Dual-energy X-ray absorptiometry and fracture prediction in patients with spinal cord injuries and disorders.

Low T-scores at the hip predict incident fractures in persons with a SCI. INTRODUCTION: Persons with a spinal cord injury (SCI) have substantial morbidity and mortality following osteoporotic fractures. The objective of this study was to determine whether dual-energy X-ray absorptiometry (DXA) measurements predict osteoporotic fractures in this population. METHODS: A retrospective historical analysis that includes patients (n = 552) with a SCI of at least 2 years duration who had a DXA performed and were in the VA Spinal Cord Disorders Registry from fiscal year (FY) 2002-2012 was performed. RESULTS: The majority of persons (n = 455, 82%) had a diagnosis of osteoporosis or osteopenia, with almost half having osteoporosis. BMD and T-scores at the lumbar spine were not significantly associated with osteoporotic fractures (p > 0.48) for both. In multivariable analyses, osteopenia (OR = 4.75 95% CI 1.23-17.64) or osteoporosis (OR = 4.31, 95% CI 1.15-16.23) compared with normal BMD was significantly associated with fractures and higher T-scores at the hip were inversely associated with fractures (OR 0.73 (95% CI 0.57-0.92)). There was no significant association of T-scores or World Health Organization (WHO) classification with incident fractures in those with complete SCI (p > 0.15 for both). CONCLUSION: The majority (over 80%) of individuals with a SCI have osteopenia or osteoporosis. DXA-derived measurements at the hip, but not the lumbar spine, predict fracture risk in persons with a SCI. WHO-derived bone density categories may be useful in classifying fracture risk in persons with a SCI.

Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders.

UNLABELLED: Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture. INTRODUCTION: Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care. METHODS: The Veteran's Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures. RESULTS: There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9-11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4-6.1) and 6.7 years (median 6.7, IQR 3.1-11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14-0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period. CONCLUSIONS: There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.

Morbidity following lower extremity fractures in men with spinal cord injury.

UNLABELLED: The Veterans Affairs Spinal Cord Dysfunction Registry from 2002 to 2007 was reviewed to determine whether men with spinal cord injury (SCI) and lower extremity fractures had an increased risk of complications compared to those without fractures. We determined that fractures are associated with significant consequences, particularly during the first month postfracture. INTRODUCTION: Despite increasing longevity, patients with SCI have a substantial number of illnesses and comorbid conditions. Lower extremity fractures are frequent events in these patients. However, whether these fractures are associated with any increased risk of complications in SCI is not certain. The purpose of this report was to determine the impact of lower extremity fractures on morbidities in men with SCI. METHODS: A population-based, nested, case-control (1,027 cases and 1,027 propensity-matched controls) of men enrolled in the Veterans Affairs Spinal Cord Dysfunction Registry from fiscal years 2002 to 2007 was reviewed to determine whether lower extremity fractures were associated with an increased risk for complications. RESULTS: In propensity score models matched for demographic (age, race) and SCI-related injury factors (level/completeness of SCI), Veterans Affairs-service connection status, and comorbidities, at 1 month following the fracture, there was an increased risk for respiratory infections, pressure ulcers, urinary tract infections, thromboembolic events, depression, and delirium (p ≤ 0.03 for all). Over 12 months, the only complication more common in fracture cases was pressure ulcers (p < 0.01), with an absolute difference of less than 2 % when compared to controls. There was no significant increased risk of cardiac arrhythmias at any time examined following fracture (≥0.12). CONCLUSIONS: Lower extremity fractures are associated with significant consequences in men with SCI during the first month postfracture, but they do not persist for a long term, except for pressure ulcers. Targeted interventions to prevent complications should be considered following lower extremity fractures in SCI, particularly in the first month following fracture.

Relationship between self-reported disability and caregiver hours.

OBJECTIVE: In a large, population-based cohort of patients with spinal cord dysfunction, we assessed the relationship between self-reported physical function and hours of care received. DESIGN: Data were obtained by a cross-sectional, self-administered survey used to help establish a national registry of veterans with spinal cord dysfunction. Participants were originally identified from Department of Veterans Affairs databases as having a high probability of spinal cord dysfunction. All 13,542 respondents reporting spinal cord dysfunction and also having complete data on physical function and caregiver hours (CGHs) were included. Physical function was measured using the Self-Reported Functional Measure, and CGHs were obtained from a self-report of hours of caregiving received during the last 2 wk. RESULTS: The relationship between self-reported disability and CGHs was strong (Spearman correlation = -0.70). Subjects with moderate levels of disability had the most variability in CGHs. After stratifying by total Self-Reported Functional Measure score, the strongest predictors of CGHs were instrumental activities of daily living and individual Self-Reported Functional Measure items, explaining a moderate amount of variation in CGHs. CONCLUSION: These data support the construct validity of the Self-Reported Functional Measure and suggest that self-reported disability measures can be of use in describing the clinical epidemiology of patients with spinal cord dysfunction.

Degenerate ground state in a mesoscopic YBa2Cu3O(7-x) grain boundary Josephson junction.

We have measured the current-phase relationship I(varphi) of symmetric 45 degrees YBa2Cu3O7-x grain boundary Josephson junctions. Substantial deviations of the Josephson current from conventional tunnel-junction behavior have been observed: (i) The critical current exhibits, as a function of temperature T, a local minimum at a temperature T*. (ii) At T approximately T*, the first harmonic of I(phi) changes sign. (iii) For T

The self-reported functional measure: Predictive validity for health care utilization in multiple sclerosis and spinal cord injury.

OBJECTIVE: To examine the predictive validity of the Self-Reported Functional Measure (SRFM), a new measure derived from the FIMtrade mark instrument, for health care utilization in multiple sclerosis (MS) and spinal cord injury (SCI). DESIGN: Prospective cohort study using a mailed survey in 1995 and administrative records from 1996 and 1997. SETTING: Veterans Health Administration hospitals and outpatient clinics. PATIENTS: A total of 6361 veterans with SCI and 1789 veterans with MS. MAIN OUTCOME MEASURES: SRFM score was compared with subsequent outpatient visits, hospitalizations, hospital lengths of stay (LOSs), and residence peri-hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these variables. RESULTS: A total of 3836 subjects (47.6%) were hospitalized during 1996-1997, and all but 874 (10.7%) had 1 or more outpatient visits. SRFM score predicted inpatient, but not outpatient health care utilization. Persons in the lowest SRFM quartile were over 90% (OR = 1.91, 95% CI = 1.71-2.13) more likely to be hospitalized compared with those in the highest SRFM quartile; also, they were over 2 times (OR = 2.18, 95% CI = 1.85-2.57) more likely to have a LOS greater than 7 days, were over 2 times (OR = 2.41, 95% CI = 1.62-3.58) more likely to die in hospital, and were nearly 3 times (OR = 2.86, 95% CI = 2.00-4.08) more likely to be discharged to an institution. CONCLUSIONS: SRFM had excellent predictive validity for hospitalization, LOS, and discharge destination among patients with MS or SCI.

Stroke care: a method for measuring compliance with AHCPR guidelines.

The purpose of this article is to describe a method for converting practice guidelines to measurement criteria. To evaluate the processes of care received by patients with stroke at 11 Veteran's Administration hospital sites, we developed a measurement system based on Agency for Health Care Policy and Research (AHCPR) Post-Stroke Rehabilitation Clinical Practice Guidelines. Guideline recommendations were used as the framework for identifying important dimensions of care, and for developing chart abstraction instruments for both the acute and postacute settings. Using a modified Delphi technique to solicit opinions from an expert panel, a method was developed for aggregation of item-level chart abstraction components to overall guideline compliance scores. The measurement system was shown to have good-to-excellent intrarater and interrater reliability at the item, dimension, and overall compliance score levels. Abstraction of a sample of 100 medical records demonstrated the ability of the instruments to detect variability in processes of post-stroke care. This study provides the foundation for future research, which will evaluate associations between processes of post-stroke care, as measured by this medical chart abstraction system, and patient outcomes. (All abstraction instruments, criteria, and scoring algorithms described in this article are available for download at http://www2.kumc.edu/coa.)

Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals.

OBJECTIVE: To examine the relationship of services for post-acute care (PAC) to stroke patient outcomes. DATA SOURCES/STUDY SETTING: Veterans Health Administration (VHA) hospitals from two facility-level surveys and extant data files. STUDY DESIGN: Cross-sectional study of veterans hospitalized with acute stroke during the period June 1995 through May 1996 in one of 182 geographically distinct locations within the VHA. Study variables included (1) a typological classification of hospitals according to the level of PAC; (2) a taxonomy of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (3) patient outcomes (discharge destination, length of stay). DATA COLLECTION/EXTRACTION METHODS: Data were collected from two mailed surveys and extant data files. Rehabilitation variables were identified for the study in conjunction with a panel of expert rehabilitation researchers and clinicians, using an a priori model for measuring rehabilitation characteristics. Two sets of variables were derived to categorize these rehabilitation characteristics: (1) a rehabilitation typology, classifying the VA hospitals according to the continuum of PAC settings in the facility, and (2) a rehabilitation taxonomy that used an empirical approach to derive a list of key rehabilitation characteristics. PRINCIPAL FINDINGS: Twenty-seven percent of veterans with acute stroke were cared for in VA hospitals with neither a geriatric nor a rehabilitation unit, and 50 percent were cared for in hospitals without a rehabilitation unit. Hospitals with rehabilitation units had the greatest sophistication, and those with geriatric units had intermediate sophistication in rehabilitation organization and resources. Statistically significant differences were found in outcomes for stroke patients cared for in hospitals classified according to the continuum of post-acute care on site. Exploratory multivariable analyses revealed independent associations between stroke patient outcomes and (1) staffing ratios for nurses and physicians, (2) the diversity of physician and rehabilitation staff, (3) presence of a simulated home environment, and (4) the total number of care settings on site. CONCLUSIONS: The PAC continuum defines an important hierarchy of stroke rehabilitation services.

Case study to evaluate a standing table for managing constipation.

Standing devices have been advocated as a potentially beneficial treatment for constipation in persons with spinal cord injury (SCI); however, definitive data are lacking. A case of a patient who requested a standing table to treat chronic constipation is presented as an illustration of a method to address this problem on an individual patient level. The patient was a 62-year-old male with T12-L1 ASIA B paraplegia who was injured in 1965. The patient was on chronic narcotics for severe, nonoperable shoulder pain. His bowel program had been inadequate to prevent impactions. A systematic approach was used to measure the effects of a standing table on frequency of bowel movements (BMs) and on length of bowel care episodes. There was a significant (p < 0.05) increase in frequency of BMs and a decrease in bowel care time with the use of the standing table 5 times/week versus baseline. For this patient, the use of the standing table was a clinically useful addition to his bowel care program.

The structure and structural effects of VA rehabilitation bedservice care for stroke.

The purpose of this study was to: 1) examine the variation in organizational structure within rehabilitation bed-service units (RBU) in the Veterans Health Administration (VHA), and 2) evaluate the effects of RBU and parent hospital structure on stroke rehabilitation outcomes. Two VHA-wide surveys of acute and rehabilitation services for stroke were linked with 2 y of VHA rehabilitation outcomes for stroke patients. A random effects mixed model was used to adjust for patient level covariates, control for unique site effects, and test for facility level structural effects. After adjusting for patient covariates, four structural variables were associated with length of stay or patient functional gain. These results indicate that rehabilitation structure is important to rehabilitation outcome. The individual variables identified in this study, namely, diverse multidisciplinary staff, expert physician leadership, staff participation in team care, and richer rehabilitation equipment resources, may represent the distinct aspects of a successful, comprehensive rehabilitation unit.

A taxonomy for classification of stroke rehabilitation services.

OBJECTIVE: To develop a taxonomy for use in measuring stroke rehabilitation services. DESIGN: A cross-sectional study using facility-level survey data and extant data files. SETTING: Veterans Administration medical centers (VAMCs). VARIABLES: (1) A list of rehabilitation characteristics, including personnel, physical facilities, coordination of care, and hospital characteristics; and (2) a classification or typology of VAMCs according to the type of postacute stroke care on-site. MAIN OUTCOME MEASURES: Data sources included extant Veterans Administration (VA) computerized databases, VA central office administrative files, and 2 mailed surveys to VA rehabilitation medicine services and stroke acute care services. The rehabilitation taxonomy was derived using 2 methods that assess face and construct validity, respectively: (1) an expert panel rating, using a modified Delphi process, of the clinical importance of each of the rehabilitation characteristics; and (2) a comparison of rehabilitation characteristics across the different types of VAMCs. Variables were included in the final taxonomy if the expert panel reached consensus that the variable was clinically important, or if there were statistically significant differences in these characteristics across the different types of medical centers. RESULTS: Of 67 possible rehabilitation characteristics, a multidisciplinary expert panel reached consensus about the likely clinical importance of 21 rehabilitation characteristics, 11 of which showed statistically significant differences across different types of VAMCs. An additional 9 variables that lacked expert panel consensus differed significantly among the different medical centers. These 30 variables represent a preliminary taxonomy of key rehabilitation characteristics. Among the 20 variables that varied significantly across the different types of medical centers, 18 showed a pattern with the greatest amount of resources and organizational sophistication being found in VAMCs with rehabilitation units, followed by medical centers with geriatric units, and the least amount of resources and organizational sophistication was seen in medical centers whose postacute care services were limited to nursing home or intermediate care. CONCLUSION: Thirty rehabilitation characteristics had face validity and/or construct validity, and can be considered to represent a preliminary taxonomy for measuring stroke rehabilitation services. This study also shows that there are significant differences among hospitals in resources and organization of care deemed to be important for stroke patients.

Rapid assessment of rehabilitation options for functional disability.

Although functional disability is common in elderly patients, physicians often overlook it or focus on acute illness, perhaps in part because they are unsure how to efficiently address the problem. A simple, stepwise protocol can be used in either an office or hospital setting to rapidly assess functional disabilities and identify potentially useful interventions.

The validity in persons with spinal cord injury of a self-reported functional measure derived from the functional independence measure.

STUDY DESIGN: A cross-sectional, mailed survey on impairment and function using 6361 respondents to the Spinal Cord Dysfunction National Veterans Survey who reported spinal cord injury as the sole cause of their spinal cord dysfunction. OBJECTIVES: To establish the concurrent and construct validities of a Self-Reported Functional Measure appropriate for use in patients with spinal cord injuries. SUMMARY OF BACKGROUND DATA: Functional assessment is of increasing importance in clinical care, quality assurance, and national health-care planning. There is a conspicuous need for validated functional assessment measures that are rapid, reliable, and appropriate for use in the disabled population. METHODS: The correlation was examined of hours of personal assistance, number of affected limbs, amount of motor impairment, and amount of combined limb-motor impairment to Self-Reported Functional Measure response tertile (scores, 13-32, 33-45, 46-52; lower scores indicated worse function). RESULTS: There were statistically significant correlations between Self-Reported Functional Measure score and hours of personal assistance (P < 0.001), the number of affected limbs (P < 0.001), the amount of motor impairment (P < 0.001), and the amount of combined limbmotor impairment (P < 0.001). For example, 87% of people with the most limb-motor impairment (four affected limbs and no useful movement) were in the lowest Self-Reported Functional Measure tertile, compared with 3% of people in the least-affected category of limb-motor impairment. Furthermore, visual, sensory, or memory impairment did not influence the correlation between limbmotor impairment and Self-Reported Functional Measure score. CONCLUSION: The Self-Reported Functional Measure shows good concurrent and construct validities.

New horizons in stroke rehabilitation research.

To promote health services research in stroke rehabilitation, we gathered information about stroke rehabilitation structures, processes, and outcomes (SPO), using extant databases and the Donabedian theoretical model of health services evaluation. We found that, in the United States, over S3.6 billion was spent by third-party payers in 1992 on rehabilitation, including stroke. Total disability-related costs now amount to over $170 billion per year. However, there are few studies identifying cost-effective stroke rehabilitation practices. Existing studies indicate that the organizational structure of rehabilitation influences stroke outcomes, but it is less clear exactly what organizational practices constitute optimal stroke rehabilitation. Data about specific, beneficial rehabilitation processes are scanty for stroke. There are a number of valid and reliable outcome measures pertinent to stroke rehabilitation health services research. We conclude that health services research in stroke rehabilitation is sparse. To be more informative, rehabilitation health services research should be guided by the SPO model.

Disability fingerprints: patterns of disability in spinal cord injury and multiple sclerosis differ.

BACKGROUND: Models for causation of functional disability differ as to whether different diseases lead to common expressions of disability versus producing unique "disability fingerprints." Multiple sclerosis (MS) and Spinal Cord Injury (SCI) both affect the spinal cord; however, their pathophysiologies differ (progressive vs. nonprogressive; multifocal vs. unifocal). METHODS: Patterns of disability were compared among veterans who reported in a national survey that they had MS (n = 1789) or SCI (n = 6361) as the sole cause of their spinal cord dysfunction. The study used self-reported information on disease duration, physical impairments, and self-care skills to compare the two samples for differences in disability overall and after stratification according to (a) disease duration, and (b) specific physical impairments. RESULTS: Patterns of disability differed significantly among persons with MS compared to SCI (p = .001). Differences in level of disability between the two samples remained statistically significant after stratification on disease duration. There were substantial, statistically significant differences between the two samples in the amount and kinds of physical impairment. However, differences in level of disability between the two conditions remained highly significant after stratifying on number of affected limbs (p = .003), amount of useful movement (p = .001), overall motor impairment (p = .003), amount of sensation (p = .001), impairment in memory and thinking (p = .001), and visual impairment (p = .001). CONCLUSIONS: This study shows differing diseases indeed have unique disability fingerprints, which remain unique after controlling for disease duration and for population-specific differences in physical impairment. These findings point out the need to explain the disablement process more fully.

The reliability of a self-reported measure of disease, impairment, and function in persons with spinal cord dysfunction.

OBJECTIVE: To develop a self-report instrument that would provide information about the different levels of the disablement process, and that (1) was suitable for persons with spinal cord disease (SCD), (2) could be completed quickly, (3) could be mailed, (4) had acceptable reliability, and (5) would be clinically useful. STUDY DESIGN: Test-retest using a convenience sample. METHODS: Review of the literature and an expert panel were used to develop the instrument. It was mailed to 49,458 individuals in June 1995 and a second mailing was done in August 1995. A subset of 725 individuals who responded to both mailings was used to examine the instrument's test-retest reliability. RESULTS: The instrument has a 4th grade reading level and has questions on causal disease, disease severity, impairment, activities of daily living (including a self-reported version of the Functional Independence Measure, the SRFM), and resource utilization. Individual item test-retest reliability was high for a mailed questionnaire; all kappa coefficients were near or above .60 and most were over .70. Intraclass correlation coefficient for the SRFM was .90 and internal consistency (Chronbach's alpha) was .96. CONCLUSION: This instrument provides a new, rapid way to obtain information relative to the differing levels of the disablement process.

Developing a national registry of veterans with spinal cord dysfunction: experiences and implications.

We describe the development of a registry of veterans with spinal cord dysfunction who have been treated within the Department of Veterans Affairs health care facilities. The registry departs from the function and structure of traditional registries by a more extensive utilization of advances in computer technology; in particular, by its reliance upon computerized record linkage and by its association with a set of computer-based clinical management and reporting tools. We discuss some of the applications of the registry to research for persons with spinal cord dysfunction as well as implications that our experiences provide for developing other registries of persons with disabilities.

Geriatric rehabilitation: state of the art.

OBJECTIVES: To provide a clinically useful conceptual framework for the evaluation and treatment of disability in older persons, to review the rehabilitation of common conditions affecting function in older persons, and to discuss the effects of the ongoing changes in the healthcare system on geriatric rehabilitation. METHODS: MedLine search and review of relevant texts for information on (1) geriatric disability and its treatment, (2) recent high quality research, guidelines, and review articles relevant to the rehabilitation of conditions commonly causing geriatric disability, (3) effects of recent changes in the healthcare system on geriatric rehabilitation. RESULTS: Several pertinent models for geriatric disability were identified. These are explicated, along with information on the epidemiology of geriatric disability and its causes and relevant clinical applications. Rehabilitation is reviewed for musculoskeletal disorders, stroke and peripheral vascular disease, amputation, cardiopulmonary disorders, hip fracture, and deconditioning. Changes in the healthcare system appear to be affecting geriatric rehabilitation, especially the advent of managed care; relevant articles and opinions are reviewed, along with strategies to accommodate these changes. CONCLUSIONS: Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise-related interventions. However, the cost-effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons.