A latent structural equation model of risk behaviors and pressure ulcer outcomes among people with spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVE: Our purpose was to develop a latent structural model to demonstrate the relationship between factor structures of risk health behaviors and pressure ulcer (PrU) outcomes among participants with spinal cord injury (SCI). SETTING: Data were collected at a large specialty hospital and analyzed at a medical university in the Southeastern USA. METHODS: In total, 1871 participants with traumatic SCI of at least 1-year duration were recruited. Four latent risk behavior indicators were developed and further linked with a higher dimension which is classified as the risk dimension. A latent PrU variable was created and measured by four observable PrU-related outcomes. Latent structural equation modeling was performed to assess the relationship between the latent risk behavior and the latent PrU outcome. Several exogenous variables were also included in the structural equation model. RESULTS: The risk behavior dimension had a significant direct effect on the latent PrU (direct effect=0.323, P<0.01). All direct relationships between the risk behavior dimension and risk behaviors were also significant (rsmoking=0.436, rprescription compliance=0.351 and rspecific prescription misuse=0.502), except alcohol consumption (ralcohol consumption=0.087). Participants who were African American, had higher injury levels and longer time since SCI were more likely to have worse PrU outcomes. CONCLUSIONS: The overall findings of this study suggest the need to reduce risk behaviors to prevent adverse PrU outcomes. The risk of PrU outcomes is especially high among people who are African American, have higher level of SCI and have longer time since SCI.

A latent structural equation model of protective behaviors and pressure ulcer outcomes among people living with spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVE: To develop a latent structural model to demonstrate the relationship between factor structures of protective health behaviors and pressure ulcer (PrU) outcomes among participants with spinal cord injury (SCI). SETTING: Data were collected at a large specialty hospital and analyzed at a medical university in the Southeastern USA. METHODS: A total of 1871 participants with traumatic SCI of at least 1 year duration were included. A latent PrU variable was measured by four observable PrU-related outcomes. Latent variable structural equation modeling was performed to assess the relationship between latent protective behavior (fitness and productive activities) and latent PrU outcome. Several exogenous variables were included: sex, age, race, marital status, injury severity and years since injury. RESULTS: The protective behavior dimension had a significant direct effect on the latent PrU (direct effect=-0.275, P<0.01). All direct relationships between protective behavior dimension and healthy behaviors were also significant (rfit=0.899 and rproductive activity=0.568). Relationships between the latent PrU and fitness (indirect effect=-0.247) and productive activities (indirect effect=-0.156) were mediated through the protective behavior dimension. Participants who were African American, had higher injury levels, and had longer time since SCI were more likely to have worse PrU outcomes. CONCLUSIONS: The overall findings of this study suggest the need to enhance healthy behaviors to prevent adverse PrU outcomes, especially among people who are African American, have longer time since SCI and have higher level of SCI.

The association between metabolic syndrome and pressure ulcers among individuals living with spinal cord injury.

OBJECTIVE: The objective of this study was to identify the relationship between metabolic syndrome (MetS) and pressure ulcers (PrU), after controlling for demographic and injury characteristics, socioeconomic factors, health behaviors and fatigue among participants with spinal cord injury (SCI). METHODS: This cross-sectional study recruited 350 participants with SCI from a hospital in the western region of the USA. Blood tests and physical examination were performed. Waist circumference, high-density cholesterol, triglycerides, blood pressure and fasting glucose were used to diagnose MetS according to Criteria for Clinical Diagnosis of Metabolic Syndrome defined by the American Heart Association. All other variables were self-reported. Three-stage multivariate logistic regression models were conducted to evaluate the effects of three sequential sets of predictors, including demographic/injury, socio-environmental/behavioral and health factors, basing the order of analysis on the Theoretical Risk and Prevention Model. RESULTS: The prevalence of PrU and MetS was 11.0% (n=36) and 35.3% (n=115), respectively. Ethnicity, smoking, alcohol consumption and MetS were statistically associated with PrU in the full model. Participants who were non-Hispanic (odds ratio (OR)=10.30, 95% confidence interval (CI): 3.46-30.65), smokers (OR=2.69, 95% CI: 1.00-7.27) and drank over 30 drinks per month (OR=5.26, 95% CI: 1.24-22.26) had greater odds of having a PrU compared with those who were Hispanic, non-smokers and non-drinkers, respectively. We also observed a positive association between MetS and PrU (ORMetS=3.71, 95% CI: 1.45-9.52), even after controlling for all other factors. CONCLUSION: Participants who had MetS had higher odds of PrU than those without MetS after adjusting for multiple covariates. Unhealthy behaviors such as smoking and excess drinking were positively associated with PrU.

Effects of aerobic exercise training on fitness and walking-related outcomes in ambulatory individuals with chronic incomplete spinal cord injury.

STUDY DESIGN: Single group, pretest-post-test study. OBJECTIVES: To determine the effects of a non-task-specific, voluntary, progressive aerobic exercise training (AET) intervention on fitness and walking-related outcomes in ambulatory adults with chronic motor-incomplete SCI. SETTING: Rehabilitation research center. METHODS: Ten ambulatory individuals (50% female; 57.94±9.33 years old; 11.11±9.66 years postinjury) completed voluntary, progressive moderate-to-vigorous intensity AET on a recumbent stepper 3 days per week for 6 weeks. The primary outcome measures were aerobic capacity (VO2peak (volume of oxygen that the body can use during physical exertion)) and self-selected overground walking speed (OGWS). Secondary outcome measures included walking economy, 6-minute walk test (6MWT), daily step counts, Walking Index for Spinal Cord Injury (WISCI-II), Dynamic Gait Index (DGI) and Berg Balance Scale (BBS). RESULTS: Nine participants completed all testing and training. Significant improvements in aerobic capacity (P=0.011), OGWS (P=0.023), the percentage of VO2peak used while walking at self-selected speed (P=0.03) and daily step counts (P=0.025) resulted following training. CONCLUSIONS: The results indicate that total-body, voluntary, progressive AET is safe, feasible, and effective for improving aerobic capacity, walking speed, and select walking-related outcomes in an exclusively ambulatory SCI sample. This study suggests the potential for non-task-specific aerobic exercise to improve walking following incomplete SCI and builds a foundation for further investigation aimed at the development of exercise based rehabilitation strategies to target functionally limiting impairments in ambulatory individuals with chronic SCI.

Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI.

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVES: To investigate a mediational model where pain (intensity and interference) and fatigue mediate the relationship between the use of mobility aids and moderate-to-severe depressive symptomatology among ambulatory participants with spinal cord injury (SCI). SETTING: A medical university in the southeastern United States. METHODS: Ambulatory adults (N=652) with chronic SCI responded to a mail-in survey. The Patient Health Questionnaire-9 was used to assess moderate-to-severe depressive symptomatology. The Brief Pain Inventory was used to assess pain intensity and interference, and the Modified Fatigue Impact Scale-5-item version was used to assess fatigue. Participants self-reported use of mobility aids. RESULTS: On examining mobility aids used for ambulation, 65% were found to have used at least one aid. Severe pain intensity was reported by 11%, and 14% reported severe pain interference. Disabling fatigue was reported by 10% of the participants. Twenty-one percent (n=138) reported moderate-to-severe levels of depressive symptoms. On examining the relationships between mobility aids and depressive symptomatology, using people as a mobility aid was associated with increased odds of depressive symptomatology (2.6) and always using a wheelchair was associated with lower odds (0.3). However, these relationships were no longer significant after controlling for the mediating variables pain intensity, pain interference and fatigue. CONCLUSIONS: Pain and fatigue mediate the relationship between usage of certain mobility aids and depressive symptomatology. The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while always using a wheelchair is associated with lower odds.