Recent estimates in the United States indicate that between 225,000 and 296,000 persons have some type of spinal cord injury and/or disorder (SCI&D) that significantly affects their life activities. Of these, more than 25,000 receive care within the VA healthcare system, making it the largest integrated healthcare system in the world serving persons with SCI&D. Further, most spinal cord injuries in Veterans occur prior to typical retirement age, with an average onset age of 39. Today, people with SCI&D are living longer; more than half of Veterans with SCI&D have had their injury for 20 years or more, and approximately 80% are 50 years of age or older. This increased life expectancy, coupled with the aging of the SCI&D Veteran population, is associated with greater prevalence of chronic diseases common in older life. Therefore, in addition to providing specialty medical services for the chronic impairments associated with SCI&D, it is essential to provide preventive care to promote healthy aging and quality of life among Veterans with SCI&D.

Presented here are four recently completed studies that address several aspects of caring for those with spinal cord injury.

Keywords: spinal cord injury, respiratory care, smoking, smoking cessation, falls, peer visitors

1. Developing a Better Understanding of Respiratory Care in Veterans with Spinal Cord Injury

This study sought to understand treatment patterns and care delivery for certain conditions associated with respiratory impairments in those with spinal cord injury. (Study no. SCS 03-216. Fran Weaver, PhD.)

Questions

What are the current practice patterns for a variety of respiratory concerns (e.g., smoking-cessation, sleep apnea, community-acquired pneumonia, and chronic obstructive pulmonary disorder) in Veterans with spinal cord injury (SCI)? Are Veterans with SCI receiving the evidence-based guideline recommended care for these concerns?

Results

In this two-year study, investigators collected a variety of data from seven VA SCI centers. Data included self-assessments, VA administrative data, chart review, and semi-structured provider interviews. Findings showed: Of the respondents, 22% were current smokers,
• Of the respondents, 22% were current smokers, and 51% were past smokers. More often, current smokers reported respiratory illnesses and/or symptoms, alcohol use, pain, and depression than those who had either smoked in the past or had never smoked at all.
• Approximately half made quit attempts in the past year, and those interested in quitting received referral to counseling (57%) and/or prescription for medication/nicotine replacement (23%).
• According to the patient survey, 19% of Veterans with SCI self-reported having been told by a doctor that they had sleep apnea. In addition, chart reviews were conducted among a select group of individuals with SCI; findings revealed that over one third had a documented sleep apnea diagnosis.
• The majority of pneumonia cases (83%) were treated as inpatients and had chest x-rays when first admitted, however only a small number had sputum or blood cultures collected. 61.8% received antibiotics within the first eight hours, and 89.9% within the first three days. Only half received guideline recommended antibiotic treatment.
• Of the chart review sample, 42% had a documented diagnosis of COPD, of which 43% were current smokers. Seven percent of the patient survey sample, self-reported as having complications with COPD during the prior year.

Implications

Veterans with SCI&D are at increased risk for respiratory complications and this study suggests that there is variability in provision of evidence-based care. Further implications include:

• COPD is of greater concern in the SCI&D population than has been documented previously and appears to be related to the higher smoking rate. Efforts to reduce smoking should help to improve quality of life for Veterans with SCI&D.
• Veterans with SCI&D who smoke and are attempting to quit are offered counseling and medication, but providers often have difficulty following and supporting patients. Identifying other support methods (telehealth, considering the use of combination cessation therapies, and addressing other health concerns) may help those interested in quitting smoking.
• Screening of sleep apnea is low, and strategies to encourage increased screening are recommended.
• Improvements are needed in obtaining cultures to determine etiology of CAP and ultimately appropriate treatment.

2. Creating a New Tool to Monitor Pressure Ulcer Healing in Veterans with Spinal Cord Injury

This study sought to establish the validity, reliability, and sensitivity of a tool to monitor pressure ulcer healing over time in individuals with spinal cord injury. (Study no. NRI 03-245. Audrey Nelson, PhD, RN, FAAN.)

Question

Is it possible to establish a valid, reliable, and sensitive new tool (SCI-PUMT) to monitor pressure ulcer healing over time in individuals with SCI?

Results

Based on a three-year longitudinal study involving 66 Veterans, investigators used a variety of regression analyses and determined that the new tool was reliable, valid, and sensitive for measuring pressure ulcer healing in those with SCI.

Implications

While results showed the SCI-PUMT to be effective, investigators suggest that further psychometric analysis will be required to determine whether the results of the regression model can be replicated over time.

Publication Note: This study resulted in the following publication: Pressure Ulcer Healing in SCI: A Novel Evidence-Based Tool (Journal of Wound Ostomy & Continence Nursing)

3. Assessing Risks and Costs in Wheelchair Falls for Veterans with Spinal Cord Injury

This study sought to determine causes and risk factors for wheelchair-related tips and falls among Veterans with spinal cord injury (SCI). (Study no. IIR 03-003. Audrey Nelson, PhD, RN, FAAN.)

Question

Can the causes of wheelchair falls be determined by close observation over a three-year period? Further, can these observations also contribute to an understanding of both risk factors and predictors for wheelchair falls?

Results

Investigators examined a sample of 702 community-dwelling wheelchair users from three VAMCs (Tampa, Boston, and Augusta) and determined that there are specific associations and predictors contributing to increased falls, including:

• increased pain in the two months prior to the fall
• positive alcohol abuse
• having had a fall in the previous year
• fewer years of SCI
• a shorter length of time as a wheelchair user

In an effort to further ascertain an understanding of risk factors and predictors, qualitative interviews were also conducted. Study participants tended to describe falls as unanticipated, inevitable, and part of daily life with SCI.

Implications

Investigators were able to identify the etiology, risk factors, and predictors for wheelchair falls in Veterans with SCI. The investigators believe that these results extend the science about fall risk, particularly given that existing literature typically defines fall predictors within a geriatric population. Investigators also suggest that data confirm the need to view wheelchair fallers as a unique population within VA, for which screening should begin early on after impairment.

Publication Note: This study resulted in the following journal articles:

• Wheelchair-related falls: Current evidence and directions for improved quality care. Journal of Nursing Care Quality
• Effects of wheelchair posture on patient safety. Rehabilitation Nursing: The Official Journal of The Association of Rehabilitation Nurses

4. Developing a Peer Visitation Program for Veterans with SCI

This study focused on adapting an existing peer visitation program model to suit the needs of Veterans with SCI. (Peer visitation provides individuals with spinal cord injury an opportunity to interact with and learn from successful role models.) (Study No.: RRP 07-349. M. Jan Tackett, PhD and Randi K. Lincoln, PhD.)

Questions

Can existing peer visitation (PV) program materials be improved upon and effectively adapted for use by the VA system of care?

Results

In collaboration with the United Spinal Association, investigators obtained and reviewed PV materials from a variety of existing PV programs. After this review, the investigators interviewed an expert advisory panel to obtain their input about the selection and modification of the United Spinal Association materials.

Investigators developed three manuals for use by VA care managers, trainers, and Veteran mentors. These manuals include: a Peer Mentor Training Manual, a Peer Mentor's Handbook, and a Peer Self-Management Planner. Feedback from a geographically diverse group of Veterans endorsed the feasibility of supporting a PV program.

Implications

Implementation of this PV program should result in improved peer support for Veterans with SCI, allowing for potential improvements in adjustment to injury and quality of life.