Using the consolidated Framework for Implementation Research to integrate innovation recipients' perspectives into the implementation of a digital version of the spinal cord injury health maintenance tool: a qualitative analysis.

BACKGROUND: Despite advances in managing secondary health complications after spinal cord injury (SCI), challenges remain in developing targeted community health strategies. In response, the SCI Health Maintenance Tool (SCI-HMT) was developed between 2018 and 2023 in NSW, Australia to support people with SCI and their general practitioners (GPs) to promote better community self-management. Successful implementation of innovations such as the SCI-HMT are determined by a range of contextual factors, including the perspectives of the innovation recipients for whom the innovation is intended to benefit, who are rarely included in the implementation process. During the digitizing of the booklet version of the SCI-HMT into a website and App, we used the Consolidated Framework for Implementation Research (CFIR) as a tool to guide collection and analysis of qualitative data from a range of innovation recipients to promote equity and to inform actionable findings designed to improve the implementation of the SCI-HMT. METHODS: Data from twenty-three innovation recipients in the development phase of the SCI-HMT were coded to the five CFIR domains to inform a semi-structured interview guide. This interview guide was used to prospectively explore the barriers and facilitators to planned implementation of the digital SCI-HMT with six health professionals and four people with SCI. A team including researchers and innovation recipients then interpreted these data to produce a reflective statement matched to each domain. Each reflective statement prefaced an actionable finding, defined as alterations that can be made to a program to improve its adoption into practice. RESULTS: Five reflective statements synthesizing all participant data and linked to an actionable finding to improve the implementation plan were created. Using the CFIR to guide our research emphasized how partnership is the key theme connecting all implementation facilitators, for example ensuring that the tone, scope, content and presentation of the SCI-HMT balanced the needs of innovation recipients alongside the provision of evidence-based clinical information. CONCLUSIONS: Understanding recipient perspectives is an essential contextual factor to consider when developing implementation strategies for healthcare innovations. The revised CFIR provided an effective, systematic method to understand, integrate and value recipient perspectives in the development of an implementation strategy for the SCI-HMT. TRIAL REGISTRATION: N/A.

The Swedish version of the Moorong Self-Efficacy Scale (s-MSES) - translation process and psychometric properties in a community setting.

STUDY DESIGN: Psychometric study. OBJECTIVES: To i) describe the translation process and ii) explore the data completeness, targeting, reliability and aspects of validity of the Swedish version of Moorong Self-Efficacy Scale (s-MSES). SETTINGS: Community rehabilitation program. METHODS: Ninety-two program participants and 42 peer mentors with spinal cord injury (SCI) in Active Rehabilitation training programs (enrolled in the International Project for the Evaluation of activE Rehabilitation (Inter-PEER)) were included. The s-MSES was completed online, once for program participants and twice for peer mentors. The translation process was based on guidelines and involved researchers, clinicians and consumers. RESULTS: Minor linguistic adaptations were made. Ninety-one percent obtained a total score. As expected, peer mentors exhibited ceiling effects in all subscales. Cronbach´s alpha for the total scale was 0.92 (subscales 0.74-0.83). The intraclass correlation coefficient was excellent for the total and subscale scores (0.78-0.91). The s-MSES exhibited sensitivity to changes and there were no systematic changes between evaluation points. The s-MSES correlated significantly and positively with life satisfaction and resilience, and negatively with depression/anxiety. CONCLUSION: The s-MSES was translated through a rigorous, consumer-involved process ensuring accurate linguistic translation and cultural adaptation. Our results support the data completeness, targeting, reliability and aspects of validity of the s-MSES. The s-MSES can thus be considered suitable to assess self-efficacy in persons with SCI in community rehabilitation settings. The now available Swedish version of the MSES will facilitate national research, clinical evaluations and international comparisons. SPONSORSHIP: Not applicable.

Unmet healthcare needs, access to services and experiences with health providers among persons with spinal cord injury in Australia.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: Appropriate and timely lifelong access to healthcare following a spinal cord injury (SCI) is critical, yet unmet healthcare needs in this population are common. Poor experiences with healthcare providers can be a barrier to health-seeking behaviour, and we hypothesised that there would be an association between unmet healthcare needs and care experiences. This study aimed to: (1) describe healthcare provider utilisation in the past year, unmet care needs and satisfaction with healthcare services; (2) explore the association between experiences with healthcare providers and unmet healthcare needs; and (3) explore the association between healthcare provider utilisation and participant characteristics, including unmet healthcare needs. SETTING: Community. METHODS: Analysis of data for 1579 Australians aged ≥ 18, who were ≥ 1-year post-SCI and living in the community. Bayesian penalised regression was used to model six binary outcomes: unmet healthcare needs; the use of general practitioners (GPs), allied health practitioners, rehabilitation specialists; medical specialists; and hospitalisations in the past 12-months. RESULTS: Unmet needs were reported by 17% of participants, with service cost the common deterrent. There was evidence of an effect for provider experiences on unmet healthcare needs, but no evidence that unmet healthcare needs was associated with the use of GPs, allied health practitioners, and rehabilitation or medical specialists. CONCLUSIONS: Unmet healthcare needs were reported in the context of high healthcare use and large proportions of secondary conditions in a cohort with long-term SCI. Improved health access for people with SCI include better primary-secondary care collaboration is needed.

Relationship between secondary health conditions and life satisfaction in persons with spinal cord injury: study across twenty-one countries.

PURPOSE: To determine the relationships between impact of secondary health conditions (SHCs), treatment of SHCs, and life satisfaction (LS) following spinal cord injury (SCI) across 21 countries. Hypotheses were as follows: (1) Persons with SCI and fewer SHCs report higher LS and (2) Persons who receive treatment for SHCs report higher LS than those who do not receive treatment. METHODS: Cross-sectional survey, including 10,499 persons with traumatic or non-traumatic SCI aged 18 years or older and living in the community. To assess SHCs, 14 items adapted from the SCI-Secondary Conditions Scale were used (range 1-5). SHCs index was calculated as the mean of all 14 items. LS was assessed using a selection of 5 items from the World Health Organization Quality of Life Assessment. LS index was calculated as the mean of these 5 items. RESULTS: South Korea, Germany, and Poland exhibited the highest (2.40-2.93) and Brazil, China, and Thailand the lowest (1.79-1.90) impact of SHCs. Indexes for LS and SHCs were inversely correlated (- 0.418; p < 0.001). Mixed Model Analysis showed that the fixed effect (key predictors of the study) of SHCs index (p < 0.001) and the positive interaction between SHCs index and treatment (p = 0.002) were significant determinants of LS. CONCLUSION: Persons with SCI across the world are more likely to perceive better LS if they experience fewer SHCs and receive treatment for SHCs, in comparison to those who do not. Prevention and treatment of SHCs following SCI should be a high priority in order to improve the lived experience and enhance LS.

Integrating competency analysis into national rehabilitation workforce evaluation: a case study.

BACKGROUND: Establishing a workforce capable of meeting population needs is contingent on evaluation that can inform sound policy and planning. Health workforce evaluation has traditionally relied on health labour market analysis and workload estimations. To date, competency analysis has not been included in national health workforce evaluation, despite that fact that the findings may go far in guiding decisions around workforce composition, optimisation and education and training. This case study sought to assess the feasibility and perceived added value of integrating competency analysis into national rehabilitation workforce evaluation, and to determine how competency analysis can shape rehabilitation workforce planning. The findings of the case study can be used to explore the integration of competency analysis in the evaluation of other health-related occupational groups. METHODS: Participant observation was complemented by key informant interviews with experts engaged in the national rehabilitation workforce evaluation in Poland. These experts represented stakeholders in policy, education, research, clinical practice and professional associations. RESULTS: The results indicated that competency analysis can be feasibly integrated into national rehabilitation workforce evaluation, particularly when implementation is supported through the use of online platforms. However, the collection of additional data using other tools, such as a survey of the behaviours and tasks of a wider sample of rehabilitation workers, could strengthen data reliability. Experts perceived findings of the competency analysis to be valuable for expanding the understanding of rehabilitation, shedding light on task allocation and deployment of the existing rehabilitation workforce, and advocating for the rehabilitation workforce to be strengthened, especially in relation to those occupations which may not be recognised or valued as rehabilitation workers. Although it was not possible to fully explore the impact of competency analysis data on rehabilitation workforce planning and development in this study, experts suggested that its availability would likely foster greater cooperation among occupations, which has been missing at the policy and planning level to date. It further demonstrates what competency data should be collected and reported, and provides richer information to guide decisions. CONCLUSIONS: Competency analysis complements traditional labour market analysis and workload estimates, adding depth to the understanding of how members of the workforce perform and perceive themselves, and how deficiencies in the workforce impact on the provision of care to specific population groups.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 3. Drivers of quality of life in people with spinal cord injury.

STUDY DESIGN: Cross-sectional population-based survey for the Australian cohort of the International Spinal Cord Injury (InSCI) Community Survey. OBJECTIVES: To differentiate subgroups of people with spinal cord injury (SCI) who self-report good and poor overall quality of life (QoL) using domains of the International Classification of Functioning (ICF), and to evaluate how these factors contribute to QoL when considered together, while controlling confounders. SETTING: Australian survey data from four state-wide SCI services, one government insurance agency, and three not-for-profit consumer organisations. METHODS: Explanatory factors for QoL were compared between participants reporting poor vs. good QoL. Path models estimated total, direct and mediated contributions from each explanatory factor to QoL ratings after accounting for confounders. RESULTS: Most participants (62%) reported good or very good QoL, 12% reported poor or very poor QoL. When explanatory factors were considered together, the strongest total effects on QoL involved social integration (+0.36 SDs), subjective social position (+0.29), secondary health condition burden (-0.28), activity/participation problem burden (-0.26), day-to-day assistance (-0.26), mental health (+0.18), pain (-0.16), self-efficacy (+0.15), vitality (+0.14) and environmental barriers (-0.11). Effects of social integration, mental health, vitality, self-efficacy, pain and activity/participation problems were partly or wholly direct. CONCLUSION: Opportunities to improve QoL in people with SCI exist at every level of the health system. Virtually all aspects of the ICF framework make a substantive difference to QoL outcomes. Social and psychological factors and ability to complete desired activities have key direct effects and influence effects of secondary health condition burden and environmental barriers.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) community survey: 1. population-based design, methodology and cohort profile.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To describe design and methods of Australian arm of International Spinal Cord Injury (Aus-InSCI) community survey, reporting on participation rates, potential non-response bias and cohort characteristics. SETTING: Survey of community-dwelling people with SCI at least 12 months post-injury, recruited between March 2018 and January 2019, from state-wide SCI services, a government insurance agency and not-for-profit consumer organisations across four Australian states. METHODS: The Aus-InSCI survey combined data for people with SCI from nine custodians, using secure data-linkage processes, to create a population-based, anonymised dataset. The Aus-InSCI questionnaire comprised 193 questions. Eligibility, response status and participation rates were calculated. Descriptive statistics depict participant characteristics. Logistic regression models were developed for probability of participation, and inverse probability weights generated to assess potential non-response bias. RESULTS: 1579 adults with SCI were recruited, a cooperation rate of 29.4%. Participants were predominantly male (73%), with 50% married. Mean age was 57 years (range 19-94) and average time post-injury 17 years (range 1-73). Paraplegia (61%) and incomplete lesions (68%) were most common. Males were more likely than females to have traumatic injuries (p < 0.0001) and complete lesions (p = 0.0002), and younger age-groups were more likely to have traumatic injuries and tetraplegia (p < 0.0001). Potential non-response bias evaluated using selected outcomes was found to be negligible in the Aus-InSCI cohort. CONCLUSIONS: The Aus-InSCI survey made efforts to maximise coverage, avoid recruitment bias and address non-response bias. The distributed, linked and coded (re-identifiable at each custodian level) 'virtual quasi-registry' data model supports systematic cross-sectional and longitudinal research.

Factors Related to Engagement in Employment After Spinal Cord Injury in Australia: A Cross-sectional Study.

OBJECTIVE: To explore the association between sociodemographic, health, functional independence, and environmental variables with engagement in paid work for people with spinal cord injury (SCI). DESIGN: Self-reported, cross-sectional Australian data from a large international SCI survey. SETTING: Community-based. PARTICIPANTS: 1189 working-age people with SCI (18-67 years) or aged >67 years and engaged in paid employment. Respondents were community based and at least 1 year after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment and work integration variables. Bayesian penalized regression was used to determine associations between 23 predictor variables and engagement in paid work. RESULTS: Most participants (87%) were employed pre-injury, with 39% in paid employment at the time of the survey. Participants who attained a master's/doctoral degree (odds ratio [OR]=3.01; 95% credible interval [CrI], 1.63, 5.44) and those married (OR=1.68; 95% CrI, 1.13, 2.49) were more likely to be engaged in paid work. Women (OR=0.55; 95% CrI, 0.37, 0.81), people receiving a disability pension (OR=0.17; 95% CrI, 0.13, 0.24), and older participants (OR=0.75; 95% CrI, 0.63, 0.90) were less likely to be in paid work. Working participants identified hardships including problems completing their work (60%) and accessing the workplace (32%), as well as unmet needs relating to assistive devices required for completing their work (50%). CONCLUSIONS: Findings from the current study can assist in directing resources to subgroups within the SCI population who need greater assistance or intervention related to employment outcomes, including through vocational rehabilitation services/programs. Unmet needs and workplace issues expressed by employed individuals identify gaps in work integration and satisfaction that could affect employment sustainability that need to be addressed.

Comparison of Life Satisfaction in Persons With Spinal Cord Injury Living in 22 Countries With Different Economic Status.

OBJECTIVE: To analyze and compare life satisfaction (LS) in persons with spinal cord injury (SCI) living in 22 countries participating in the International Spinal Cord Injury (InSCI) community survey. The study tested the hypothesis that there are differences in LS across InSCI countries according to the countries' economic status specified as gross domestic product per capita purchased power parity (GDP-PPP). DESIGN: Cross-sectional survey. SETTING: Community setting (22 countries representing all 6 World Health Organization regions). PARTICIPANTS: Persons (N=12,108) with traumatic or nontraumatic SCI aged at least 18 years, living in the community and able to respond to one of the available language versions of the questionnaire. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: LS measured by 5 items selected from the World Health Organization Quality of Life Assessment-BREF: satisfaction with overall quality of life, health, daily activities, relationships, and living conditions. LS index was calculated as the mean of these 5 items. RESULTS: The highest level of LS was reported by persons with SCI living in the United States, Malaysia, and Switzerland (mean range, 3.76-3.80), and the lowest was reported by persons with SCI living in South Korea, Japan, and Morocco (mean range, 2.81-3.16). There was a significant cubic association between LS index and GDP-PPP. Regression tree analysis revealed the main variables differentiating LS index were GDP-PPP and monthly income, followed by time since injury and education. CONCLUSIONS: Life satisfaction reported by persons with SCI related mainly to their country economic situation expressed by GDP-PPP and monthly income. The results of this study underscore the need for policy dialogues to avoid inequalities and improve the life experience in persons with SCI.

An international survey of the structure and process of care for traumatic spinal cord injury in acute and rehabilitation facilities: lessons learned from a pilot study.

BACKGROUND: To describe the key findings and lessons learned from an international pilot study that surveyed spinal cord injury programs in acute and rehabilitation facilities to understand the status of spinal cord injury care. METHODS: An online survey with two questionnaires, a 74-item for acute care and a 51-item for rehabilitation, was used. A subset of survey items relevant to the themes of specialized care, timeliness, patient-centeredness, and evidence-based care were operationalized as structure or process indicators. Percentages of facilities reporting the structure or process to be present, and percentages of indicators met by each facility were calculated and reported separately for facilities from high-income countries (HIC) and from low and middle-income countries (LMIC) to identify "hard to meet" indicators defined as those met by less than two-thirds of facilities and to describe performance level. RESULTS: A total of 26 acute and 26 rehabilitation facilities from 25 countries participated in the study. The comparison of the facilities based on the country income level revealed three general observations: 1) some indicators were met equally well by both HIC and LMIC, such as 24-hour access to CT scanners in acute care and out-patient services at rehabilitation facilities; 2) some indicators were hard to meet for LMIC but not for HIC, such as having a multidisciplinary team for both acute and rehabilitation settings; and 3) some indicators were hard to meet by both HIC and LMIC, including having peer counselling programs. Variability was also observed for the same indicator between acute and rehabilitation facilities, and a wide range in the total number of indicators met among HIC facilities (acute 59-100%; rehabilitation 36-100%) and among LMIC facilities (acute: 41-82%; rehabilitation: 36-93%) was reported. CONCLUSIONS: Results from this international pilot study found that the participating acute and rehabilitation facilities on average adhered to 74% of the selected indicators, suggesting that the structure and processes to provide ideal traumatic spinal cord injury care were broadly available. Recruiting a representative sample of SCI facilities and incorporating regional attributes in future surveys will be helpful to examine factors affecting adherence to indicators.

Australian arm of the International Spinal Cord Injury (Aus-InSCI) Community Survey: 2. Understanding the lived experience in people with spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To identify common problems across key domains of functioning, health and wellbeing, as well as evaluate self-reported quality of life (QoL) by people with SCI, examining differences by age, gender, injury characteristics and level of mobility. SETTING: Data from four state-wide SCI clinical services, one government insurance agency and three not-for-profit consumer organisations. METHODS: Participants were 18 years or over with SCI and at least 12 months post-injury, recruited between Mar'18 and Jan'19. The Aus-InSCI questionnaire comprised 193 questions, including socio-demographics, SCI characteristics, body functions and structures, activities and participation, environmental and personal factors, and appraisal of health and well-being. General linear model was used to examine differences in functioning and QoL. RESULTS: Participants (mean age 57 years, range 19-94 years) with tetraplegia and/or complete injuries had more health problems, activity/participation problems and environmental barriers. However, self-rated overall QoL did not differ for injury level or completeness. Participants with more recent injuries exhibited lower independence levels, more mental health problems and poorer satisfaction with self and their living conditions. Major activity/participation problems related to intimate relationships and accessing public transportation. Less than half of the working age population were engaged in paid work. The top two environmental barriers frequently related to accessing public places or homes and unfavourable climatic conditions. CONCLUSIONS: This large, comprehensive community survey draws a detailed picture of the lived experience of people with SCI in Australia, identifying priority needs, gaps in services and barriers to achieving a full and satisfying life.

The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord injury: 2021 update.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: The objective was to update the 2016 version of the Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient, outpatient and community SCI rehabilitation settings in Canada. METHODS: The guidelines were updated in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS: The working group identified and reviewed 46 additional relevant articles published since the last version of the guidelines. The panel agreed on 3 new screening and diagnosis recommendations and 8 new treatment recommendations. Two key changes to these treatment recommendations included the introduction of general treatment principles and a new treatment recommendation classification system. No new recommendations to model of care were made. CONCLUSIONS: The CanPainSCI recommendations for the management of neuropathic pain after SCI should be used to inform practice.

An Exploratory EEG Analysis on the Effects of Virtual Reality in People with Neuropathic Pain Following Spinal Cord Injury.

Neuropathic pain in people with spinal cord injury is thought to be due to altered central neuronal activity. A novel therapeutic intervention using virtual reality (VR) head-mounted devices was investigated in this study for pain relief. Given the potential links to neuronal activity, the aim of the current study was to determine whether use of VR was associated with corresponding changes in electroencephalography (EEG) patterns linked to the presence of neuropathic pain. Using a within-subject, randomised cross-over pilot trial, we compared EEG activity for three conditions: no task eyes open state, 2D screen task and 3D VR task. We found an increase in delta activity in frontal regions for 3D VR with a decrease in theta activity. There was also a consistent decrease in relative alpha band (8-12 Hz) and an increase in low gamma (30-45 Hz) power during 2D screen and 3D VR corresponding, with reduced self-reported pain. Using the nonlinear and non-oscillatory method of extracting fractal dimensions, we found increases in brain complexity during 2D screen and 3D VR. We successfully classified the 3D VR condition from 2D screen and eyes opened no task conditions with an overall accuracy of 80.3%. The findings in this study have implications for using VR applications as a therapeutic intervention for neuropathic pain in people with spinal cord injury.

Development and Validation of the WHO Rehabilitation Competency Framework: A Mixed Methods Study.

OBJECTIVES: To identify the competencies, behaviors, activities, and tasks required by the rehabilitation workforce, and their core values and beliefs, and to validate these among rehabilitation professionals and service users. DESIGN: Mixed methods study, involving a content analysis of rehabilitation-related competency frameworks, a modified Delphi study, and a consultation-based questionnaire of service users. SETTING: Desk-based research. PARTICIPANTS: Participants who completed the first (N=77; 47%) and second (N=68; 67%) iterations of the modified Delphi study. Thirty-seven individuals participated in the service user consultation. Collectively, the participants of the mixed methods study represented a significant range of rehabilitation professions from a broad range of countries, as well as both high- and low-income settings. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: The mixed methods study resulted in the inclusion of 4 core values, 4 core beliefs, 17 competencies, 56 behaviors, 20 activities, and 62 tasks in the Rehabilitation Competency Framework. The content analysis of rehabilitation-related competency frameworks produced an alpha list of competencies, behaviors, activities and tasks ("statements"), which were categorized into 5 domains. The final iteration of the modified Delphi study revealed an average of 95% agreement with the statements, whereas the service user consultation indicated an average of 87% agreement with the statements included in the questionnaire. CONCLUSIONS: Despite the diverse composition of the rehabilitation workforce, this mixed methods study demonstrated that a strong consensus on competencies and behaviors that are shared across professions, specializations, and settings, and for activities and tasks that collectively capture the scope of rehabilitation practice. The development of the Rehabilitation Competency Framework is a pivotal step toward the twin goals of building workforce capability to improve quality of care and strengthening a common rehabilitation workforce identity that will bolster its visibility and influence at a systems-level.

A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study.

BACKGROUND: Timely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement. METHODS: This record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013-2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications. RESULTS: Inclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others. CONCLUSIONS: Getting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

Employment outcomes following spinal cord injury: a population-based cross-sectional study in Australia.

STUDY DESIGN: Self-reported cross-sectional data for the Australian cohort participating in the International Spinal Cord Injury Community survey. OBJECTIVES: To contextualise post-injury employment for people with spinal cord injury (SCI) in Australia, including work participation rates, time to resuming work, underemployment and pre- and post-SCI employment changes. SETTING: Australian survey data from four state-wide SCI services, one government insurance agency and three not-for-profit consumer organisations across New South Wales, Queensland, South Australia and Victoria. METHODS: Data were analysed from 1579 participants with SCI who are at least 1-year post discharge from an inpatient facility. Survey measures included 16-items dedicated to employment. Pre- and post-injury job titles were based on the International Standard Classification of Occupations (ISCO-08) major classification. A mix of chi-squared, t-test and negative binomial regression were used to analyse data. RESULTS: The absolute post-injury employment rate was 49.9%, with one-third of the sample currently working. Pre-injury employment and engagement with vocational rehabilitation resulted in higher employment rates. Individuals who were unable to return immediately following inpatient rehabilitation took mean 28 months (SD, 35.9) to return. Time to employment was significantly lengthier for those without pre-injury jobs, at 59.7 months [SD, 43.8] (p < 0.001). Engagement in less manual roles increased post-injury, accounting for three quarters of post-SCI jobs. Underemployment was identified by 16.6% of those currently working. CONCLUSIONS: While there are current services and programmes in place in Australia that support post-injury employment, findings indicate a need for more comprehensive early intervention focused services targeted towards employers and individuals.

The short-term effects of head-mounted virtual-reality on neuropathic pain intensity in people with spinal cord injury pain: a randomised cross-over pilot study.

STUDY DESIGN: Within-subject, randomised cross-over trial. OBJECTIVES: To determine whether a commercially available 3D head-mounted (HMD) virtual reality (VR) device results in significant reductions in neuropathic pain compared to using a 2D screen device in people with spinal cord injury (SCI). SETTING: Greenwich Hospital, Sydney, Australia. METHODS: Sixteen men with established SCI and chronic neuropathic pain participated in a single-session randomised cross-over trial. We compared the effects of 3D HMD VR and a 2D screen application on SCI neuropathic pain intensity and levels of perceived presence. RESULTS: Participants reported significantly lower pain intensity after 3D HMD VR compared to 2D screen application (1.9 ± SD 1.8 versus 3.4 ± SD 1.6, mean 95% CI: 1.5, P < 0.0001). Participants reported significantly higher perceived levels of presence with the 3D HMD VR compared to 2D screen of (49.6 ± SD 8.9 versus 32.8 ± SD 11.1, mean 95% CI: 16.6, P < 0.0001). Increased perceived presence was associated with significantly lower pain intensity regardless of randomised sequencing of the two conditions (mean 95% CI: 0.06, P = 0.005). Effect size for pain reduction using 3D HMD VR was 0.80. CONCLUSIONS: We suggest that 3D HMD VR may provide neuropathic pain relief for people with SCI. Given the lack of cybersickness and ease of access, we propose that immersive VR could be a helpful adjunct to current pharmacotherapy. Further research is required to show that VR can be effective for more long-term reductions in SCI pain.

Proposing a re-conceptualisation of competency framework terminology for health: a scoping review.

BACKGROUND: Competency frameworks are being taken up by a growing number of sectors and for a broad range of applications. However, the topic of competency frameworks is characterised by conceptual ambiguity, misunderstanding and debate. Lack of consistency in the conceptualisation and use of key terminology creates a barrier to research and development, consensus, communication and collaboration, limiting the potential that competency frameworks have to deal with real workforce challenges. This paper aims to advance the field by conducting a detailed review of the literature to understand the underlying causes of conceptual differences and divergent views and proposing a re-conceptualisation of competency framework terminology for use by the health sector. METHODS: A broad scoping review of literature was conducted to identify publications relating to the conceptualisation of competency frameworks and key terms, examine how they are conceptualised and determine how this evolved. In addition, a purposive sample of health-related competency frameworks was chosen to illustrate how the terms and concepts are currently being applied in the health context. RESULTS: Of the 4 155 records identified, 623 underwent text searches and broad quantitative analysis, and 70 were included for qualitative analysis. Quantitative analysis identified 26 key terms, which were coded under six thematic headings. Qualitative analysis using the thematic areas revealed two distinct conceptualisations of competency frameworks and their terminology emerging concurrently in the education and employment sectors, with different underpinnings and purposes. As competency frameworks have developed, these two conceptualisations intertwined, resulting in the same terms being used to convey different concepts. Examination of health-related frameworks showed that this merging of concepts is prominent, with lack of consistency in definitions and use of key terms even within a single organisation. DISCUSSION AND CONCLUSIONS: Building on previous efforts to address the lack of conceptual clarity surrounding competency frameworks, this paper proposes a re-conceptualisation of the terminology that encompasses two distinct competency framework interpretations, using a glossary of mutually exclusive terms to differentiate concepts. The re-conceptualisation holds relevance for multiple competency framework applications within health, enabling harmonisation, clear communication, consensus-building and effective implementation of competency frameworks.

Traumatic spinal cord injury in Victoria, 2007-2016.

OBJECTIVE: To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016. MAIN OUTCOMES AND MEASURES: Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more). RESULTS: There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths). CONCLUSIONS: Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support.

Bowel Dysfunction in Spinal Cord Injury.

PURPOSE OF REVIEW: To evaluate and report current evidence regarding the management of bowel dysfunction in spinal cord injury. There is a paucity of high-quality large studies on which to base management advice. RECENT FINDINGS: Recent research has focused on defining the nature of symptomatology of bowel dysfunction in SCI and describing the effects on quality of life and social interactions. Technical aspects of colonoscopy have received attention, and aspects of understanding the pathophysiology in relation to both neural and non-neural dysfunction have been studied. There has been refinement and expansion of the pharmacological and non-pharmacological treatment options for bowel dysfunction in SCI. Management of bowel dysfunction in SCI requires a comprehensive and individualized approach, encompassing lifestyle, toileting routine, stimulation, diet, medications, and surgery. Further high-quality research is required to inform best practice.