P1. ACCESSIBILITY AND ACCOMMODATION OF WHEELCHAIR-RELIANT INDIVIDUALS IN COMMUNITY FITNESS FACILITIES NEAR HATTIESBURG, MISSISSIPPI
David R. Dolbow1, Stephen F. Figoni2
1University of Southern Mississippi, Hattiesburg, MI, USA; 2VA Long Beach Healthcare, Long Beach, CA, USA
Objective: To determine the level of compliance with Americans with Disability Act (ADA) of 1990 and accommodation of wheelchair-reliant individuals with paralytic conditions such as SCI, multiple sclerosis, or stroke in community fitness facilities in the Hattiesburg, Mississippi metropolitan area.
Design: Survey
Participants/Methods: Ten of 14 facilities were evaluated with an 82-item checklist covering accessibility of the building and adequacy of adaptive equipment and staff training. Percentage of facilities that were fully compliant/accommodating in 12 areas were computed.
Results: No facilities were fully ADA compliant and accommodating. The most severe barriers included inadequate spacing (>36 in.) between/around equipment (0% facilities) and lack of specialized training/certification of staff to work with clients with physical disabilities (0% of facilities). 20% of facilities had fully accessible restrooms with adequate toilet stall dimensions (<60 in. x 59 in.), mirror placement (<40 in. from floor) for wheelchair users, and adequate leg clearance under sinks. Adapted exercise equipment such as stabilization straps, wrist cuffs, arm or arm + leg cycles, electrical stimulation leg cycles, swimming pool ramps/lifts, and a quiet room were available in only 20% of facilities. 50% of facilities lacked a customer service desk with ≥36 in. from floor and entrance/doors without grasp handles and manual opening. Drinking fountains (adequate knee clearance for wheelchair users), paths of travel to rooms (≥36 in. wide without obstructions), and properly graded ramps were available in 60–70% of facilities. Accessible parking and elevators existed in 80% and 100% of facilities, respectively.
Conclusion: ADA compliance and accommodation of community fitness facilities in the Hattiesburg, Mississippi metro area were found to have room for improvement, especially lack of staff training regarding disabilities, restrooms, and passageways between rooms and pieces of exercise equipment. ADA noncompliance and architectural and programmatic barriers in community fitness facilities persist and impede community reintegration and opportunities for persons with SCI/D to exercise and be physically active and healthy.
P2. ACTIVITY-BASED THERAPY PRINCIPLES WITH HARNESS TRAINING DURING INPATIENT REHABILITATION
Michele McAuliffe, Katherine Young
Kessler Institute for Rehabilitation, West Orange, NJ, USA
Introduction: According to the National SCI database, 66% of new spinal cord injuries are incomplete tetraplegia or paraplegia. According to the current clinical practice guidelines, the likelihood of community ambulation following traumatic spinal cord injury classified as AIS C is 75% and AIS D is 90%. Acute inpatient rehabilitation is a critical step in the recovery process for successful ambulation with individuals with incomplete SCI.
Background: Activity-based therapy (ABT) has been defined as “interventions that target activation of the neuromuscular system below the level of the lesion, with the goal of retraining the nervous system to recover a specific motor task”. Neurorestorative benefits, improvements in strength and bone density as well and more “clinically meaningful outcomes” have been found with use of ABT. Use of a harness system incorporates balance, proprioception, weight bearing, closed chain strengthening, pelvic stability and improved posture at an earlier stage of recovery while promoting therapist assessment and ensuring the safety of patients and therapists in a cost effective manner. This decreases the need for assistive devices, which can encourage compensatory postures and gait deviations. At Kessler Institute of Rehabilitation, ABT principles are utilized in our inpatient spinal cord injury program to promote neurological recovery, reduce compensations and develop a foundation for return to function, including ambulation.
Case report: A case study of an 18-year-old male with T12 AIS-D demonstrates the positive effects of ABT coupled with overhead harness training.
Findings: Participation in this ABT program assisted him in reaching his goals of functional independence upon discharge. Noted improvements include change in FIM scores, patient self-report, and qualitative and quantitative improvements including manual muscle testing. ABT interventions were used to challenge him through prolonged lower extremity weight bearing, closed chain strengthening, proper facilitation and prompting pelvic stability.
Conclusion: This patient reached his goal of addressing his specific impairments and transitioning from inpatient rehabilitation to higher intensity gait training and return to the community.
P3. CARDIOVASCULAR CHARACTERISTICS OF SCI/D OUTPATIENTS REFERRED TO A WELLNESS EXERCISE PROGRAM
Stephen F. Figoni, Lily K. Chen
VA Long Beach Healthcare System, Long Beach, CA, USA
Objective: To describe characteristics and prevalence of comorbidities and risk factors for cardiovascular disease (CVD) among outpatients referred to a Kinesiotherapy wellness exercise program for Veterans with SCI/D.
Design: Retrospective cross-sectional analysis of electronic medical records.
Methods: N = 178 consecutive adult SCI/D outpatients referred for wellness exercise at a large rehabilitation center for Veterans.
Results: Descriptive statistics: male 94%; median age 66 yr; ”race”: white 54%, black 29%, non-white Hispanic 14%; mean height 70 in., mean body mass 195 lb.; etiology: SCI 85%, multiple sclerosis 13%; SCI levels: cervical 59%; ASIA Impairment Scale D 49%; median duration of SCI/D 16 yr. Comorbidities: chronic pain 48% (shoulder 15%), CVD 26%, stage III-IV chronic renal insufficiency 8%, depression 22%, dementia 12%, psychosis 12%, history of substance abuse 11%, post-traumatic stress disorder 8%. CV risk factors: advanced age 91%, dyslipidemia 72%, obesity (body mass index ≥25%) 67%, hypertension 62%, prediabetes/diabetes 46%, smoking 13%. Median 10-yr ACC/AHA CVD risk estimate 14% (optimal risk 7.5%) (n = 142). Eight (4.5%) patients died within 1 yr of referral (non-exercise-related). No patients received an exercise tolerance test to guide exercise prescription or had formal cardiac rehabilitation. All intended to become more physically active through exercise.
Conclusion: This population was predominately older males with long-standing tetraparesis. One-quarter had diagnosed CVD and most had ≥3 CVD risk factors and 2x optimal 10-yr CVD risk, supporting the need for close evaluation and intervention. The high prevalence of CVD risk factors and secondary health conditions in this population strongly suggests (a) the presence of potential barriers to safe exercise and physical activity and (b) the need for systematic CVD risk factor stratification/management, multidisciplinary wellness programming for metabolic syndrome, medically supervised exercise testing; exercise, nutritional, and behavioral counseling; and preventative and therapeutic cardiopulmonary and inclusive fitness programs. The high incidence of mental illness may hinder behavioral changes necessary for a healthy lifestyle.
P4. DEPRESSION, DISABILITY APPRAISALS, & SATISFACTION WITH LIFE AFTER SPINAL CORD INJURY
Herb Ames1,2, Becca Martin1,2, Tom Anderson1,2, Sally Ann Holmes1,2
1Michael E. DeBakey VA Medical Center, Houston, TX, USA; 2Baylor College of Medicine, Houston, TX, USA
Objective: Psychological distress negatively impacts life satisfaction. Our clinical experience is that a segment of Veterans with SCI deny distress and psychosocial concerns yet show low Satisfaction with Life Scale scores (SWLS; Diener et al., 1985); they often make atypical comments when reading item 5. Vautier et al. (2004) suggested the semantic structure of the SWLS's last two items, which relate to the past, may explain studies finding a poor uni-dimensional scale fit. Geyh et al. (2010) suggested the SWLS's first items relate to present satisfaction, while the last two items may connect to grief/regret. We hypothesized that the historic evaluative nature of items 4 & 5 may lend to differential association with depression. We also hypothesized that past-focused SWLS items, alluding to the impact of loss, may lend to differential association with disability appraisals.
Design: Chart Review.
Participants/Methods: 137 (96.4% male) Veterans seen for SCI annual evaluation. Mean age was 56.9 years (SD = 12.5) and mean time since injury was 17.9 years (SD = 12.5). Level of injury was divided into Paraplegia (AIS A, B, or C; 36.5%), Tetraplegia (AIS A, B, or C; 24.8%), and AIS D (35.0%). Veterans completed depression, PTSD, and anxiety screens, the Appraisals of Disability: Primary & Secondary Scale short form (ADAPSS-sf; two factors—Catastrophic Negativity, CN, & Determined Resilience, DR), and the SWLS. The SWLS was broken into “present” (three items) and “past” components (two items). Data were analyzed using bivariate Pearson r and spearman rho correlations to determine relationships between SWLS components and demographics, ADAPSS-sf, depression, anxiety, PTSD, and injury characteristics. Variables significantly related to outcomes were entered into a linear regression model for each SWLS component.
Results: Correlations revealed both SWLS components were related to depression, anxiety, PTSD, ADAPSS-sf factor scores, and level of injury (P < 0.005). Of note, the correlation of depression scores with the present component was r =0.55, P < 0.001 and r = 0.45, P < 0.001 with the past component. Follow-up regression revealed ADAPSS-sf factors predicted present and past SWLS components over and above depression and other variables [F(7,81) = 23.9, P < 0.0001; R2 = 0.540)] and [F(7,81) = 22.0, P < 0.0001; R2 = 0.458)].
Conclusion: While distress is associated with life satisfaction after SCI, depression in particular is not differentially associated with past versus present-focused SWLS items. Disability appraisals predict both past and present-focused SWLS items over and above other variables.
P5. DOCUMENTATION OF WEIGHT MANAGEMENT PRACTICES IN SPINAL CORD INJURY/DISORDERS
Sara M. Locatelli1,2, Sherri L. LaVela1,2,3
1Spinal 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 Healthcare Studies, Institute for Public Health and Medicine, General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
Objective: Individuals with spinal cord injuries/disorders (SCI/D) are frequently overweight/obese, increasing risk for negative health consequences and challenged mobility. This study was conducted to understand weight management (WM) services being offered Veterans with SCI/D.
Design: Veterans Affairs facilities delivering SCI healthcare. Chart reviews conducted over a 12-month period (November 1, 2012–October 31, 2013).
Methods: Veterans with SCI/D seen in the previous 12 months at a VASCI facility. Chart reviews conducted to extract 1) need for WM (e.g. ICD-9 diagnosis, body mass index (BMI)), 2) referrals, treatment, and WM follow-up, and 3) progress notes from most recent annual evaluation. Descriptive statistics conducted on quantitative data; summaries of weight-related discussions documented in charts analyzed using qualitative content analysis.
Results: 111 charts were reviewed; 11 were excluded because the individual died during the study period (n = 9) or no evidence of SCI/D was found in chart (n = 2). Participants were predominantly male (95%), Caucasian (68%), with paraplegia (52%); 42% had complete injuries. 73% of Veterans with SCI/D demonstrated a need for WM (elevated BMI 61%, 2+ weight-related conditions 40%, ICD-9 overweight/obesity diagnosis 26%, description of overweight by provider 17%, or patient-declared interest in WM 8%). 75% had progress notes on a recent annual evaluation; 92% received cardiovascular assessment, 87% psychosocial assessment, 81% rehabilitation assessment, but only 52% nutritional assessment. Weight, if addressed, was mostly discussed during the nutritional assessment versus other assessments. 57% received WM education during outpatient visits. 25% had at least one inpatient stay. Weight-related discussions during inpatient encounters involved reasons for selecting a particular inpatient diet, targeting irrational beliefs about WM, and setting general WM goals with the Veteran (n = 2, 8.0%), or specific goals about nutrition (n = 4, 16.0%), physical activity (n = 4, 16.0%), or weight loss (n = 1, 4.0%).
Conclusions: Weight was infrequently discussed with patients during outpatient visits, inpatient stays, and annual evaluations. Nutrition assessments, where weight was often addressed, were frequently skipped. Additional support is needed to ensure Veterans with SCI/D receive a nutrition assessment, and to help SCI providers incorporate WM information into care.
Financial Support: Research funded by the Department of Veterans Affairs Health Services Research & Development Quality Enhancement Research Initiative (QLP 97-006, PI: LaVela, Co-PI: Locatelli).
P6. EFFECT OF IMPLANTED NEUROPROSTHESIS ON WALKING DISTANCE AND SPEED
Lisa M. Lombardo, Kevin M. Foglyano, Stephanie Nogan Bailey, John R. Schnellenberger, Rudi Kobetic
Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
Background: Approximately 273,000 individuals in the United States are living with spinal cord injury (SCI) with increasing numbers of incomplete SCI (iSCI). Reciprocal ambulation is a high priority for these individuals. Functional electrical stimulation (FES) triggered by a heel-switch has been used to correct for foot-drop in hemiplegic patients. Activation of hip flexors, extensors and ankle plantar flexors, the power generators for forward propulsion, may be necessary to increase walking speed beyond the gain achievable by merely correcting foot-drop. This case study investigated the effect of an implanted neuroprosthesis to stimulate hip flexors in addition to ankle dorsiflexors on walking speed and distance.
Methods: Subject was a 27-year-old male who sustained a C6 iSCI AIS C, with significant lower extremity, upper extremity and trunk weakness. Informed consent was obtained prior to installation of an 8-channel implanted stimulator. Electrodes were implanted bilaterally to improve hip flexion, ankle dorsiflexion and knee extension at terminal swing. Gait speed and distance were measured during six-minute walk tests (6MWT) at baseline, discharge and one-year follow-up to evaluate the effect of stimulation on ambulation. Speed was also measured during 10-meter (10m) walk tests. The neurotherapeutic effects were assessed by comparing volitional walking pre- and post-training. The neuroprosthetic effects were assessed by comparing post-training volitional with FES-assisted walking.
Results: A neurotherapeutic effect of training with FES was shown with statistically significant (P = 0.006) increases of 155% in walking distance during the 6MWT when comparing baseline volitional to volitional and FES-assisted at discharge and follow-up. Similarly, there was an increase in speed of 93% (P ≤ 0.003) during the 6MWT. With training, there was a significant increase in speed (P ≤ 0.008) during the 10-m walk test from volitional baseline to volitional discharge (39%) and follow-up (62%). A neuroprosthetic effect was not detected, as there was no difference between volitional walking and FES-assisted walking at discharge and follow-up. However, with FES-assisted walking his maximum walk distance was 27% further.
Conclusion: When training with FES-assisted walking there were significant improvements in volitional ambulation in both speed and distance. While there was no difference between volitional and FES-assisted walking at discharge and follow-up, this subject was able to continue walking farther with stimulation.
P7. EFFECTIVENESS OF OCCUPATIONAL THERAPY AND FES CYCLING IN AN INDIVIDUAL WITH CHRONIC C4–C5 INCOMPLETE TETRAPLEGIA
Pollie Price
University of Utah, Salt Lake City, UT, USA
Learning Objective: Participants will become more aware of the potential contribution of a protocol of FES cycling, repetitive task training and Occupational Therapy on UE function in this population.
Design: This is a single case report, where data were analyzed retrospectively, to be reported as a clinical study. The design was a pre-post design using quantitative measures and analyzed with descriptive statistics.
Participants/Methods: Client was a 30-year-old male 2.5 years post incomplete C4–C5 SCI. Data were collected pre and post intervention utilizing the Capabilities of Upper Extremity Instrument (CUE), Manual Muscle Test (MMT) and the Jebsen Taylor Hand Function Test (JTHFT). Following a comprehensive Occupational Therapy assessment, including establishing baseline of BUE function, and establishment of client-centered goals, the FES training protocol and task training was established as an independent therapeutic exercise program to address primarily LUE function. The client was assisted daily to access the equipment in the outpatient rehabilitation gym by a rehabilitation aide. The intervention protocol was conducted for 21 days over a 4-week period and included 45 minutes of UE FES *, followed by 20–30 minutes of repetitive functional task training. In addition, the client was seen for skilled Occupational Therapy twice a week for 4 weeks (9 one hour sessions), which included assessment and modification of the FES protocol and task training, neuromuscular re-education and facilitation of normal movement patterns in tasks important to the client.
Results: At the conclusion of the intervention, UE function was re-assessed. CUE improvements noted in 15 of 17 sub-items (6 LUE, 9 RUE). MMT improvements measured in left shoulder extension, internal rotation, elbow flexion and extension by 0.5 grade. Left pronation improved in strength by 2 muscle grades and wrist extension by 1 muscle grade. The JTHFT demonstrated significant improvements in all subsets with LUE and 5/7 Subsets with the RUE. Although the RUE was not the target of intervention, clinically significant improvements were noted.
Conclusion: FES cycling followed by repetitive task training coupled with Occupational Therapy produced clinically significant improvements in bilateral upper extremity function. Client reported using his LUE more often with improved control in desired activities upon follow-up.
*Restorative Therapies RT300
P8. EVALUATING THE SPINAL CORD INJURY PRESSURE ULCER MONITORING TOOL IMPLEMENTATION
Marylou Guihan1,2,3, Barbara Bates-Jensen1,4, Jennifer Hill1, Hira Khan1, Susan Thomason5, Gail Powell-Cope5,6
1Spinal Cord Injury QUERI, Hines, IL, USA; 2CINCCH, Hines, IL, USA; 3Northwestern University, Chicago, IL, USA; 4UCLA School of Nursing, Los Angeles, CA, USA; 5HSR&D CINDRR, Tampa, FL, USA; 6USF College of Nursing, Tampa, FL, USA
Background: Pressure ulcers (PrUs) are a significant source of morbidity, mortality, and diminished quality of life of Veterans with spinal cord injury (SCI) and treatment is expensive (>$100,000 annually). The SCI Pressure Ulcer Monitoring Tool (SCI-PUMT) is a reliable tool for evaluating PrUs in Veterans with SCI. A multi-faceted strategy (national train-the-trainer conference, toolkit and 12 monthly facilitation calls) was used to implement the SCI-PUMT in VA. One year later, a survey indicated that only about half of 24 VA SCI centers were consistently using the SCI-PUMT.
Objective: To evaluate the SCI-PUMT implementation to identify barriers/facilitators and best practices for a future study to promote its full implementation at all VA SCI Centers.
Design: Mixed methods were used to evaluate SCI-PUMT implementation at high (n = 3), moderate (n = 2), and low (n = 2) adopting SCI centers (n = 7 total).
Participants/methods: Semi-structured interviews with VA wound care clinicians (n = 49) obtained information on the wound care process and barriers/facilitators to SCI-PUMT use. Interviews were transcribed and coded using the Consolidated Framework for Implementation Research (CFIR). Completion of the SCI-PUMT assessment was examined using medical record reviews for a random sample (n = 137) of Veterans admitted to the 7 SCI centers for PrUs from January–September 2013.
Results: Inner setting characteristics were cited as barriers (e.g. time/staffing constraints, training, leadership) as well as facilitators (e.g. presence of an experienced/dedicated interdisciplinary wound care team, strong staff/leadership support). Documentation (inner setting) was reported as a facilitator because it provided a common language and as a barrier because some facilities were documenting PrUs in up to three different places. Chart reviews identified 72 unique Veterans with 206 PrUs (mean = 2.9 ulcers/Veteran); only a quarter had a weekly SCI-PUMT score documented. More severe PrUs (stage III–IV) were twice as likely to be documented than less severe PrUs (Stage II) (mean = 40% vs. 19%, range 15%–66%).
Conclusion: Findings show that intervention and inner setting characteristics (reflecting organizational and unit-level factors) influenced implementation. Our evaluation identified high and moderate adopting centers as potential targets for increased implementation and improved sustainability. Findings contributed to a growing literature on CFIR domains and constructs.
Financial Support: VA HSR&D QUERI: RRP 12-561, “Evaluating the implementation of the SCI-PUMT.”
P9. EXPLORING JOB-RELATED PARTICIPATION AMONG YOUTH WITH SPINAL CORD INJURY
Anne L. Riordan1, Erin H. Kelly1,2, Lawrence C. Vogel1,3
1Shriners Hospitals for Children, Chicago, IL, USA; 2Marquette University, Milwaukee, WI, USA; 3Rush Medical College, Chicago, IL, USA
Objective: Employment is one hallmark of successful transition to adulthood among youth with disabilities; however, employment rates are typically low among adults with spinal cord injury (SCI). Youth with SCI may therefore need additional supports to prepare for future employment. The purpose of this study was to explore job-related participation among youth with SCI, and its relationship to demographic factors, quality of life (QOL), and mental health.
Design: Survey research.
Participants/methods: Youth ages 7–18 years with SCI from three pediatric centers completed standardized measures of participation; anxiety; depression; and physical and psychosocial (emotional, social, school) QOL. Primary caregivers also completed a standardized measure of child QOL. Descriptive statistics summarized job-related participation using four items: whether or not youth do chores, homework, paid work, and volunteering.
Results: Subjects included 316 youth; 55% male, 66% Caucasian, 8.54 years (SD = 5.76) at injury and 13.71 years (SD = 3.42) at interview, and 27% had tetraplegia ABC, 58% paraplegia ABC, and 15% D injuries. For all four job-related participation items, responses varied significantly by age, sex, level of injury, and means of mobility. In particular, youth ages 6–12 years were less likely to do paid work or volunteer, and youth 16–21 years were less likely to do chores or homework; girls did more chores and homework than boys; youth with paraplegia did more chores and paid jobs, but less volunteering, than youth with tetraplegia; and youth who could walk did more chores than youth who used wheelchairs. Engagement in activities was also related to other positive youth psychosocial outcomes. Specifically, doing chores was related to greater parent- and child-report physical QOL and lower child depression, doing homework was related to greater parent- and child-report school QOL, doing a paid job was related to greater child-report social QOL, and volunteering was related to greater parent-report school QOL.
Conclusion: Results indicate that engagement in job-related participation differs by demographics and is related to youth outcomes. While longitudinal research is needed, findings indicate that steps should be taken to target early job skill-building opportunities among youth with SCI. In particular, interventions may need to focus on increasing job-related activities for youth with more significant injuries.
Financial Support: Supported by Shriners Hospitals for Children, #9143.
P10. NOVEL APPLICATION OF PEER HEALTH COACH MODEL IN CHRONIC SPINAL CORD INJURY
Bethlyn Vergo Houlihan1,2, Damara Gutnick6,7, Diana Pernigotti1,3, Judi Zazula1,2, Miriam Brody1,2, Hannah Mercier1,2, Christa Green1,4; David Rosenblum1,3, Timothy Belliveau1,4, Subramani Seetharama5, Alan Jette1,2
1New England Regional Spinal Cord Injury Center Model Systems Network, Boston, MA, USA; 2The Health and Disability Research Institute, Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA; 3Rehabilitation Services and Outpatient Services, Spinal Cord Injury Program, Gaylord Hospital, Wallingford, CT, USA; 4Hospital for Special Care, New Britain, CT, USA; 5Hartford Hospital, Hartford, CT, USA; 6Langone School of Medicine, New York University, New York, NY, USA; 7The Centre for Collaboration, Motivation & Innovation, Sumas, WA, USA
Objectives: To describe the development and results of a pilot test of a telephone-based peer-led health care empowerment intervention, “My Care My Call” (MCMC), geared toward those living with SCI; and subsequent revisions to MCMC and training methods.
Design: A Content Expert Panel with 5 healthcare professionals and 3 consumers met biweekly over 6 months and confirmed peer support as crucial. We adopted the PHC model to develop MCMC, which provides goal-setting support, education, and referral to empower consumers in actively addressing primary care needs, via phone over 6 months. Brief-Action Planning (BAP), an evidence-based goal-setting technique developed for use in the primary care setting, was incorporated as a person-centered approach and adapted for peer delivery. Motivational Interviewing skills were also included in PHC training. A “PHC Toolkit” was developed, offering 6 key tools for goal-related support, education, and resources. Based on existing guides, we developed a Resource Book (RB) and Consumer Workbook, with expert and consumer input.
Participants/methods: We pilot tested MCMC's feasibility and acceptability for participants and PHCs. PHCs called 7 participants with SCI (3 with paraplegia, 4 with tetraplegia) 6 times over 3 weeks. Participants completed a brief online survey after calls, and qualitative exit phone interviews.
Results: Participants completed 81% of calls; for 80% of calls, PHCs were rated very good or excellent. Mostly positive feedback highlighted feeling supported, confidence-building toward goals, and resource connection. PHCs identified a need for important process changes: 1) how to appropriately address participants’ needs beyond the study's primary healthcare focus; 2) additional PHC training focused on role plays to master PHC tools, as the peer component superseded the need for training in relationship-building; and 3) detailed scripting of the PHC Toolkit.
Conclusion: Smaller goals proved important to support participants towards meeting larger health-related goals. PHCs used role-plays to revise the Toolkit and developed scripted outlines for each tool. The Resource Book and Workbook were combined into one Resource Guide for ease of use. PHCs were certified in BAP. Based on results of the current randomized controlled trial (N = 80), current peer support service models could be expanded with the PHC model to include structured support specifically designed for people with chronic SCI.
Financial Support: MCMC is supported by NIDRR grant H133N120002.
P11. PROMOTING NEUROPLASTICITY AND MOTOR RELEARNING AFTER SPINAL CORD INJURY
Frank Hyland, Nicole Smith, Sue Golden
Good Shepherd Rehabilitation Network, Allentown, PA, USA
Background: Effective rehabilitation strategies for the patient with SCI must be based on evidence-based motor learning principles and therapeutic interventions that promote neuroplasticity and enhance functional recovery. Plasticity and motor learning in the CNS is dependent upon the provision of specific sensory input associated with the proper performance of the desired motor activity followed by repetitive performance of that task. The recent development of robotic exoskeletons that provide assistance with stepping and body weight supported locomotor training systems that challenge core musculature combined with therapeutic interventions that enhance the patient's ability to learn complex, dynamic motor performance skills are leading to new approaches for rehabilitation after SCI.
Design: Three case studies that demonstrate this approach to enhance neuroplasticity and functional recovery after spinal cord injury.
Results: Unexpected findings of partial sensory, motor and autonomic recovery were found in one case. Subject 1 had a T11 spinal cord injury classified as ASIA A; Subject 2 had a C3–C6 spinal cord injury classified as ASIA C; Subject 3 had a C4 spinal cord injury classified as ASIA D. All subjects improved their stepping ability while using a robotic exoskeleton. Subject 2 and subject 3 then incorporated body weight-supported training (BWST) into their rehabilitation program. Subject 2 and subject 3 enhanced their walking abilities by incorporating Pilates into their program. Each of the three subjects achieved contact guard to modified independence in over ground walking. Unexpectedly, subject 1 who was 12 years s/p spinal cord injury experienced full recovery of bowel and bladder function and saw his sensory and motor zone of partial preservation increase by four levels from T11 to L3.
Summary: This case series outlines the progression of locomotor recovery in 3 individuals with SCI in which all patients improved their walking ability after a course of robotic exoskeleton training, BWST, and Pilates.
P12. RACIAL/ETHNIC DIFFERENCES IN PATTERNS OF SPINAL CORD INJURY – FUNCTIONAL INDEX (SCI-FI) SCORES
Denise Fyffe1,2, Rachel Byrne1, Mary Slavin3, Pamela Kisala4, Claire Kalpakjian5, David Tulsky4, Alan Jette3
1Kessler Foundation; West Orange, NJ, USA; 2Rutgers, The State University of New Jersey, Newark, NJ, USA; 3Boston University, Boston, MA, USA; 4University of Delaware, Newark, DE; 5University of Michigan Medical School, Ann Arbor, MI, USA
Objective: Functional status is a crucial determinant of quality of life after a spinal cord injury (SCI); however, few studies have examined racial/ethnic disparities in functional outcomes after an SCI. The Spinal Cord Injury – Functional Index is a newly developed patient-reported outcomes measure that assesses functional ability. The goal of this study is to examine patterns of SCI-FI scores across racial/ethnic groups of individuals with SCI.
Design: Cross-sectional design.
Participants/Methods: Using the SCI-FI calibration sample drawn from 6 Spinal Cord Injury Model Systems centers, we conducted a secondary analysis of 442 participants with motor-complete traumatic SCI (ASIA A and B). We conducted MANOVAs to compare the SCI-FI scores of different racial/ethnic groups in 5 domains: wheelchair mobility (56 items); self-care (90 items); fine-motor function (36 items); basic mobility (54 items). For this study, we compared the SCI-FI scores of individuals who self-identified as Hispanic (n = 65; 14.7%), Non-Hispanic White (n = 298; 67.4%), and Non-Hispanic Black (n = 65; 14.7%).
Results: Preliminary results indicate similar patterns of SCI-FI scores were observed across participants with tetraplegia and paraplegia. However, Non-Hispanic White participants scored highest across all SCI-FI domains, relative to Non-Hispanic Black and Hispanic individuals. Significant differences were observed across Non-Hispanic White and Non-Hispanic Black participants in the self-care and wheelchair mobility domains.
Conclusion: Non-Hispanic White, Non-Hispanic Black and Hispanic participants with SCI reported similar SCI-FI scores in fine-motor function, and basic mobility domains. However, race/ethnicity group differences in SCI-FI self-care and wheelchair mobility domains suggest that there may be barriers against sustaining self-care functional activities and wheelchair mobility after rehabilitation for Non-Hispanic Blacks with SCI, relative to Non-Hispanic Whites.
Financial Support: Supported by Northern New Jersey Spinal Cord Injury System (NNJSCIS), a National Institute on Disability and Rehabilitation Research (NIDRR) funded SCI Model System of care.
P13. SCI OUTCOMES: PROVIDER'S META-PERCEPTIONS OF PATIENT BELIEFS REGARDING CLINICAL ASSESSMENTS
Jason H. Raad
Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs, Edward Hines, Jr. Hospital, Hines, IL, USA
Objectives: Does what a clinician thinks their patient believes, affect clinical decision-making and behavior? Prior research suggests that one's own beliefs regarding the beliefs of others, known as meta-perception, may impact behaviors and attitudes in subtle but important ways. This study assessed the role that meta-perceptions regarding the use of standardized clinical assessment may play in clinical decision-making and behaviors among clinicians who treat spinal cord injury (SCI).
Design: Survey
Participants: Two hundred nineteen clinicians at 38 facilities participated in an online survey assessing attitudes regarding evidence-based practice. This study included only respondents who treat SCI (n = 67). Clinicians were asked to rate their perception of patients’ attitudes regarding standardized assessments as well as items assessing their own attitudes, beliefs and behaviors related to the use of these instruments.
Results: A six-item measure was used to assess clinician meta-perceptions (alpha = 0.78); a three-item measure assessed clinician attitudes (alpha = 0.76) and a single item assessed the use of standardized assessments (M = 1.86, SD = 3.22). Linear regression was used to evaluate the relationship between clinician meta-perceptions, attitudes and clinical behavior. First, clinician meta-perceptions were regressed on clinician attitudes. Results were significant (F(1,64) = 19.11, P < 0.001) with an R2 of 0.230. Second, meta-perceptions were regressed on the number of measures used. Results were not significant (F(1,68) = 0.62, P = 0.434) with an R2 of 0.009. A post-hoc exploratory analysis was then conducted using a three-item measure (alpha = 0.74) of constraints on clinician's time. Results were significant (F(1,11) = 5.61, P = 0.037) with an R2 of 0.338, suggesting meta-perceptions are more common with time demands.
Conclusion: Results suggest that clinicians’ beliefs regarding standardized assessments significantly predicted meta-perceptions of patient attitudes regarding the utility of these tools. Unexpectedly, these beliefs were not found to be significantly related to assessment-related behaviors. However, constraints on clinician's time may enhance meta-perceptions. There is a danger that clinicians may hold unfounded inferences regarding clinical assessment. Two important implications emerge: first, perceptions regarding patient attitudes may simply reflect those of clinicians. Second, demands on a clinician's time may result in heuristic decision-making strategies.
P14. SHOULDER PAIN IN SPINAL CORD INJURY: EFFECTIVENESS OF A HOME REHABILITATION PROGRAM AND ACTIVITY MODIFICATION
Jennifer Silvestri1, Cristina Sadowsky1,2
1International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD, USA; 2Johns Hopkins University School of Medicine, Department of Physical Medicine and Rehabilitation, Baltimore, MD, USA
Objective: To determine the effectiveness of and compliance with a home based rehabilitation to reduce shoulder pain and improve quality of life in patients with spinal cord injury (SCI).
Design: Cohort study.
Participants/methods: Fifteen individuals with SCI who had shoulder pain that limited their participation and independence in self-care skills and functional mobility, and negatively impacted their quality of life. A structured interview, evaluation, and the Wheelchair Users Shoulder Pain Index (WUSPI) were used to collect data pre-intervention. A home rehabilitation program was introduced and a structured interview used six weeks post-intervention.
Results: All participants reported a decrease in their shoulder pain six weeks post-intervention from an average of 6.23 to 2.2 on a 10-point analog scale. Compliance with the prescribed program varied amongst participants but on average, they participated in stretching 4.5 times per week and strengthening 3.7 times per week. Common barriers to compliance included time, difficulty attaining prone and decreased assistance. Participants reported improvements in shoulder pain, motivation for rehabilitation, and independence with daily activities.
Conclusion: A thorough evaluation of body mechanics during daily activities and functional mobility in conjunction with participation in a home rehabilitation program reduces shoulder pain in patients with SCI, leading to improvements in independence and quality of life.
P15. SLEEP DISTURBANCE FOLLOWING SPINAL CORD INJURY
Donald J. Fogelberg
Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
Purpose: To provide an overview of sleep problems following spinal cord injury (SCI).
Background: Sleep disturbance is a highly prevalent but understudied co-morbid condition in people with SCI. Sleep dysfunction in SCI may have roots in a number of factors that are unique to this population. SCI frequently affects physiological functions directly or indirectly involved in sleep, including neuroendocrine functions and thermoregulation. Care routines for pressure ulcer prevention and for bowel and bladder management, as well as decreased physical activity levels secondary to SCI may all contribute to sleep dysfunction. Based on research in the general population, it is also likely that sleep disturbance contributes to pain, depression, obesity, poor health, limited functional abilities, and diminished quality of life in people with SCI.
Significance for SCI practice: Understanding sleep disturbances in SCI is critical given the strong associations within the general population between sleep disturbances and depression, pain, and obesity, all of which are prevalent in the SCI population. Existing research in the general population has established that the relationship between each of these conditions and sleep is reciprocal. For example, pain not only interferes with sleep, it is also exacerbated by disturbed sleep. Insomnia, the most prevalent form of sleep disturbance, is both a symptom of major depressive disorder and a risk factor for it. Obesity is a risk factor for sleep-related breathing disorders in the general population, and sleep difficulties predispose a person to weight gain. The reciprocal nature of these relationships creates the potential for a detrimental feedback loop; for example, pain leads to worse sleep which leads in turn to greater pain. The role of sleep in multiple reciprocal relationships involving conditions highly prevalent in the SCI population indicates it could be a key area for intervention to improve function and quality of life in those with SCI.
Conclusion/Summary: A critical task for rehabilitation professionals is the identification of modifiable factors that contribute to deficits in functional ability and diminished quality of life. While an extensive body of research has demonstrated the negative impact of sleep disturbance on functional ability and quality of life in the general population, these relationships have not been systematically investigated in the context of SCI.
P16. SURVEY OF UPPER EXTREMITY MUSCLE STRENGTH ACROSS TIME FOLLOWING SPINAL CORD INJURY
Jeff Jaramillo, Minna Hong, Lisa Johanson, Jenny Kiratli
Spinal Cord Injury Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
Objective: Upper limb function is important to individuals with spinal cord injury (SCI). Loss of strength may impair wheeled mobility as well as functional performance. This may be due to natural aging and/or the rigorous demands of chronic use. The purpose of this analysis was to evaluate the effects of aging and duration of injury on upper extremity strength after SCI.
Participants/methods: In this cross-sectional analysis, strength data were pooled for forty-nine individuals with SCI (26 tetraplegia/23 paraplegia), mean age of 48 years (range 21 to 72 yr), and mean injury duration of 15 years (range 1.5 to 40). Upper extremity strength was measured using a handheld dynamometer and maximum break tests in a seated position. Three measurements for each position were averaged to obtain strength mean scores for muscle groups including: shoulder flexion, abduction, external rotation, internal rotation and elbow flexion and extension. Non-parametric (Spearman ρ) statistics were used to determine associations between the strength of each muscle group, analyzed separately for tetraplegia and paraplegia, in relation to age and time since injury.
Results: For persons with paraplegia, there were significant negative correlations between injury duration and all bilateral shoulder strength scores; flexion (–0.64, P = 0.0043), abduction (–0.76, P = 0.0002), external rotation (–0.62, P = 0.0058), internal rotation (–0.56, P = 0.0131). Conversely, there was a positive correlation between injury duration and elbow extension (0.96, P = 0.0005) but no effect for elbow flexion. Overall decline was on the order of 50% (range 39 to 62) in the first decade after injury but did not change substantially afterwards in paraplegia. No differences were evident in shoulder or elbow strength for persons with tetraplegia. Finally, there were no significant associations between strength decline and age.
Conclusions: Time since injury and not age is the best predictor of strength decline in paraplegia. Based on this analysis it is prudent to carefully and thoroughly evaluate the shoulders of persons with paraplegia for strength deficiencies in the first decade, and presumably early in this period, in order to evaluate for degenerative changes and implement most effective therapies to prevent loss of independence in mobility.
P17. THE EXPERIENCE OF NEUROPATHIC PAIN DURING ACUTE SPINAL INJURY REHABILITATION
Jasmine Hearn
The Department of Psychology, The University of Buckingham, Buckingham, United Kingdom
Objective: Neuropathic pain (NP) can be both psychologically, and physically, debilitating, and is present in a large majority of the spinal cord injured (SCI) population. This paper presents an in-depth, idiographic study exploring the lived experience of chronic NP following SCI, and how it is mediated by its meaning to the sufferer.
Design: This was a single interview study. Eight people with SCI and chronic NP, in an inpatient setting, at a specialist SCI Centre in the UK.
Methods: Semi-structured interviews were conducted with the participants. Verbatim transcripts were subjected to Interpretative Phenomenological Analysis in order to further understand the experience.
Results: Analysis suggested that NP has a number of consequences upon the sufferer's psychological and social well-being. Four super-ordinate themes were identified: difficulty in describing indescribable pain; the spectrum of medication experience; interpreting the hospital environment; and dichotomous acceptance.
Conclusion: The results provide clinical importance in terms of enhancing self-efficacy and feelings of safety in hospital, as well as the evaluation of pain-related imagery. The possible application of acceptance-based therapy and the potential for the alleviation of the debilitating consequences of NP is also raised.
Support: This study was conducted as part of a DPhil studentship in Psychology by Research.
P18. USE OF ELECTRICAL STIMULATION AS AN ACTIVITY-BASED THERAPEUTIC INTERVENTION FOR PATIENTS WITH LOWER MOTOR NEURON SPINAL CORD INJURY
Miranda Garvin, Kristine Rizzo
Frazier Rehab Institute, Louisville, KY, USA
Objective: To demonstrate the effects of lower extremity electrical stimulation as an activity-based therapeutic intervention for patients with lower motor neuron (LMN) spinal cord injury (SCI).
Design: Retrospective case series.
Participants/methods: Sixteen patients with LMN SCI (AIS A–D) received physical therapy 5 days per week for at least 40 sessions consisting of 60 minutes of lower extremity electrical stimulation (stimulation parameters: 100Hz, 500 µs, <140mA) followed by 30 minutes of over ground assessment and community integration. Each patient completed the following outcome measures at initial evaluation, 20 session re-assessments, and discharge from physical therapy: Neuromuscular Recovery Scale, Berg Balance Scale, lower extremity muscle torque testing, 10-meter walk test and 6-minute walk test (if applicable).
Results: Following lower extremity electrical stimulation, improvements were noted in lower extremity muscle strength and functional abilities based on the outcome measures assessed.
Conclusion: For patients with LMN SCI, the use of lower extremity electrical stimulation at 100Hz, 500 µs, <140 mA combined with activity-based therapy may be useful in improving lower extremity strength and function.
P19. USE OF NITRO-BID 2% TOPICAL OINTMENT FOR THE TREATMENT OF AUTONOMIC DYSREFLEXIA IN PEOPLE WITH SPINAL CORD INJURY
Jenn Wahl
Craig Hospital, Englewood, CO, USA
Objective: To evaluate the use of Nitro-Bid® 2% topical ointment for pharmacological treatment of AD in patients with SCI at or above level T6. There are currently no clinical studies supporting the use of Nitro-Bid ® 2% topical ointment for the treatment of AD.
Design: Randomized control pilot research study.
Participants/methods:
Participants: a) current inpatient at Craig Hospital, b) age ≥ 18 years of age, c) English speaking, d) SCI level at or above T6, e) no medical history contraindicating the use of nitroglycerin, f) qualification for the use of Nitro-Bid® 2% topical ointment; defined as a symptomatic episode of Autonomic Dysreflexia (AD) with an uncontrolled blood pressure greater than 150mmHg, g) willingness to participate and be treated with Nitro-Bid® 2% topical ointment.
Methods: This study compares treatment efficacy of Nitro-Bid® 2% topical ointment based on the location of ointment application. We will compare the application of Nitro-Bid® 2% topical ointment on the forehead versus the chest to evaluate symptom response and thereby establishing a preferential placement of Nitro-Bid 2% topical ointment. The system responses to be evaluated include duration of AD episode, amount of Nitro-Bid® 2% topical ointment required, symptom relief and overall patient outcomes based on ointment placement. This study will also serve to provide clinical data regarding the use of Nitro-Bid ® 2% topical ointment to treat AD in people with SCI at the T6 level and above. For the purpose of this study, individuals with an injury below T6 will be excluded from participation.
Results: The goal is to enroll 200 participants with 60 participants with qualifying episodes of AD. Fifty-four participants have been enrolled to date, with 4 participants experiencing study-qualifying episodes of AD.
Conclusion: This pilot research study is essential for enhancing the knowledge of the SCI community on treatment options regarding AD and will serve to provide literature supporting pharmacological treatment of AD using Nitro-Bid 2% topical ointment.
Financial Support: Craig Hospital provides financial support for this research study.
P20. URETEROSCOPIC STONE TREATMENT OUTCOMES IN PATIENTS WITH SPINAL CORD INJURY
Duncan R. Morhardt, Miriam Hadj-Moussa, J. Stuart Wolf, Jr., Gary J. Faerber, William W. Roberts, John T. Stoffel, He Chang, Anne P. Cameron
University of Michigan Health System, Ann Arbor, MI, USA
Objective: Spinal cord injury (SCI) results in immobility, infection, lower urinary tract dysfunction, and changes in body habitus that contribute to stone formation. Surgical positioning issues and the complexity of stone burden require repeated interventions and complications often necessitate intensive care unit admissions. In the era of flexible ureteroscopy, evidence clarifying safe and effective treatment in this cohort remains scarce and would be instructive for directing appropriate surgical stone management.
Design: Records from 7000 consecutive stone procedures from 1996–2013 were retrospectively reviewed for patients with SCI.
Methods: Data were compiled and analyzed for patient, disease, and operative factors with approval from the University of Michigan Institutional Review Board. Patients without stones on post-operative imaging were considered stone free. Bivariate relationships were tested. Sample size prevented the ability to adjust for other factors in a multivariable analysis.
Results: 47 patients with SCI underwent a total of 95 ureteroscopic procedures. Overall complication rate was ∼15%. Based on post-operative imaging, 16% of patients were stone free. On bivariate analysis, cervical injury was associated with higher risk of complication (P < 0.0001). Sacral injury was associated with stone free status (P < 0.0001), as was post-operative stenting (P = 0.018) and ASIA A class (“complete injury”, P = 0.028). There was a trend of lower level SCI with improved stone clearance. Pre-operative fluorourodynamic study parameters were not significantly associated with outcomes. Interestingly, COPD (P = 0.94) and respiratory comorbidities were not associated with complications. Contractures, use of sheath, stone size (P = 0.09), and bladder management method were not associated with stone-free status.
Conclusions: Both stone clearance and complications of ureteroscopy are associated with level of injury in patients with SCI. Lower level SCI and complete SCI are associated with stone-free status.
P21. UTILIZING HIGH-INTENSITY INTERVAL TRAINING AS THERAPEUTIC INTERVENTION FOR PATIENTS ON PROLONGED BED REST FOLLOWING SKIN FLAP SURGERY: A CASE REPORT
Kristen Gill, Andrew Stamatelos
Magee Rehabilitation Hospital, Philadelphia, PA, USA
Background: Individuals living with a spinal cord injury frequently experience pressure ulcers that often result in skin flap surgeries and subsequent prolonged time on bed rest. In fact, according to the 2013 National Spinal Cord Injury Statistical Center's Annual Report, the second most common cause of rehospitalization for individuals with spinal cord injury is disease of the skin, ranging from 17.7% to 37.4% in the first 20 years post-injury. Many challenges arise for occupational and physical therapists working with individuals on prolonged bed rest, including preventing deconditioning, promoting wound healing, and maintaining healthy joint integrity. Prolonged bed rest has many negative physiological effects on the human body, including an approximate 26% decrease in VO2max and 26% decline in cardiac output over a 20-day period (Stuempfle KJ & Drury DG, 2007). Additionally, a major factor affecting those on bed rest is a loss of approximately 16–30% of muscle volume depending on the muscle group (Stuempfle KJ & Drury DG, 2007).
Objective: To minimize these medical complications, a high–intensity interval training program was utilized during occupational and physical therapy sessions with a patient at Magee Rehabilitation Hospital.
Design: Case Report
Findings: This patient, who was hospitalized on bed rest, post flap surgery, and with a past medical history of T5 complete spinal cord injury, participated in high-intensity training with a total of five, 4-minute cycles of a pre-determined sequence of five exercises during each therapy session. One cycle of high-intensity interval training consists of 20 seconds of high-intensity exercise followed by 10 seconds of rest for a total of 4 minutes. Within the research, there is considerable evidence to support the use of high-intensity interval training to promote both cardiovascular and skeletal muscle adaptations that are linked to improved health outcomes (Gibala et al. 2012). Data were collected over the course of five weeks in order to assess the patient's response to the intervention, including VO2max, blood pressure, resting heart rate, and peak heart rate with exercise.
Conclusion: The results from this individual case support the use of high-intensity interval training for an individual on bed rest in order to promote cardiovascular endurance and strengthening while preventing overall deconditioning.
P22. WHY ARE YOU LEAVING SO SOON?
Robin Bischoff, Michele Ward
Kessler Institute for Rehabilitation, West Orange, NJ, USA
Purpose: To determine the causes of acute care transfer (ACT) in a freestanding traumatic spinal cord injury (T-SCI) nursing unit and assess predictors to best assess for focused interventions.
Design/method: Quantitative evaluation data was obtained from rehabilitation ACT records over a 12-month period (January–December 2014). Frequency of ACT of patients with T-SCI was undertaken along with determining the reasons for transfers based upon rehabilitation hospital chart review and subsequent diagnostic information from the accepting hospital. Inclusion criteria included age >17 years of age, a diagnosis of traumatic SCI, including patients requiring ventilator support. ACT predictors that were assessed included co-morbidities, amounts of medications, and length of stay in acute care prior to rehab admission.
Results: Of the 149 patients admitted with traumatic SCI in 2014, a total of 29 patients were acutely transferred from January through December 2014; representing 19%. ACT rate. The most common reasons included respiratory (33.33% of transfers), followed by altered mental status (15.38%), gastrostomy tube malfunction (12.82%), radiological tests not available and requiring admission to another facility, neurological decline, EKG changes, worsening pain and sepsis (each 5.13%), with individual cases of new onset of seizures, gastrointestinal bleed, severe hyponatremia, epistaxis and wound dehiscence (each 2.56%). 35.8% of the 39 patients were over the age of 65. 41% had a length of stay less than 2 weeks in acute care and 56.4% were prescribed greater than 10 medications.
Conclusion: Understanding the causes of ACT in an SCI-specific rehabilitation unit is important to assist in decreasing the incidence of transfers. At our facility, respiratory issues followed by altered mental status and g-tube malfunction were identified as leading causes of ACT. Knowledge of these allows for institution of potential additional preventative measures in addition to current nursing practice. With a focus of hospitals to decrease ACT, defining diagnosis and unit specific causes of transfer is critical to nursing practice change.