Pain medication misuse among participants with spinal cord injury.

STUDY DESIGN: Self-reported survey. OBJECTIVE: Our purpose was to identify the predictors of pain medication misuse (PMM) among participants with spinal cord injury (SCI). SETTING: A medical university in the southeastern United States. METHODS: A total of 919 adults with impairment from traumatic SCI of at least 1-year duration, who reported at least one painful condition and were taking prescription medication to treat pain, were included in this study. PMM was measured by the Pain Medication Questionnaire (PMQ). RESULTS: The average PMQ score was 19.7, with 25.8% of participants scoring at or above the cutoff of 25, which is indicative of PMM. A three-stage logistic regression analysis was conducted by sequentially adding three sets of predictors to the equation: (1) demographic and injury characteristics; (2) pain characteristics and (3) frequency of pain medication use. Age and education level were protective of PMM, whereas pain intensity, pain interference and pain medication use were risk factors. Number of painful days was not significant in the final model. CONCLUSION: PMM must be of concern after SCI, given its high prevalence among those with at least one painful condition and its relationship with pain indicators.

Prevalence of cigarette smoking and attempts to quit in a population-based cohort with spinal cord injury.

OBJECTIVE: The purposes of this study were to assess (i) prevalence of smoking in a population-based cohort of persons with spinal cord injury (SCI), (ii) history of quit attempts and (iii) the relationship between access to health care, socioeconomic status (SES), smoking status and history of quit attempts. STUDY DESIGN: Cross-sectional study. SETTING: Population-based SCI cohort. METHODS: A total of 833 adults with SCI of at least 1-year duration were identified through a population-based surveillance system. Current smoking status, attempts to quit smoking in the past year and seeking professional help to quit smoking were assessed. RESULTS: Over one-third (35.3%) of the sample were current smokers, of whom 75.4% had ever tried to quit, and of these, only 27.9% had ever sought professional help. Those with lower SES were more likely to be current smokers, as were those with less access to health care. Access to care was positively related to likelihood of having sought professional help. CONCLUSIONS: We found rates of smoking among persons with SCI to be well above national prevalence rates. We also found poorer access to care related to a greater likelihood of being a current smoker, had no association with trying to quit smoking, but decreased likelihood of using cessation support among those who did attempt to quit.

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.

Determinants of in-hospital death after acute spinal cord injury: a population-based study.

OBJECTIVES: First, to evaluate the influence of comorbid diseases and concomitant injuries on the risk of in-hospital death after traumatic spinal cord injury (TSCI). Second, to identify the risk characteristics of TSCI patients with likelihood of death. STUDY DESIGN: Population-based retrospective cohort study. SETTING: Sixty-two acute care hospitals in South Carolina, USA. METHODS: Records of 3389 TSCI patients hospitalized with acute TSCI were evaluated. Days elapsing from the date of injury to date of death established the survival time (T). Cox regression examined risk of in-hospital death as a function of counts of comorbid conditions and injuries along with their joint effects controlling for other covariates. RESULTS: Counts of comorbid conditions and injuries showed dose-dependent risk of death while in-hospital independent of demographical and clinical covariates. Hazard ratios (HR) for counts 3+, 2 and 1 comorbid conditions were 2.19 (P<0.001), 1.73 (P=0.005) and 1.20 (P=0.322), respectively. For counts of 4+, 3 and 2 other injuries were 1.85 (P<0.001), 1.81 (P<0.001) and 1.46 (P=0.022), respectively. The joint effect of the two was transadditive with statistically significant HR ranging from 1.72-3.14. CONCLUSION: Counts of comorbid conditions and injured body regions strongly indicate risk of in-hospital death after TSCI and their joint effects elicited dose-dependent gradient independent of demographical and clinical covariates. Assessing risk of in-hospital death based on joint use of counts of comorbid diseases and injuries is highly informative to target TSCI patients at high risk of dying.

Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population?

OBJECTIVE: To evaluate the association of demographic, behavioral and socioeconomic factors with all-cause mortality while controlling for health status among a cohort of participants with severe disability related to spinal cord injury (SCI). STUDY DESIGN: Prospective cohort study. SETTING: Data were analyzed at a major medical university in the Southeast United States of America. METHODS: Participants included 1361 adults with traumatic SCI of at least 1-year duration who were recruited through a large specialty hospital in the Southeast United States of America. Three Cox proportional hazard models were generated relating the predictors to all-cause mortality. RESULTS: Age, disability, smoking and income were significant in the final model. Both current (hazard ratio (HR)=2.03, 95% confidence interval (CI)=1.46-2.82) and former smokers (HR=1.58, CI=1.16-2.16) were at elevated hazard of mortality, as were those with incomes below $10,000 (HR=2.29, CI=1.53-3.44) and between $10,000 and $35,000 (HR=1.47, CI=1.03-2.10). CONCLUSIONS: Even after controlling for health and severity of disability, the coefficients for smoking and income were significant, exceeding that reported previously within the general population. The importance of these factors may be magnified after severe disability, even though life expectancy is already greatly diminished in this population.

A longitudinal study of depression in survivors of spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVES: The objective of this study is to assess depression over a 5-year period in persons with spinal cord injury (SCI) and to assess risk factors for depression over time. SETTING: Rehabilitation hospitals in the Southeast and Midwest. METHODS: Participants included 801 adults with residual effects from a traumatic SCI averaging over 15 years post injury. Participants responded to two questionnaires, one in 2002 (Time1) and another in 2008 (Time 2). Probable major depression (PMD) was measured by the Older Adult Health and Mood Questionnaire. RESULTS: In all, 22.1% of participants had PMD at Time 1 and 20.2% at Time 2. There was a non-significant trend for change in PMD status (P=0.058). Of those who had PMD at Time 1, 55.7% had PMD at Time 2. Between the two time points, the most change occurred in the group with clinically significant symptomatology. Demographic factors (race-gender, age, time since injury) and health behaviors (pain medication use, hours out of bed, days out of the house, exercise) were significantly associated with PMD over time. Socioeconomic factors (income, education) were significantly related to depression but were not significant after controlling for behavioral factors. CONCLUSION: Depression is fairly consistent over time in persons with SCI, with the majority of change coming from those in the clinically significant symptomatology group. Examining depression at multiple time points, our results underscore the importance of health behaviors in relation to PMD, even after controlling for demographic, injury and environmental factors.

Stability of predictors of mortality after spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVES: To identify the stability of socio-environmental, behavioral and health predictors of mortality over an 8-year time frame. SETTING: Data were analyzed at a large medical university in the Southeast United States of America (USA). METHODS: Adults with residual impairment from a spinal cord injury (SCI) who were at least 1-year post-injury at assessment were recruited through a large specialty hospital in the Southeast USA. A total of 1209 participants were included in the final analysis. A piecewise exponential model with two equal time intervals (8 years total) was used to assess the stability of the hazard and the predictors over time. RESULTS: The hazard did significantly change over time, where the hazard in the first time interval was significantly lower than the second. There were no interactions between the socio-environmental, behavior or health factors and time, although there was a significant interaction between age at injury (a demographic variable) and time. CONCLUSION: These results suggest there is stability in the association between the predictors and mortality, even over an 8-year time period. Results reinforce the use of historic variables for prediction of mortality in persons with SCI.

Gainful employment and risk of mortality after spinal cord injury: effects beyond that of demographic, injury and socioeconomic factors.

OBJECTIVE: To evaluate the association of three levels of gainful employment with the risk of mortality after traumatic spinal cord injury (SCI) while controlling for known predictors of mortality status (including education and income). STUDY DESIGN: Prospective cohort study. SETTING: A total of 20 federally funded SCI Model Systems of care in the United States. METHODS: Participants included 7955 adults with traumatic SCI. Preliminary assessments were conducted between 1995 and 2006. Mortality status was determined by the Social Security Death Index (1308 deaths). A two-stage logistic regression model was used to estimate the chance of dying in any given year. Life expectancy was calculated under different economic assumptions. RESULTS: Compared with those who were working 30+ h per week, the odds of mortality was 1.37 for those who worked 1-29 h and 1.67 for those who were unemployed. The addition of gainful employment only modestly reduced the effects of household income and education, both of which remained significant. For instance, the odds of mortality for household income (referent $75 000+) decreased from 1.50 to 1.38 for $25 000-$75 000 and from 2.10 to 1.82 for < $25 000. Life expectancy varied widely depending on socioeconomic characteristics more than doubling under certain assumptions. CONCLUSION: Substantial variation in mortality is attributable to employment, above and beyond the effects of previously established demographic, injury and socioeconomic predictors. Although some excess mortality may be the inevitable consequence of SCI, risk is substantially increased with poor socioeconomic characteristics.

Association of spasticity and life satisfaction after spinal cord injury.

STUDY DESIGN: Cross-sectional survey; secondary analysis of existing data by linear regression analysis between spasticity and quality of life. OBJECTIVE: To identify the relationship between spasticity and life satisfaction as measured by three multi-item factor scales and a rating of overall quality of life among participants with spinal cord injury (SCI). SETTING: Large specialty hospital in the Southeastern United States. METHODS: Participants included 1549 adults with traumatic spinal cord injuries, at least 18 years of age and a minimum of 1-year post-injury at survey. Outcome measures included: (1) home life satisfaction, (2) global satisfaction, (3) vocational satisfaction, (4) overall quality of life and (5) three subscales from the Patient Reported Impact of Spasticity Measure. RESULTS: Three aspects of spasticity (daily activities, positive impact and spasticity at its worst) all were negatively correlated with home life satisfaction, global satisfaction and overall quality of life. Only the daily activities scale and the spasticity at its worst rating had a significant negative correlation with vocational satisfaction. CONCLUSION: Spasticity is negatively associated with quality of life after SCI. These negative outcomes need to be considered in an individual's rehabilitation and treatment methods.

Psychological factors affecting alcohol use after spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVE: The purpose of this study is to assess risk factors, including personality and socioeconomic indicators, with alcohol use among persons with spinal cord injury (SCI). SETTING: A large rehabilitation hospital in the Southeastern United States. METHODS: A total of 1549 participants responded to a survey on outcomes after SCI. We used polychotomous logistic regression to assess the relationships of personality and socioeconomic factors with alcohol use. RESULTS: In this study population, 19.3% were heavy drinkers, 29.4% moderate and 51.7% abstinent. Annual household income and education were both associated with heavy alcohol use, with persons with higher income or education more likely to be heavy drinkers. Impulsive sensation seeking, neuroticism-anxiety and aggression-hostility were associated with increased odds of heavy drinking. CONCLUSION: This study adds to the body of evidence indicating a substantial portion of individuals with SCI are heavy drinkers, and that personality and socioeconomic status are associated with heavy drinking.

Delayed entry into employment after spinal cord injury: factors related to time to first job.

STUDY DESIGN: Data were cross-sectional and were collected by survey methodology. OBJECTIVES: To investigate factors predictive of length of time between spinal cord injury (SCI) onset and start of first post-injury employment and full-time employment. SETTING: A large specialty hospital in the Southeastern United States, with additional participant samples from two hospitals in the Midwestern United States. METHODS: Participants were identified from patient records at the participating hospitals. They met the following three exclusion/inclusion criteria: traumatic SCI, at least 18 years of age at time of survey, and a minimum of 1-year after SCI. Outcome measures were years from injury onset to beginning first post-injury job and years to first full-time post-injury job. Two separate models were developed for each outcome using a regression analysis. All those 10 years and more post-injury were censored (that is eliminated) in the analysis. RESULTS: Having a higher level of education, less severe injury, being Caucasian, and returning to the pre-injury employer were associated with a shorter interval to initiation of employment with 10-year censoring. In addition to these variables, gender was associated with time to return to first full-time job. CONCLUSION: The findings underscore the importance of using pre-injury education and opportunities to return to the pre-injury employer to minimize the length of time until initiation of employment after SCI.

Risk of hospitalizations after spinal cord injury: relationship with biographical, injury, educational, and behavioral factors.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To assess the risk factors associated with hospitalization and the relationship of individual health behaviors with hospitalizations after spinal cord injury (SCI). SETTING: A large specialty hospital in the southeastern USA. METHODS: Persons with SCI responded (n=1386) to a mail survey assessing various aspects of their health, including health behaviors and number of hospitalizations in the past year. Logistic regression was used to assess the relationships between biographical, injury, educational, and health behavior factors with hospitalization in the past year. RESULTS: Overall, 36.6% of participants were hospitalized on at least one occasion during the earlier year. Two biographical and injury characteristics were associated with hospitalization: race and SCI severity. Specifically, minorities and persons with non-ambulatory high cervical or non-cervical SCI were more likely to be hospitalized. Three behavioral factors were significantly associated with hospitalization after controlling for biographical and injury characteristics. Persons who used prescription medications, those who engaged more in smoking behaviors, and persons who reported more SCI-specific health behaviors were more likely to be hospitalized. CONCLUSION: Specific health behaviors are associated with an increased hospitalization among persons with SCI. Future research is needed to assess the time sequence of these relationships.