methods study of 280 persons with SCI receiving EBP-SE for 24 months to investigate best practices show that the employment rate is exceeding that seen in the previous study, with demonstrated improvements in QOL, social participation, and earning ability. Dr. Goetz will discuss how realizing these outcomes requires targeted medical management of SCI-related sequelae to support job acquisition and maintenance. Dr. Cotner will share qualitative data illustrating QOL changes associated with EBP-SE. Finally, Mr. Edelston, vocational rehabilitation specialist, will discuss the practical teambased application of integrating EBP-SE in the SCI Center at the VA Boston Healthcare System.

Conclusion: Evidence-based employment services can be effectively integrated with rehabilitation care to improve outcomes.

16. LONELINESS AMONG PEOPLE WITH SPINAL CORD INJURY

Susan Robinson-Whelen^1,2, Heather B Taylor^1,3, Michelle Feltz¹, Jose Vega¹

¹Texas Institute for Rehabilitation and Research (TIRR) - Memorial Hermann, Houston, TX, USA; ²Baylor College of Medicine, Houston, TX, USA; ³University of Texas Houston Health Science Center, Houston, TX, USA

Background: Loneliness has received little attention in the literature on spinal cord injury (SCI). Other than a few qualitative studies, loneliness has been ignored by researchers and health care providers.

Design: This cross-sectional study is the first to administer an established loneliness measure to examine loneliness and its correlates among persons with SCI. In addition to examining descriptive data on the Loneliness Scale, internal consistency and convergent/divergent validity was examined to evaluate the appropriateness of the measure for individuals with SCI.

Methods: The Three-Item Loneliness Scale (Hughes et al., 2004) was administered by phone in English or Spanish to 90 men and 23 women with SCI as part of the Texas SCIMS Form-II Follow-up Interviews. The sample was predominantly White (73%) or Black (14%) with approximately 20% describing themselves as Hispanic.

Results: The average loneliness score for this mostly middle-aged sample, on average 20 years post-injury, was 4.63 (SD = 1.77)—a value higher than that found among middle-aged and older adults participating in the Health and Retirement Study (HRS; Mean = 3.89, SD = 1.34; t = 5.62, df = 2293; Cohen's d = .54). Approximately 40% reported they lacked companionship (43%), felt left out (42%), and felt isolated from others (38%) at least some of the time. Cronbach's coefficient alpha was .78, a value comparable to the HRS. Among demographics, loneliness was only related to marital status (F = 4.63, df = 2,110, P = 0.01). Although unrelated to most disability variables, loneliness was related to CHART Mobility scores (r = –0.42). Loneliness was relatively weakly correlated with CHART Social Integration (r = –0.23) and Occupation (r = –0.32). Of relevance to intervention efforts, daily internet and e-mail users had lower loneliness scores (Mean = 4.21, SD = 1.52) than weekly (Mean = 5.85, SD = 2.23) or monthly (Mean = 5.86, SD = 1.95; F = 9.05, df = 2,96, P < 0.001) users.

Conclusions: This study provides preliminary evidence supporting the reliability and validity of a brief loneliness scale for individuals with SCI and also suggests that loneliness may be a significant issue for people with SCI and not simply a function of limited social interaction. Given the serious health consequences of loneliness documented in the general literature, it is imperative that the experience of loneliness among people with SCI be given serious and systematic attention.

Financial Support: Partially funded by NIDRR Spinal Cord Injury Model Systems

17. LONG-TERM OUTCOMES AFTER REHABILITATION FOR CERVICAL SPONDYLOTIC MYELOPATHY

David J Powell^1,2, Sunil Sabharwal^1,2, Rachel A Lawson¹, Diane C Acerra¹

¹VA Boston Healthcare System, Boston, MA, USA, ²Harvard Medical School, Boston, MA, USA

Background/Objective: Cervical spondylotic myelopathy (CSM) is the most common cause of non-traumatic spinal cord injury in the United States. However, literature about post-rehabilitation outcomes of CSM is very sparse and is limited to initial rehabilitation outcomes (McKinley et al., 2002) with no published data about long-term sustainability. Our primary objective was to examine motor outcomes at one-year post rehabilitation in a cohort with CSM, and to compare those with a traumatic SCI (TSCI) cohort of similar neurological level and completeness.

Design: Retrospective cohort study at a Veterans Administration (VA) Spinal Cord Injury (SCI) Center. Our primary outcome measure was motor Functional Independence Measure (FIM) score at 1 year post-rehabilitation discharge.

Methods: Patients with CSM and TSCI were identified from the VA Spinal Cord Injury and Disorders Outcome (SCIDO) database. Chart review was conducted to obtain additional or missing data. In addition to motor FIM scores at rehabilitation admission, discharge, and 1-year follow-up, we collected data on demographics, cognitive function, ambulation status, and bladder management. Repeated measures ANOVA was conducted to assess change in FIM scores for both groups, and paired samples t-test was conducted to compare groups on FIM scores at stages of treatment (admission, discharge, 1-year follow-up).

Results: All subjects had motor incomplete tetraplegia (ASIA Impairment Scale D). The CSM cohort (n = 19) exhibited improvement in FIM motor score across time, F(2, 32) = 102.82, P < 0.001, with a significant average increase from initial evaluation to discharge of 41.11 points (SD = 16.84; C.I., 32.74, 49.49) and of 4.78 (SD = 9.33, C.I., 0.14, 9.42) from discharge to 1-year follow-up. Similarly, patients with TSCI (n = 14) exhibited improvement in FIM score across time, F(2, 18) = 148.38, P < 0.001. Patients with CSM did not differ from TSCI in FIM motor score at discharge (t[31] = 1.37, P = 0.179) or at 1-year follow-up (t[26] = –1.15, P = 0.263).

Conclusions: Our CSM cohort demonstrated additional or sustained improvement in motor function at one-year post-rehabilitation discharge. There were no significant differences between our CSM cohort and TSCI cohort. Our findings have significant implications for demonstrating long-term effectiveness of rehabilitation for CSM and for post-rehabilitation treatment planning. Future studies with a larger sample size across multiple sites would be helpful to determine generalizability of our findings.

18. MARITAL STATUS' IMPACTS ON 20-YEAR LIFE SITUATION TRAJECTORIES

Yue Cao, James S. Krause, Lee L. Saunders

College of Health Professions, Medical University of South Carolina, Charleston, SC, USA

Objective: Studies regarding the relationship between marital status and well-being after spinal cord injury (SCI) have increased in recent years, but little longitudinal research has been conducted. Because well-being and needs change over time after SCI, looking at outcomes at a single point in time only paints a part of the picture. Changes in well-being are important to better prepare for future needs. We addressed this knowledge gap by using 20-year longitudinal data to study the impact of marital status on life situation trajectories after SCI.

Design: Prospective cohort study.

Methods: We assessed 1032 participants from 2 Midwestern hospitals and a Southeastern specialty hospital at 5 time points separated by 5 years from 1993 to 2013. Inclusion criteria were: traumatic SCI with residual effects, 18 years of age, and minimum of 1 year post-injury. The Life Situation Questionnaire-Revised version was used to measure multiple aspects of life situation after SCI. Marital status was a time-variant predictor, categorized into 3 groups: Married or Co-habitating (MC), Divorced, Separated, or Widowed (DSW), and Single (S). All other control variables were measured at baseline: chronologic age, age at injury, race, gender, injury severity, and years of education. We used SAS 9.3 PROC MIXED procedure to implement the multilevel model for the longitudinal analysis.

Results: On average, compared to the MC group, both the DSW and S groups experienced significantly lower home satisfaction and vocational satisfaction, higher social isolation, emotional distress, environmental barriers, and money problems, and fewer opportunities at each time point. However, the DSW group had slightly increasing trajectories over time in home satisfaction and opportunities, and decreasing trajectories in social isolation, emotional distress, environmental barriers, and money problems. The MC and S groups had slightly decreasing trajectories in home satisfaction and increasing trajectories in social isolation.

Conclusions: Even with some slight unfavorable changes over time, the MC group still has the best outcomes in life situation after SCI. The DSW group reported the worst life situation at the beginning but showed slow recovery over time.

Financial Support: The contents of this presentation were developed under a grant from the Department of

Education, NIDRR grant number H133G110157, and grant SCIRF 11-006 from the South Carolina Spinal

Cord Injury Research Fund (SCSCIRF).

19. NEIGHBORHOOD DISADVANTAGE AND SELF-REPORTED HEALTH AFTER SPINAL CORD INJURY

Yue Cao, James S. Krause, Lee L. Saunders

College of Health Professions, Medical University of South Carolina, Charleston, SC, USA

Objective: Empirical studies in the general population have found the places where people live to be associated with health problems such as obesity, cardiovascular disease, diabetes, and depression. However, few studies have investigated the residential environmental impact on people's health outcomes after spinal cord injury (SCI). We addressed this knowledge gap by linking Census aggregate-level data with individual-level survey data to study the relationship between neighborhood disadvantage and self-reported health after SCI.

Design: Cross-sectional study.

Methods: We surveyed a total of 833 participants with SCI between 2010 and 2013, who were identified from South Carolina SCI Surveillance System Registry (SCSCISR). Inclusion criteria were: traumatic SCI with residual effects, 18 years of age, and minimum of 1 year post-injury. Among participants, 488 (59%) had a valid address, which was matched with Census tract geocode. We calculated the index of objective neighborhood disadvantage based on Census tract level, and then combined it with our survey data. Multivariate regression models were used to analyze the association between neighborhood disadvantage index and 8 self-reported health questions controlling for age at injury, years post-injury, injury severity, race, gender, income, and education.

Results: The index of objective neighborhood disadvantage was associated with hospitalization times, hospitalization days in the past year, days of mental health not good in the past month, days of feeling sad, blue, or depressed, and days of feeling worried, tense, or anxious. After controlling for individual socioeconomic factors, the neighborhood disadvantage significantly related to unfavorable mental health outcomes.

Conclusions: Although parts of the neighborhood's effects were explained by individual socioeconomic factors, neighborhood disadvantages still had significant independent impacts on participants' self-reported mental health.

Financial Support: The contents of this presentation were developed under grants from the South Carolina Spinal Cord Injury Research Fund (SCIRF), grant numbers SCIRF 11-006 and SCIRF 09-001.

20. PATIENT EDUCATION REVAMPED AND REINVIGORATED

Jon Rose

Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA.

Objective: Describes process and outcomes changing a curriculum-based patient education program for persons in spinal cord injury and disorders (SCI/D) rehabilitation into a milieu-based model supporting community responsibility and life-long learning.

Design: Questionnaires determined areas of interest and education program deficiencies. Interdisciplinary staff and a consumer designed the new program with ongoing modifications as indicated by questionnaires from each class. Attendance and surveys were analyzed after each class to assess outcomes.

Participants/Methods: 112 consecutive adults with SCI/D admitted to a regional inpatient rehabilitation program. Additional consumers with SCI/D recruited via consumer newsletter. Lunchtime classes for all patients were offered featuring monthly question and answer (Q&A) sessions and monthly single-topic presentations. Lunches, including food for patients on bed rest, were served in the multi-purpose room rather than bedside. Representatives from all disciplines were present at every class. Patients were encouraged to submit questions about any aspect of SCI/D rehabilitation prior to each Q&A class. A new documentation system was utilized to better track topics learned by each patient and facilitate review of the program for accreditation. Topics recommended by CARF International not requested by patients were covered 1:1 by the appropriate discipline, along with individual follow-up on topics covered in classes.

Results: The initial 18 sessions resulted in 190 class encounters including 28 patients wheeled into class in their beds, compared to a handful of encounters in the final 4 weeks of the old program. Inpatient attendance averaged 41%, and outpatients have begun to attend. Patients completed satisfaction surveys following each class. Over 80% responded that they felt comfortable asking questions and the class attended was personally valuable. Ninety percent valued input from both peers and staff. The program continues to be modified in response to patient feedback. Changes include improved amplification system and free telephone access.

Conclusion: Improved attendance and effectiveness, greater enthusiasm from staff, more spontaneous peer mentoring, acceptable breadth of content and high patient satisfaction. Future goals include involvement of more staff and outpatients, more patients eating in the multi-purpose room on days the program is not offered, and more peer interaction during and between classes.

21. PERCEPTIONS OF SHARED DECISION-MAKING AMONG PATIENTS WITH SPINAL CORD INJURY/DISORDERS

Sara M. Locatelli^1,2, Bella Etingen^1,2, Allen Heinemann^3,4, Holly DeMark Neumann⁵, Ana Miskovic³, David Chen^4,6, Sherri L. LaVela^1,2,7

¹Department of Veterans Affairs, Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr. VA Hospital, Hines, IL, USA; ²Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, USA; ³Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL, USA; ⁴Department of Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; ⁵Performance Measure Development and Implementation Program, RTI International, Chicago, IL, USA; ⁶Rehabilitation Institute of Chicago, Chicago, IL, USA; ⁷Center for Healthcare Studies, Institute for Public Health and Medicine, General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

Objective: Research suggests individuals with spinal cord injuries/disorders (SCI/D) are interested in, and benefit from, shared decision-making (SDM). The purpose of this study was to explore SDM among individuals with SCI/D, and how SCI/D characteristics are related to perspectives on SDM.

Design: Individuals with SCI/D who received SCI care at a Veterans Affairs (VA) or a SCI model systems facility completed a cross-sectional mailed survey measuring demographic and health/SCI characteristics, and perceptions of care, including SDM, as measured by COMRADE (Subscales: Decision-Making Effectiveness, DME, and Risk Communication, RC).

Methods: Individuals were 1+ years post-injury, had a healthcare encounter in the prior year, and an address in the Chicago metro area. 124 Veterans and 326 civilians participated. Bivariate analyses examined variables related to SDM, and multiple linear regression was used to identify variables independently associated with SDM.

Results: Participants were mostly male (83%), White (70%), average age of 54 years (SD = 14.3). 91% had traumatic etiology, 44% paraplegia, and 49% complete injury. Veteran/civilian status and demographic variables were unrelated to scores. Individuals with tetraplegia had higher DME scores (M = 65, SD = 15.8) than individuals with paraplegia (M = 62, SD = 15.1), t(396) = 2.03, P = 0.04. DME was correlated with physical health, r = 0.12, P = 0.02, and mental health, r = 0.27, P < 0.001; RC was correlated with mental health, r = 0.24, P < 0.001. Multiple linear regressions were conducted on DME and RC scores separately. Tetraplegia (b= –3.19, P = 0.04), better physical health (b = 0.19, P = 0.02), and better mental health (b = 0.32, P < 0.001) were associated with higher DME scores. Better mental health (b = 0.32, P < 0.001) was associated with higher RC scores. Nested regressions controlling for demographic variables showed similar results.

Conclusions: Though past research has shown the impact of age and race on SDM, in the present study, select SCI and health characteristics were the only variables associated with SDM. Individuals with paraplegia, poorer physical health, and poorer mental health may benefit from interventions to increase engagement in SDM. This represents an opportunity for VA to target and focus on improving SDM in these subgroups.

Financial Support: Department of Veterans Affairs, Office of Patient-Centered Care and Cultural Transformation and Health Services Research & Development Quality Enhancement Research Initiative (PEC 13-002).

22. POLICIES AND PROGRAMS ASSOCIATED WITH SUCCESSFUL EMPLOYMENT FOR INDIVIDUALS WITH SCI

James S. Krause¹, Michelle Meade², Karla S. Reed¹, Lee L. Saunders¹, Yue Cao¹

¹College of Health Professions, Medical University of South Carolina, Charleston, SC, USA; ²Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA

Objective: Spinal cord injury (SCI) is associated with unacceptably high unemployment rates, often exceeding 80%. To improve employment outcomes, we must understand better the policies and programs associated with successful employment from the perspective of persons with disabling conditions. Our objective was to identify the programs and policy-related factors, as defined by those with SCI who have worked since SCI, which impacted their employment outcomes.

Design: Qualitative approach using 6 focus groups at two sites (Minnesota, Georgia).

Participants/methods: Participants (N = 44) were identified through a 35-year longitudinal study of SCI and a community resource in Minnesota. All had been employed at some point since injury. Groups were delineated based on specific characteristics, such as education, gender, or race. A semi-structured interview format asked questions about personal, environmental, and policy related factors influencing job attainment, maintenance, and advancement following SCI. Groups were recorded, transcribed, and coded into conceptual categories to identify topics, themes, and patterns, and inferences were drawn about their meaning. NVivo 10 software using the constant comparative method was used for data analysis.

Results: Preliminary results indicated 10 themes within 3 overlapping categories. In the category of skill development, narratives reflected themes associated with: (1) education; (2) skill building/training experience; and (3) assessment of skills and potential employment possibilities. Within the category of personal connections, the themes were: (4) employment placement; (5) shared information/networking; and, (6) individual variability in program representatives. A third category on barriers and facilitators included: (7) prohibiting discrimination and ensuring equal opportunities; (8) providing health insurance, financial assistance and safety nets; and, (9) providing practical assistance or resources to make employment possible. A final theme (10) was related to the continuum of awareness about program or policies to support employment.

Conclusion: Results highlight the importance of programs and policies in successful employment of persons with SCI. Researchers, program developers, and policy makers should consider the areas of need addressed by these programs and policies, awareness of them, and if they are sufficient to address the concerns of individuals with diverse backgrounds and levels of impairment.

Financial Support: The contents of this presentation were developed under NIDRR grant H133A120122.

23. POSSIBILITY OF AN ALTERNATIVE MOTOR LEVEL DEFINITION FOR THE ISNCSCI

Dana Clark¹, Christian Schuld², Steffen Franz², Norbert Weidner², EMSCI study group³, Rüdiger Rupp², Steven C. Kirshblum^4,5

¹US Physiatry, Orlando, FL, USA; ²Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany; ³European Multicenter Study on Human Spinal Cord Injury, Zurich, Switzerland; ⁴Kessler Institute for Rehabilitation, West Orange, NJ, USA; ⁵Rutgers/New Jersey Medical School, Newark, NJ, USA

Objective: To identify frequency in which motor level defers to sensory level in non-testable myotomes and its effect on classification of motor level and ASIA impairment scale.

Design: Retrospective assessment of datasets compared to reclassification of datasets with alternative motor level rules.

Introduction: The determination of motor levels (MLs) is one of the most difficult classification tasks of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), since for clinically not testable myotomes (at C2–C4, T2–T12 and S2–S5), MLs are determined from the sensory examination. The purpose of this work was to analyze the impact of an alternative ML rule that deferring to the sensory level above the cut-off myotomes (C4 and L1) should only occur in cases where the relevant cut-off myotome is not graded as intact.

Methods: The data source utilized for this study was from the European Multicenter Study on Human Spinal Cord Injury (EMSCI). ISNCSCI datasets results based upon the current rules (where sensory above C4 must always be intact or for lumbar levels a sensation above L1 must be intact) were compared with a reclassification using the following alternative ML rule: If the cut-off myotome (C5 for upper cervical, L2 for thoraco-lumbar, and S4-5 low sacral lesions) is graded as intact, a pure ML is calculated without any influence from sensory scores.

Results: Early (<30 days after injury) ISNCSCI datasets of 1,290 patients were eligible for analysis. Of the 2,580 MLs, 1175 (46%) were deferred from the sensory levels. After reclassification of the 1175 MLs, 7.9% MLs and 4 AIS grades changed.

Conclusion: This modification of the ML rule changes the ML determination in 7.9% of cases and the AIS in <1%. However, while not occurring often in this database, these modified rules are more intuitive and may offer greater understanding of function based upon the ML alone, as opposed to the current “motor follows sensory” rule. Further analysis is necessary to best determine the benefits of a change in the ISNCSCI and 4 AIS grades changed. For the post-testing of the case presented, although instructed to determine C2 as ML, 60.4% of the attendees classified C6, indicating that the current ML rule may be counterintuitive.

24. PREVENTING PNEUMONIA IN SPINAL CORD INJURY USING ASSISTED COUGH TECHNIQUES

Trevor Dyson-Hudson^1,2, Steven Kirshblum^2,3, Amanda Botticello^1,2, Michael Feinberg³, John Bach²

¹Kessler Foundation, West Orange, NJ, USA; ²Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA; ³Kessler Institute for Rehabilitation, West Orange, NJ, USA

Background: Respiratory complications are a major source of morbidity and mortality after spinal cord injury (SCI), in part due to weakened chest and abdominal muscles that are vital to generating an effective cough. Manual and mechanical assisted cough techniques are commonly used to assist inspiratory/expiratory muscle function in SCI. The purpose of this study was to determine the efficacy of these assisted cough techniques in preventing community acquired pneumonia (CAP) and other severe respiratory tract infections (RTI) in chronic SCI.

Design: Single-blind, randomized controlled trial.

Methods: 120 persons with chronic SCI (>6mo) with an ineffective cough (cough peak flows [CPF] < 300 L/min) were randomly assigned to either a treatment group using manual and mechanical assisted cough (MMAC) or an active control group using incentive spirometry (SPIR) and followed 36 months. All participants received pneumococcal and influenza vaccines. Primary efficacy endpoints included a reduction in episodes of CAP and RTI that require antibiotics. χ² and Wald tests were used to determine treatment group differences in the occurrence of CAP and RTI. Growth curve modeling was used to assess differences in the rate of change of respiratory functioning between treatment groups over time.

Results: Eighteen participants left the study. Annual follow-up rates were 85%, 90%, and 69%, respectively. Contrary to expectations, few cases of CAP and/or RTI were reported over the course of the study. Of the 11 total episodes of severe RTIs, no significant differences between the groups were observed. Respiratory functioning (i.e. VC and MIC) significantly improved among persons receiving the MMAC versus SPIR from baseline to 12 months; however, differences in the rate of change between groups was not sustained during the latter half of the study.

Conclusions: There was no difference between manual and mechanical assisted coughing techniques and incentive spirometry in preventing CAP or RTI; however, caution should be used in drawing any conclusions given the relatively low number of cases of respiratory complications in our sample. The low rates could be due to the concomitant vaccinations as well as good adherence to the protocol by both groups. The difference in improved respiratory functioning during the first 12 months of the study by the MMAC group suggests a modest albeit short-term secondary benefit in more assertive cough-assist techniques relative to incentive spirometry.

Financial Support: NCT00448045: supported by NIDRR grant #H133N060022 & Kessler Foundation.

25. PROBLEM SOLVING ORIENTATION: IS THE GLASS HALF-FULL OR HALF-EMPTY?

Heather Russell¹, Erin H. Kelly^2,3, Lawrence C. Vogel^2,4

¹Shriners Hospitals for Children, Philadelphia, PA, USA; ²Shriners Hospitals for Children, Chicago, IL, USA; ³Marquette University, Milwaukee, WI, USA; ⁴Rush Medical College, Chicago, IL, USA

Background: Problem solving has been highlighted as an important skill for effective caregivers of youth with a variety of disabilities, but little is known about the importance of problem solving for adolescents with spinal cord injury (SCI) themselves. The current study investigated relationships between problem solving orientation (positive vs. negative) and psychosocial and physical health outcomes among youth with spinal cord injury.

Design: Youth with SCI ages 13–18 years who were patients within a pediatric specialty hospital system completed standardized measures of anxiety, depression, psychosocial and physical quality of life (QOL), global pain, parent-child relationship around SCI-related care, and the Social Problem Solving Inventory, Revised Short Form, which yields scores on positive and negative problem solving orientation. Demographics were gathered through a chart review and caregiver questionnaire.

Method: Youth were recruited during inpatient or outpatient visits and completed data on paper or through an online platform. After completing surveys, youth were classified as having a positive or negative problem solving orientation using median splits, and data were analyzed using non-parametric statistics.

Results: The 41 youth were an average of 15.98 years (SD = 1.68) at interview and 7.98 years (SD = 5.91) at injury. Fifty-one percent were male and 8.3% had C1–C4 ABC, 11.1% C5–C8 ABC, 66.7% paraplegia ABC, and 13.9% D injuries, as classified by the American Spinal Injury Association Impairment Scale (AIS). Eighteen and 23 youth had positive or negative problem solving orientation, respectively. Youth with a positive problem solving orientation experienced decreased depression (P < 0.001) and anxiety (P < 0.01), less pain (P < 0.05), increased psychosocial (P < 0.001) and physical (P < 0.05) QOL, and a more positive relationship with their primary caregiver around their SCI-related care (P < 0.05).

Conclusion: There are several affirmative relationships between positive problem solving orientation and self-reported outcomes among children with SCI: decreased depression and anxiety, increased QOL, an improved parent-child relationship and less pain. Longitudinal research is needed to understand the direction of these relationships, but problem solving may serve as a viable point of intervention for youth.

Financial Support: Shriners Hospitals for Children, #9143.

26. RESPIRATORY CONTROL AND BREATHING PATTERN IN TETRAPLEGIA ANTHONY DIMARCO LECTURESHIP

F. Dennis McCool^1,2

¹Memorial Hospital of Rhode Island, Pawtucket, RI, USA; ²Brown University, Providence, RI, USA

Summary: Respiratory failure is a common cause of morbidity and mortality in tetraplegia. Disordered pulmonary function due to respiratory muscle paralysis or to sympathetic denervation results in restrictive impairment and airway hyper reactivity, respectively. These restrictive and obstructive dysfunctions place elastic and resistive loads on the respiratory muscles. Typically these loads increase respiratory drive. However, in tetraplegia respiratory drive is reduced. The absence of afferent information from chest wall muscle spindles and tendon organs in patients with spinal cord injury may account, in part, for diminished respiratory drive. Methods used to assess respiratory control in tetraplegia include measuring the mouth occlusion pressure in 100 milliseconds (P0.1) or ventilatory (VE) responses to increasing levels of CO₂. In persons with tetraplegia, such tests have consistently demonstrated that the VE response to CO₂ is diminished when compared to controls. This blunted response has been attributed either to disordered chest wall mechanics or to reduced respiratory drive. However the observation that the P0.1 response to CO₂ is diminished in persons with tetraplegia but preserved in persons with other diseases having similar degrees of muscle weakness suggests that the blunted ventilation response to CO₂ is due to reduced respiratory drive and not altered chest wall mechanics. An alternate approach to assess respiratory control is to measure breathing patterns, namely, tidal volume, breathing frequency, and inspiratory and expiratory time, during quiet breathing. These parameters can then be used to assess respiratory timing (TI/TTOT) and motor output (VT/TI). When measured non-invasively from body surface displacements, these methods circumvent alterations in neural drive related to instrumentation with a mouthpiece or nose clips.

27. SAFE AND EFFECTIVE PREPARATION FOR COLONOSCOPIC EVALUATIONS IN INDIVIDUALS WITH SPINAL CORD INJURY

Jelena N. Svircev^1,2, Shawn Song², Jason A. Domintz^1,2, Stephen P. Burns^1,2

¹VA Puget Sound Health Care System, Seattle, WA, USA, ²Universtiy of Washington, Seattle, WA, USA

Objective: Bowel preparation prior to colonoscopic evaluation for individuals with spinal cord injury (SCI) using standard protocols often results in suboptimal colonic cleansing. There have been concerns about preparation-induced electrolyte abnormalities in this population. The objectives of this quality assurance project were to verify the safety and efficacy of a colonoscopy preparation protocol used by a SCI service.

Design: Retrospective chart review.

Participants/Methods: All SCI patients who underwent bowel preparation and colonoscopy over a 19-month period were included. Patients were placed on clear liquid diets beginning the evening 3 days prior to the colonoscopy and were made nothing per os (NPO) on the day of the procedure. One bottle (480 ml) of magnesium citrate was administered 3 days before the scheduled colonoscopy procedure. Four liters of polyethylene glycol-3350 and electrolyte colonic lavage solution (GoLYTELY) was administered orally over a 2 hour period in the morning 2 days before the procedure. This was repeated one day before the procedure. On the morning of the procedure, an additional 2 liters of GoLYTELY was administered. Routine bowel care continued during the preparation process; additionally, inpatients rectal digital stimulation performed by nursing staff as needed to facilitate complete evacuation following each bowel movement. Serum chemistry testing (calcium, magnesium, phosphorous, sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, and glucose) was performed before and after administration of 8 liters of preparation solution.

Results: Over 19 months, 60 patients underwent colonoscopic evaluations. The colonoscopy preparation was determined to be “excellent” (n = 24) or “good” (n = 24) in 80% of patients, and only 12% were rated as “poor.” No individuals experienced complications as a result of the colonoscopy preparation. Of 46 who had lab evaluation after 8 liters of GoLYTELY, the mean calcium decreased by 0.25 mg/dl and the mean phosphorous decreased by 0.45 mg/dl. Significantly abnormal low calcium and phosphorous were detected in one patient each. The two abnormalities were asymptomatic, did not require treatment, and only occurred in patients with abnormally low values prior to the preparation.

Conclusion: This colonoscopy preparation was demonstrated to be safe and effective for 60 patients with SCI reviewed in this quality assurance project. Significant electrolyte abnormalities do not commonly occur when this protocol is used.

28. SOMATOSENSORY STIMULATION WITH MASSED PRACTICE FOR IMPROVED MOTOR CONTROL

A. Almond¹, H. Schriver¹, S. Fetherolf¹, D.M. Basso²

¹The Ohio State University Wexner Medical Center, Columbus, OH, USA; ²The Ohio State University School of Health and Rehabilitation Sciences, Columbus, OH, USA

Objective: Individuals with spinal cord injuries (SCI) experience profound sensory and motor deficits associated with lesion level. Recently, somatosensory stimulation combined with massed practice improved arm and hand function after incomplete SCI in a research setting. Whether this intervention can be used clinically and for different types of SCI remains unknown. Therefore, the purpose of this case series was to determine if clinically applied somatosensory stimulation administered during massed practice will improve sensory and motor function in the upper extremities (UE) after incomplete tetraplegia and lower extremities (LE) after incomplete paraplegia.

Design: Three individuals with chronic incomplete SCI completed individualized somatosensory stimulation (SS) protocols using transcutaneous electrical nerve stimulation (TENS) at sub motor thresholds over the median nerve for the UE (n = 2) and over the common peroneal nerve for the LE (n = 1). Massed practice was based on functional tasks, which progressed in intensity and difficulty.

Participants/Methods: Case 1 UE, received SS 4 days/wk for 8 weeks, 2 days/wk with locomotor training (LT; 45 min) followed by UE massed practice (40 min), and 2 days/wk of SS with UE massed practice alone (60 min). Case 2 UE, had SS and UE massed practice (60 min) 5 days/wk for 4 weeks and then continued as a home program for 6 months. Case 3 LE had SS in combination with LT (60 min) then with LE massed practice (30 min) 5 days/wk for 12 weeks.

Results: Standardized sensory and motor outcome measures were selected for the impairments of each case. Sensory measures included protective, mechano- and thermal sensation, proprioception and reflexes. Motor measures included trunk and LE gross motor function, walking and balance function, as well as hand fine motor control. In Case 1 UE, impaired tactile sensation returned to near normal for most UE dermatomes and fine motor skills improved 29% (9-hole peg test) after treatment. In Case 2 UE, fine motor skills improved 32% and 19% (9-hole peg test) on the dominant and non-dominant hand, respectively. In Case 3 LE, over ground walking speed improved 97% (10MWT) and endurance improved 458% (6MWT).

Conclusion: This case series indicates that clinically applied somatosensory stimulation and massed practice improves sensory and motor function with or without locomotor training. We present beneficial effects on LE function for the first time.

29. SPINAL CORD INJURY WELLNESS; OUTCOMES OF A NURSE-COORDINATED CLINIC

Michelle Camicia^1,2, Hua Wang¹, Stephen Schmidt¹, Dougal MacKinnon¹, Georgina Thompson¹, Lynn Kostecki-Csanyi¹

¹Kaiser Foundation Rehabilitation Center, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, USA; ²The Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA

Objective: The Kaiser Foundation Rehabilitation Center (KFRC) provides a comprehensive interdisciplinary

Spinal Cord Injury (SCI) Wellness Clinic enhancing the continuum of care for individuals/families living with SCI. The Clinic is a Certified Registered Rehabilitation Nurse (CRRN) case managed clinic, which includes a pre-visit telephone assessment by a CRRN, a survey of self-reported quality of life (QOL), a multidisciplinary visit and telephone follow up. The team includes a CRRN Case Manager, physiatrist, physical therapist, occupational therapist, durable medical equipment specialist, and other providers as needed. We examined adherence to provider recommendations from the Spinal Cord Injury (SCI) Wellness Clinic, whether patients' goals for the SCI Clinic are attained, and if patients' QOL is improved after the clinic visit. We analyzed the barriers to adherence to recommendations.

Design: In this 18-month prospective study of patients' goals for the clinic, recommendations given at the clinic visit and followed through by patient and caregiver, QOL measures at baseline and 90-day. The study outcomes include the average of percentages of goal matched and recommendations followed, and the change of WHOQOL scores in QOL domains 90 days after SCI Wellness Clinic visit. Covariates: patient socio-demographics (age & sex), date of accident and level/severity of injury measured by the ASIA Scale.

Participants/Methods: A convenience sample of 35 consecutive patients age = 18 years treated in the SCI Wellness Program from 2013 to 2014. Crude associations of the study outcomes and explanatory variables were obtained and presented using corresponding bivariate statistics. Repeated mixed model was employed to study the effect of the SCI Wellness Clinic on improvement of QOL domains among patients with SCI controlling for baseline QOL measures and patient characteristics and injury measures. Barriers or causes for not following recommendations after the clinic visit were summarized. A significance level of .05 was set for all the analyses and SAS 9.13 was used for data analysis.

Results: There is a high level of follow-through by patients, though no change in self-reported quality of life. Stated reason for non-adherence are described.

Conclusions: The study provides evidence for the value of a comprehensive multidisciplinary annual wellness visit for individuals with SCI. Areas must be addressed to reduce barriers to completing recommendations.

30. SUSTAINED EFFICACY AND SAFETY OF REPEAT ONABOTULINUMTOXINA TREATMENT IN SPINAL CORD INJURY PATIENTS WITH NEUROGENIC DETRUSOR OVERACTIVITY

Michael Kennelly¹, Roger Dmochowski², Courtenay Moore³, Brenda Jenkins⁴, Yan Zheng⁵, Karen Ethans⁶

¹Carolinas Medical Center, Charlotte, NC, USA; ²Vanderbilt University Medical Center, Nashville, TN, USA; ³Cleveland Clinic Main Campus, Cleveland, OH, USA; ⁴Allergan, Inc., Irvine, CA, USA; ⁵Allergan, Inc., Bridgewater, NJ, USA; ⁶University of Manitoba, Winnipeg, MB, Canada

Objective: We present final results from the cohort of patients with spinal cord injury (SCI; N = 157) who received up to 4 years' treatment with onabotulinumtoxinA for urinary incontinence (UI) due to neurogenic detrusor over activity (NDO).

Design: Multicenter, 3-year extension study in urology/rehabilitation clinics or hospitals.

Participants and Methods: Patients who completed a 52-week, phase 3 study of onabotulinumtoxinA for NDO were eligible to enter a 3-year extension study; they could receive multiple onabotulinumtoxinA treatments (200U or 300U). Patients were treated ‘as needed’ based on their request and fulfillment of retreatment criteria. Assessments included mean change from baseline (week 6) in UI episodes/day (primary efficacy measure), volume/void, and Incontinence-Quality of Life (I-QOL) total summary score, proportions of patients with = 50%/100% reductions in UI episodes/day, duration of treatment effect, and adverse events (AEs). Data are presented by onabotulinumtoxinA treatment number (up to 5).

Results: Reductions in UI episodes/day were consistent following repeat onabotulinumtoxinA 200U treatment (–2.7, –2.6, –3.1, –3.0, –3.3; treatments 1–5). The proportion of patients achieving ≥50% and 100% reductions in UI episodes/day following 1 to 5 treatments (200U) ranged from 75–91% and 41–57%, respectively. Volume/void consistently increased; improvements in I-QOL total summary scores were consistently greater than the minimally important difference (+11 points; range: +18.0 to +21.4; treatments 1–5). Overall median duration of treatment effect was 34.7 weeks (200U). Efficacy results for 300U were similar. Most common AE was urinary tract infection; the AE profile for 300U was similar to 200U in this subpopulation.

Conclusion: Over 4 years, repeat onabotulinumtoxinA treatment provided consistent improvement in UI and QOL in SCI patients with UI due to NDO, with no new safety signals.

Financial Support: Allergan, Inc.

31. THE EFFECT OF COMPLICATIONS AND PREVAILING CARE PRACTICES ON QUALITY OF LIFE OF PATIENTS WITH TRAUMATIC SCI

Teenu Xavier¹, Ashia Qureshi², Dr. Ashima Nehra¹, Dr. Sumit Sinha¹

¹All India Institute of Medical Sciences, New Delhi, India; ²College of Nursing, All India Institute of Medical Sciences, New Delhi, India

Objective: To assess the effect of complications and prevailing care practices on quality of life (QOL) of patients with traumatic spinal cord injury (SCI) with a view to develop a teaching module for the patients and the care providers.

Design: Descriptive cross sectional survey

Participants/methods: Sixty persons with SCI were surveyed for medical problems and care practices followed using self-administered questionnaire. QOL was assessed using WHO QOL BREF scale.

Results: Forty-six (76.7%) men and 14 (23.3%) women participated. Mean age was 34.78 ± 8.89. 40% of the subjects reported that their quality of life was neither good nor poor, 33% reported of having good quality of life and 27% reported poor quality of life. ASIA score and type of injury had a significant association with QOL score (P < 0.05). Seventy-five percent of subjects reported bladder problems, 81.7% had bowel problems, and 71.7% reported spasticity and 58.3% reported bedsores. Respiratory problems were reported by 50% of the subjects. 48.3% of the subjects had increased sweating and 43.3% had pain. Bladder problems, bedsores, increased sweating, spasticity, bowel problems and pain had a significant effect on QOL score (P < 0.05). 70% of the subjects had poor care practices while 30 % had average care practices. A positive correlation was found between physical domain and environmental domain of QOL with integumentary and genitourinary domain of care practices (P < 0.05).

Conclusion: Complications and care practices by patients/care providers affect the quality of life of traumatic spinal cord injured patients. Education of patients/care providers can positively affect their attitude towards life that results in behavioral modification. Thus development of education material for these patients and their care providers will go a long way to help them to cope with the disease condition and to improve their care practices, thus prevent further complications.

32. THE PSYCHOLOGICAL IMPACT OF CONSTRUING A SPINAL CORD INJURY AS A KEY LIFE EVENT

Kimberley R. Monden¹, Adriel Boals², Zina Trost², Rita Hamilton³

¹Baylor University Medical Center, Department of Surgery, Dallas, TX, USA; ²University of North Texas, Department of Psychology, Denton, TX, USA; ³Baylor Institute for Rehabilitation, Dallas, TX, USA

Objective: to examine the role of event centrality in the psychological recovery from spinal cord injury (SCI).

Background: Individuals who sustain a SCI not only have to cope with the physical pain of the injury, but also the psychological consequences of the disability. Individuals who sustain a SCI can experience numerous associated and chronic conditions (e.g. spasticity, heart disease) and secondary complications (e.g. depression, pressure sores, and chronic pain). To improve outcome trajectories, there is growing interest in psychosocial variables that have been shown to impact physical and psychological recovery following SCI.

Research has revealed that one of the strongest associates of adverse psychological outcomes is event centrality. Event centrality refers to the extent to which the individual perceives the traumatic event as a central aspect of their identity and life story. To date, event centrality has mostly been explored in relation to psychological traumas. The current study is the first to examine event centrality in patients with SCI.

Participants: A total of 47 patients who acquired a traumatic or non-traumatic SCI were recruited from an inpatient rehabilitation setting. The sample comprised 31 (66%) males and 16 (34%) females with an average age of 49 years. Twenty-six (55%) participants sustained a cervical injury and 18 (38%) sustained an injury at or below the thoracic level (three are unknown). The average length of hospitalization was 46 days.

Methods: Participants completed a packet of questionnaires related to their physical and psychological well-being within two weeks of hospital admittance. The results revealed the average score for event centrality was at the mid-point of the scale (m = 19.6 on a scale that ranges 5–35). The distribution of event centrality scores resembles a classic bell-shaped curve, indicating identity large level of variability. Scores on event centrality were significantly related to PTSD symptoms (r = 0.31, P < 0.05), feelings of injustice (r = 0.50, P < 0.001), and expectations of disability (r = 0.43, P < 0.01). These results suggest that patients who experienced a spinal cord injury often construe the injury as a core part of their identity. Further, the extent to which patients make this type of construal is related to adverse psychological outcomes. Understanding coping strategies among individuals with SCI is critical to our ability to help patients recover both physically and psychologically.

33. THE RELATIONSHIP BETWEEN WHEELCHAIR TRANSFER QUALITY AND SHOULDER PATHOLOGY IS MEDIATED BY BODY-WEIGHT IN PEOPLE WITH SPINAL CORD INJURIES

Nathan S. Hogaboom^1,2, Lynn A. Worobey^1,3,4, Michael Boninger^1,3

¹Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; ²Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA, USA; ³Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA; ⁴Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA

Objective: Wheelchair users with spinal cord injury (SCI) have a higher risk of shoulder pain, which limits quality of life and independence; this study's purpose was to evaluate how transfer technique affects shoulder pathology in wheelchair users with SCI. Transfer quality, measured using the Transfer Assessment Instrument (TAI), was hypothesized to correlate with shoulder pathology, and assessed with the Ultrasound Shoulder Pathology Rating Scale (USPRS). Further, this relationship would be mediated by participants' weights.

Design: This cross-sectional study was conducted in a research laboratory, and at local and national Veterans' wheelchair athletic events. The TAI is a measure of transfer skills; higher scores indicate better transfer quality and theoretically may reduce risk of injury. The USPRS contains a series of graded ultrasonographic signs for shoulder pathology; higher scores indicate more pathology.

Methods: Wheelchair users with non-progressive SCI provided informed consent prior to participating. They were over 18 years of age and able to independently transfer to and from a surface within 30 seconds without using their leg muscles. Demographics were collected via questionnaire, and weight with a scale. A physician graded the USPRS and a physical therapist evaluated subjects' transfers with the TAI. Multiple-linear regression tested how TAI score, weight, and their interaction affected USPRS score.

Results: Sixty-nine individuals participated (19 with tetraplegia, 50 with paraplegia; weight: 82.4 ± 19.2 kg; age: 46.3 ± 12.6 years; injury duration: 15.9 ± 11.1 years). Higher transfer quality was related to less pathology (ß = –0.355, P < 0.01). A significant interaction (P < 0.05) indicated those with worse transfer quality had more pathology regardless of weight, whereas those with low weight and better transfers had the least pathology.

Conclusion: Findings suggest transfer quality can affect the development of shoulder musculoskeletal pathology. Incorporating transfer skills that reduce loading and safely position the shoulder, while reducing body weight, may act together to prevent injury more effectively than either in isolation. Further testing is needed to determine how transfer skill training affects the progression of pathology.

Financial Support: National Institute on Disability and Rehabilitation Research, U.S. Department of Education (H133N110011). National Science Foundation Graduate Research Fellowship (#1247842). The contents of this paper do not represent the views of the Department of Veterans Affairs, NSF, or U.S. Government.

34. UTILIZATION AND ACCESS TO HEALTH CARE SERVICES AMONG PEOPLE LIVING WITH SPINAL CORD INJURIES IN THE COMMUNITY

Rita G. Hamilton^1,2, Shayan Noorani³, Librada Callender¹, Samantha Cleveland¹, Simon Driver¹, Kimberly Monden²

¹Baylor Institute for Rehabilitation, Dallas, TX, USA; ²Baylor University Medical Center, Dallas, TX, USA; ³University of North Texas Health Science Center, Fort Worth, TX, USA

Objective: To describe the utilization, accessibility, and satisfaction of primary and preventative health-care services of community-dwelling individuals with spinal cord injury (SCI). Healthcare for individuals following SCI plays a significant and necessary role in reducing an individual's risk of managing and preventing associated, secondary, or chronic conditions. Barriers alongside secondary, associated, and chronic issues prevent a viable access to healthcare. Some of these factors include age, income, race, medical insurance type, accessible resources, skill and knowledge of primary care physician and spinal cord injury/rehab physician, ER visits, preventative health measures, community, and psychological issues.

Design: A cross sectional study design with a survey designed specifically for the project.

Participants/methods: The population sampled included 142 total patients whereby 100 completed the survey during a routine outpatient visit and 42 completed the survey telephonically.

Results: 99% of individuals in the current sample reported that they had healthcare visits in the past 12 months. Results of the current project also indicated that PCPs (79%) were the most frequently visited physicians, followed by SCI/rehab physicians (77%) and urologists (50%). Individuals with SCI also had a high number of ED visits (43% of sample within the past 12 months). The primary reasons for ED visits for them current sample were genital/urological (15%), wounds/skin problems (5%), and pneumonia (4%). Of note, individuals who visited the ER had a lower Geo Unit Quality Score and were less likely to have a post-secondary education.

Conclusion: For preventative health services, patients with SCI also reported similar utilization to previous SCI research and data from the general population. Accessibility was not a major issue, and the majority were satisfied with their physicians. Consequently, improved accessibility for individuals with disabilities should be considered and other barriers should be ameliorated throughout the healthcare industry. Further research and analysis on socio-demographic factors such as transportation, work-related issues, quality of life, needs for better healthcare, and psychological factors can assist in learning more about the needs of individuals with SCI.

35. VIRTUAL MULTI-INSTITUTIONAL INTERPROFESSIONAL SUICIDAL SIMULATION IN SPINAL CORD INJURY

Donna Fine¹, Janet Sprehe^2,3, Stephen Burns¹, Henry S. Park²

¹Seattle VA Hospital, Seattle, WA, USA; ²Tampa VA Hospital, Tampa, FL, USA; ³University of South Florida, Tampa, FL, USA

Objective: To demonstrate a live video-conferencing (Vtel) training technology in suicidal ideation with patients with spinal cord injury (SCI).

Design: Convenience sample among 2 large VA teaching hospitals across the country

Participants/Methods: Planning committees at each institution reviewed their experience with actual suicidal patients to design thought-provoking case scenarios. Each institution scripted clinical challenges with multiple clinical observations with opportunities for staff response. A standardized patient with SCI presented to the clinic in a wheelchair demanding more pain medication. Clinician assessment roles include a nurse who greets the patients and takes a brief history, discovers the suicidal ideation and reports it to the provider. This nurse is challenged to maintain rapport with the patient and elicit answers to critical questions specified by the facility suicide protocol. The provider further assesses the risk level for suicide and implements an appropriate treatment plan. In scenario two,a desperate phone call is made to the Veterans Crisis Line by an intoxicated caller with SCI. The scenario is a large room split to include a make-shift call center and a standardized patient in her living room. Video transmission includes the telephone communications as well as facial expressions and gestures of those communicating. Clinical assessment concentrates on suicide prevention tools and is evaluated for several critical elements.

Results: Two simulation challenges were performed with inter-institutional Vtel connection. Attendees included police, medical, nursing, social work, psychology, and chaplain service staff. A narrator introduced the scenarios, reviewed the objectives and established the setting for each clinical experience. Likert scale pre/post testing demonstrated a 56% greater knowledge of the steps and techniques for appropriate suicide interventions from the event. These case scenarios allow clinicians to concentrate on fictitious presented situations and experience less anxiety enabling self-reflection and learning thereby becoming more expert in handling veterans with SCI and suicidal ideations.

Conclusions: Simulation training utilizing video conferencing (Vtel) provides positive training outcomes.

36. WHO DOES AND DOES NOT RECEIVE ACUTE SURGERY FOR TRAUMATIC SPINAL CORD INJURY IN CANADA?

Carly S. Rivers¹, Vanessa K. Noonan², Brian Drew³, Michael G. Fehlings⁴, Jérôme Paquet⁵, Henry Ahn⁶, Najmedden Attabib⁷, Christopher S. Bailey⁸, Sean D. Christie⁹, Joel Finkelstein¹⁰, Daryl R. Fourney¹¹, R. John Hurlbert¹², Brian K. Kwon², Stefan Parent¹³, Eve C. Tsai¹⁴, Tian Shen¹, Marcel Dvorak¹⁵

¹Rick Hansen Institute, Vancouver, BC, Canada; ²University of British Columbia, Vancouver, BC, Canada; ³McMaster University, Hamilton, ON, Canada; ⁴Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, ON, Canada; ⁵Laval University, Quebec City, PQ, Canada; ⁶St. Michael's Hospital, University of Toronto Spine Program, Toronto, ON, Canada; ⁷Dalhousie University, St John, NB, Canada; ⁸Western University, London, ON, Canada; ⁹Dalhousie University, Halifax, NS, Canada; ¹⁰University of Toronto, Toronto, ON, Canada; ¹¹University of Saskatchewan, Saskatoon, SK, Canada; ¹²University of Calgary Spine Program, Calgary, AB, Canada; ¹³Université de Montréal, Montréal, PQ, Canada; ¹⁴The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; ¹⁵VGH, Division of Spine, Department of Orthopedics, UBC, Vancouver, BC, Canada

Background: Despite an increasing trend towards surgical intervention for traumatic spinal cord injury (tSCI), there is a lack of published data on surgical rates and the benefit of surgical vs non-surgical management. We describe current surgical practice for tSCI in Canada, including differences in patient characteristics in those receiving surgical vs non-surgical management.

Design: Prospective cohort study.

Methods: Consenting tSCI patients with complete records from the Rick Hansen Spinal Cord Injury Registry (RHSCIR), prospectively recruited from 2004–2014 from 18 Canadian acute specialized spine care centres were studied. Data on patient characteristics (e.g. age, comorbidities, neurology) were analyzed using χ²/Wilcoxon rank tests (means/% reported).

Results: The analysis cohort included 1787 participants; 1506 (84.3%) had surgery. Compared to those who had acute surgery, those not receiving surgery were older (52 vs 45y, P < 0.0001), more likely male (83.3 vs 78.0%, P = 0.0478), had more comorbidities (one/more 37.5 vs 27.4%, P = 0.0036), took longer to reach acute care post-injury (22.7 vs 13.2h, P < 0.0001), were injured by a fall (51.3 vs 40.9%, P = 0.0016), were more likely to have a high cervical (C1–C4) injury (45.1 vs 27.6%, P < 0.0001), and more likely to have a less severe injury (ISNCSCI ASIA Impairment Scale (AIS) C/D 78.2 vs 45.9%, P < 0.0001). Patients with a stable spine were less likely to have surgery (65.4 vs 93.1%, P < 0.0001). Surgery rates in Canada were high compared to published US data (cervical 83.5 vs 50.4%, thoracolumbar 96.6 vs 61.4%) and remained steady between 2004–2014.

Conclusions: Older participants and those with stable cervical AIS C/D injuries ('central cord') take longer to reach acute care, are less likely to receive acute surgery, and have surgery later when operated on, however it is unclear if this optimizes outcomes. Global surgery rates for tSCI are unknown, as are reasons for differences in US/Canadian surgery rates. Future investigation will concentrate on comparative outcomes for acute surgical vs non-surgical outcomes to provide evidence on optimal care to inform best practice.

Financial Support: The Rick Hansen Spinal Cord Injury Registry and this work are supported by funding from the Rick Hansen Institute, Health Canada, Western Economic Diversification Canada, and the Governments of Alberta, British Columbia, and Ontario.

37. YEARS OF LIFE LOST AFTER NON-TRAUMATIC SPINAL CORD INJURY: AN ESTIMATE OF SURVIVAL

Bryndon Hatch, Christina M Wood-Wentz, Terry M Therneau, Ronald Reeves

Mayo Clinic, Rochester, MN, USA

Design: Retrospective Cohort Study

Introduction/Objective: Non-traumatic spinal cord injury (NT SCI) compromises a significant proportion of all causes of SCI. The goal of this retrospective study is to estimate years of life lost due to traumatic SCI (TSCI) and subtypes of NT SCI.

Methods: Medical record and Social Security Death Index review for 759 participants with SCI (535 NT SCI, 221 TSCI) discharged from inpatient rehabilitation between January 1, 1995 through December 31, 2003, was conducted to estimate number of years of life lost following NT SCI. Relative survival analysis compared subtypes of NT SCI with an age-matched cohort without SCI to estimate years of life lost in the subsequent 10 years following NT SCI.

Results: Median follow up time was 11.4 years. 58% had paraparesis/paraplegia; 11% had complete injuries; 64% were male; median length of stay was 16 days (IQR 9, 28) days. All-cause NT SCI decreased 10 year life expectancy by 1.81 years (Mean 6.78 years, SE 0.17, Matched Cohort 8.59 years), compared to traumatic at 0.71 years (8.49, 0.21, 9.20). Spinal cord metastases (1.59, 0.36, 8.84), intramedullary tumors (8.00, 0.47, 9.48), extra medullary tumors (6.71, 0.58, 8.64), ischemia (5.46, 0.79, 8.39), musculoskeletal (7.61, 0.23, 8.21), infection (6.90, 0.67, 8.72), inflammatory (8.32, 0.75, 9.20), and other types of NT SCI (7.02, 0.67, 8.79) were associated with a significant increase in years of life lost. Arteriovenous malformations ((AVM); 8.02, 0.56, 8.33) were not significantly associated with years of life lost.

Conclusions: All-cause NT SCI was associated with an estimated 1.81 years of life lost in relative 10 year survival following SCI, 2.5 times higher than TSCI. Spinal cord metastases had the largest decrease in years of life lost. Extra medullary tumors interestingly had a poorer relative survival (1.93 yrs lost) compared to intramedullary tumors (1.48 yrs lost). Ischemia, degenerative disease, infection, inflammatory, and other types of NT SCI decreasing years of life lost compared to age-matched controls. AVMs did not have significant impact on relative 10-year survival.