Peer mentoring reduces unplanned readmissions and improves self-efficacy following inpatient rehabilitation for individuals with spinal cord injury.

OBJECTIVE: Evaluate effectiveness of peer interventions on self-efficacy, unplanned hospital readmissions, and quality of life for patients with spinal cord injury (SCI) undergoing inpatient rehabilitation. DESIGN: Interrupted time-series analysis (ITSA) examined effects of peer interventions on unplanned readmissions. Intervention variables added to ITSA regression examined relationships with exposure to peer interventions. Heterogeneity of treatment effects (HTE) analysis examined differences in intervention effectiveness for patients with quadriplegia and paraplegia. SETTING: Rehabilitation hospital specializing in SCI and brain injury. PARTICIPANTS: SCI inpatients (n = 1117) admitted for rehabilitation whose discharge location was home (77% male, 71% Caucasian, mean age 38.2 (SD 16.8)). A subsample of 799 patients participated in secondary analyses examining relationship between peer interventions, readmissions, changes in patient-reported outcomes, and HTE. INTERVENTIONS: One-to-one mentoring and participation in peer-led self-management classes. MAIN OUTCOME MEASURES: Unplanned readmissions, general self-efficacy (GSE), and depressive symptoms 30, 90, and 180 days post discharge; satisfaction with life at 180 days. RESULTS: After implementing the peer interventions, we observed a significant decrease in both level and slope of number of patients readmitted, and level only of unplanned hospital days 30-days post-discharge. Reduction in the number of patients and unplanned hospital days was associated with number of peer visits but not peer-led education classes attended. Higher self-efficacy (GSE) was associated with greater exposure to peer mentoring, and a significant relationship between improvement in GSE and reduced hospital readmissions was observed. CONCLUSIONS: One-to-one peer mentoring improves self-efficacy and reduces unplanned hospital readmissions following inpatient rehabilitation for persons with SCI.

Effects of Functional Electrical Stimulation Cycling on Fatigue and Quality of Life in People with Multiple Sclerosis Who Are Nonambulatory.

BACKGROUND: Functional electrical stimulation (FES) cycling provides an exercise opportunity for people with multiple sclerosis (MS) who are nonambulatory. This study evaluated the efficacy of FES cycling for reducing fatigue and improving quality of life in people with MS who are nonambulatory and compared outcomes with those in a control group that did not take part in FES cycling. METHODS: Adults with MS with self-reported Expanded Disability Status Scale scores of 7.0 to 8.5 were randomized into a training group (n = 12) or a control group (n = 9). The training group performed FES cycling for 30 minutes, two to three times a week for 12 weeks. The primary outcome was safety, measured as the number and type of adverse events and any increase in symptoms. Other outcomes collected before and after the intervention were scores on the modified Ashworth Scale, manual muscle test, 5-item Modified Fatigue Impact Scale (MFIS-5), Fatigue Scale for Motor and Cognitive Functions (FSMC), Medical Outcomes Study Pain Effects Scale, Patient Health Questionnaire-9 (PHQ-9), Multiple Sclerosis Quality of Life-54 (MSQOL-54), and Exercise Self-Efficacy Scale. RESULTS: Twelve participants completed the study and were analyzed. Six participants completed training with no adverse events. The MFIS-5 (Cohen's d = 0.60), FSMC (Cohen's d = 0.37), and PHQ-9 (Cohen's d = 0.67) scores and the physical health composite of the MSQOL-54 (Cohen's d = 1.48) improved for the training group compared with the control group (n = 6). CONCLUSIONS: Functional electrical stimulation cycling is safe for people with MS who are nonambulatory and may reduce fatigue and improve measurements of quality of life.

Modified PRISM and SCI-SET Spasticity Measures for Persons With Traumatic Spinal Cord Injury: Results of a Rasch Analyses.

OBJECTIVE: To evaluate the psychometric properties of the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) and Patient-Reported Impact of Spasticity Measure (PRISM) using Rasch analysis to optimize their validity and efficiency. DESIGN: Rasch analysis of the SCI-SET and PRISM represents a secondary analysis of data collected as part of a collaborative research project of the SCI Model Systems Centers. The overall survey was organized into 4 sections: (1) participant demographics and injury characteristics, (2) participant experiences of spasticity, (3) SCI-SET, and (4) PRISM. Participants were recruited from the community via multiple avenues. Data were collected and managed via an online survey tool using a secure web-based data management application. SETTING: Participating Spinal Cord Injury Model Systems Centers. PARTICIPANTS: Most participants (N=1239) had lived with their injury for more than 2 years and used a wheelchair as their primary mode of mobility. The majority of the sample (58%) sustained cervical injuries. INTERVENTIONS: None. MAIN OUTCOME MEASURES: SCI-SET and PRISM. RESULTS: The SCI-SET demonstrated strong measurement properties with acceptably high reliability and point-measure correlations and no evidence of multidimensionality. However, respondents underused some rating scale categories. Analyses of the PRISM demonstrated 3 distinct subscales relating to the physical, psychological, and social influences of spasticity; respondents underused some rating scale categories. Combining underused rating scale categories for both spasticity instruments resulted in increased reliability and reduced respondent burden compared with the original versions. Both the Modified SCI-SET (person separation reliability=0.93) and Modified PRISM (person separation reliability=0.85, 0.89, 0.83 for physical, psychological, and social subscores, respectively) display strong measurement properties. CONCLUSIONS: Measurement properties of the SCI-SET and PRISM improved from use of Rasch model methods. The SCI-SET required minor revisions, whereas the PRISM required definition of subscores. Both modified spasticity measures demonstrated adequate psychometric properties, and correlations among the modified measures were high, providing evidence of convergent validity. We recommend use of the Modified SCI-SET and Modified PRISM measures in future studies.

Safety and Feasibility of Various Functional Electrical Stimulation Cycling Protocols in Individuals With Multiple Sclerosis Who Are Nonambulatory.

OBJECTIVE: To examine the safety, feasibility, and response to functional electrical stimulation (FES) cycling protocols requiring differing levels of effort in people with multiple sclerosis (MS) who are nonambulatory. DESIGN: Pilot study with pre-post intervention testing. SETTING: Outpatient clinic setting of a long-term acute care hospital. PARTICIPANTS: Individuals (N=10) with MS (6 men; mean age 58.6±9.86y) who use a wheelchair for community mobility. Participants' Expanded Disability Status Scale score ranged from 6.5 to 8.5 (median 7.5). INTERVENTION: Participants performed 3 or 4 FES cycling protocols requiring different levels of volitional effort during 6-8 testing sessions. MAIN OUTCOME MEASURES: The primary outcome was safety, measured by adverse events and increase in MS symptoms, all assessed throughout, immediately post- and 1 day postsession. FES cycling performance for each protocol was also recorded. Exploratory outcome measures collected before and after all testing sessions included functional assessment of MS, MS Impact Scale, Exercise Self Efficacy Scale, Patient Health Questionnaire-9 item, and the Zarit Caregiver Burden Scale. RESULTS: All participants (4 women, 6 men) completed all testing sessions. There were no serious adverse events or differences in vitals or symptoms between protocols. Two participants had an isolated episode of mild hypotension. Changes in pain, spasticity, and fatigue were minimal. Five participants were able to cycle for 30 minutes and completed interval training protocols requiring increasing difficulty. The remainder cycled for <3 minutes and completed a rest interval protocol. There was modest improvement on the exploratory outcome measures. CONCLUSIONS: People with MS who use a wheelchair for community mobility can safely perform FES cycling requiring more effort than previously reported research. Therefore, the individuals may experience greater benefits than previously reported. Further study is required to better understand the potential benefits for optimizing function and improving health in people with MS.

Service-Learning through conference-based, interdisciplinary workshops on Age-Friendly design.

For three consecutive years, the Age-Friendly Design Committee (AFDC) of the Academy for Gerontology in Higher Education (AGHE) used AGHE's annual meeting as a platform to conduct community-based service-learning workshops focusing on age-friendly design. These workshops assembled local stakeholders, conference attendees from multiple disciplines, and landscape and architectural designers to discuss age-friendly design issues and solutions for local environments. Each workshop provided hands-on design experience and the opportunity for AGHE participants to contribute to conference host communities by using their gerontological expertise to translate knowledge into practice. Local stakeholders learned the value of gerontological input when considering design issues. We describe the process of incorporating service-learning into the conference experience through age-friendly design workshops and how these bring together students, faculty, and design professionals from different backgrounds and disciplines to address local age-friendly design issues.

Functional passive range of motion of individuals with chronic cervical spinal cord injury.

OBJECTIVE: Functional passive range of motion (PROM) requirements for individuals with cervical spinal cord injury (SCI) are clinically accepted despite limited evidence defining the specific PROM needed to perform functional tasks. The objective of this investigation was to better define the minimum PROM needed for individuals with cervical SCI to achieve optimal functional ability, and as a secondary outcome gather self-reported standardized functional data via the Spinal Cord Independence Measure-III (SCIM-III), and the Spinal Cord Injury Functional Index (SCI-FI). DESIGN: Observational cohort. SETTING: 128-bed rehabilitation hospital with inpatient and outpatient spinal cord injury rehabilitation programs. PARTICIPANTS: A convenience sample of 29 community-dwelling individuals with chronic (greater than one year) tetraplegic SCI (C5-8) who use a wheelchair for mobility. INTERVENTIONS: None. OUTCOME MEASURES: Therapist goniometric measurement of upper and lower extremity PROM, and participant completion of a demographic questionnaire and two functional self-report measures (SCIM-III and SCI-FI) were completed. RESULTS: Compared to the general population, differences observed in our study participants included limitations in forearm pronation and elbow extension and increased shoulder extension and wrist extension (likely related to prop sitting). Elbow hyperextension was noted in one-third of the participants. Limitations in straight leg raise, hip flexion, abduction, and internal rotation, in combination with increased hip external rotation suggested these individuals with cervical SCI potentially completed activities of daily living (ADLs) in frog-sitting, rather than long-sitting. Ankle plantarflexion contractures were found in many participants. Shoulder horizontal adduction, elbow extension, hip flexion, knee flexion, ankle plantarflexion, and forefoot eversion ROM were associated with functional performance. CONCLUSION: Based on our results healthcare providers should work with individuals with cervical SCI to develop long term PROM plans to optimize functional abilities.

Regulating hearing aid compatibility of cell phones: results from a national survey.

Accessibility of telecommunication technologies by people who are deaf or hard of hearing has been a critical issue since the invention of the telephone. As both telephone and hearing-aid technologies have evolved, finding compatible solutions has been an ongoing challenge. This paper uses the findings of a longitudinal study to examine the impact of Federal hearing-aid compatibility (HAC) regulations in resolving this problem. The study ran concurrently with the phase-in of Federal Communications Commission regulations requiring that mobile handset manufacturers and wireless service providers make available minimum numbers of cell phones with shielding to reduce electromagnetic interference when cell phones are positioned close to a hearing aid user's ear. These regulations also require package labeling and printed information to assist buyers in selecting a hearing-aid compatible phone. The survey presented here focused on changes in satisfaction with sound quality and ease of finding a hearing-aid compatible mobile handset. Data analysis suggests that the regulations have had limited success, and problems persist for consumers in locating a hearing aid compatible phone. The FCC has requested input on more stringent hearing-aid compatibility requirements; study findings suggest that these changes are not likely to remedy the problem.

Comparison of peak oxygen consumption response to aquatic and robotic therapy in individuals with chronic motor incomplete spinal cord injury: a randomized controlled trial.

STUDY DESIGN: Randomized dual center controlled clinical trial. OBJECTIVE: To determine and compare the cardiorespiratory impact of 3 months of aquatic and robotic therapy for individuals with chronic motor incomplete spinal cord injury (CMISCI). SETTINGS: Two rehabilitation specialty hospitals. METHODS: Thirty-one individuals with CMISCI with neurological level between C2-T12 at least 1 year post injury were randomized to either aquatic or robotic treadmill therapy for 36 sessions. Customized sessions lasted 40-45 min at 65-75% heart rate reserve intensity with peak oxygen consumption (peak VO2) measured during arm ergometry at baseline and post intervention. Additional peak robotic treadmill VO2 assessments were obtained before and after training for participants randomized to robotic intervention. RESULTS: Peak VO2 measured with arm ergometry was not significantly different with either aquatic intervention (8.1%, p = 0.14, n = 15) or robotic intervention (-0.7%, p = 0.31, n = 17). Peak VO2 measured with robotic treadmill ergometry demonstrated a statistical improvement (14.7%, p = 0.03, n = 17, two-tailed t-test) across the robotic intervention. Comparison between the two interventions demonstrated a trend favoring aquatic therapy for improving arm ergometry peak VO2 (ANOVA, p = 0.063). CONCLUSIONS: Neither 3-month exercise interventions statistically improved arm cycle ergometry peak VO2, our cardiorespiratory surrogate marker, although percent improvement was greater in the aquatic exercise condition. Robotic ergometry peak VO2 did improve for the robotic intervention, confirming previous work. These results suggest that either intervention may hold utility in improving cardiorespiratory fitness in CMISCI, but peak VO2 measurement technique appears critical in detecting effects. SPONSORSHIP: DOD CDMRP SCI Research Program Clinical Trial Award SC090147, FY 2009. This study is registered under ClinicalTrials.gov Identifier: NCT01407354.

Peer-led, transformative learning approaches increase classroom engagement in care self-management classes during inpatient rehabilitation of individuals with spinal cord injury.

OBJECTIVE: Evaluate effects of revised education classes on classroom engagement during inpatient rehabilitation for individuals with spinal cord injury/disease (SCI/D). DESIGN: Multiple-baseline, quasi-experimental design with video recorded engagement observations during conventional and revised education classes; visual and statistical analysis of difference in positive engagement responses observed in classes using each approach. PARTICIPANTS/SETTING: 81 patients (72% male, 73% white, mean age 36 SD 15.6) admitted for SCI/D inpatient rehabilitation in a non-profit rehabilitation hospital, who attended one or more of 33 care self-management education classes that were video recorded. All study activities were approved by the host facility institutional review board. INTERVENTION: Conventional nurse-led self-management classes were replaced with revised peer-led classes incorporating approaches to promote transformative learning. Revised classes were introduced across three subject areas in a step-wise fashion over 15 weeks. OUTCOME MEASURE: Positive engagement responses (asking questions, participating in discussion, gesturing, raising hand, or otherwise noting approval) were documented from video recordings of 14 conventional and 19 revised education classes. RESULTS: Significantly higher average (per patient per class) positive engagement responses were observed in the revised compared to conventional classes (p=0.008). CONCLUSION: Redesigning SCI inpatient rehabilitation care self-management classes to promote transformative learning increased patient engagement. Additional research is needed to examine longer term outcomes and replicability in other settings.

Lymphedema techniques to manage edema after SCI: a retrospective analysis.

STUDY DESIGN: Retrospective analysis of treatment data for a cohort of clients with spinal cord injury (SCI) who received therapy for management of edema. OBJECTIVE: To evaluate the safety, feasibility, and benefit of a modified lymphedema treatment approach for treatment of chronic lower extremity edema in persons with SCI. SETTING: A specialty rehabilitation hospital in Atlanta, GA, USA. METHODS: Certified lymphedema therapists with experience in SCI rehabilitation modified standard complete decongestive therapy (CDT) techniques to accommodate sensory and motor impairments and ensure skin safety. Therapists applied the modified CDT (mCDT) approach as part of treatment in 59 adults with SCI and lower extremity edema. Limb volume was measured using standardized volumetric measurement, pitting was scored using a standardized scale (range 0-4), and edema characteristics were determined to be present or absent. Outcomes of the mCDT intervention were analyzed for 105 lower extremities. RESULTS: Outcomes indicated that mCDT was associated with significant reduction in limb volumes, with a mean decrease of 11 ± 7.6%. Significant decreases were also observed in pitting edema and edema-specific characteristics, mean pitting scale score was reduced from a 3/4 to a 1/4. Minor adverse events were identified in a small number of patients. CONCLUSIONS: We found the mCDT approach to be safe and well-tolerated by the patients with SCI. The intervention was associated with decreased edema, and was feasible for use in a clinical setting. We recommend considering this mCDT approach for management of edema in individuals with SCI, while remaining vigilant about skin inspection.

Effects of Peer Mentoring on Self-Efficacy and Hospital Readmission After Inpatient Rehabilitation of Individuals With Spinal Cord Injury: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effect of intensive peer mentoring on patient-reported outcomes of self-efficacy and unplanned hospital readmissions for persons with spinal cord injury/disease (SCI/D) within the first 6 months after discharge from inpatient rehabilitation. DESIGN: Randomized controlled trial. SETTING: Nonprofit inpatient rehabilitation hospital specializing in care of persons with SCI/D and brain injury. PARTICIPANTS: Patients (N=158) admitted to the SCI/D rehabilitation program whose discharge location was a community setting. Participants (51% with paraplegia and 49% with tetraplegia) were 73% white and 77% men, with a mean age of 38 years. INTERVENTIONS: Participants in the experimental group received initial consult/introduction with a peer support program liaison and were assigned a peer mentor, who met with the participant weekly throughout the inpatient stay and made weekly contact by phone, e-mail, or in person for 90 days postdischarge. Participants also were encouraged to participate in regularly scheduled peer support activities. Nonexperimental group participants were introduced to peer support and provided services only on request. MAIN OUTCOME MEASURES: General Self-efficacy Scale (adapted to SCI/D), project-developed community integration self-efficacy scale, and patient-reported unplanned rehospitalizations. RESULTS: Growth rate for self-efficacy in the first 6 months postdischarge was significantly higher for experimental group participants than nonexperimental group participants. Experimental group participants also had significantly fewer unplanned hospital days. CONCLUSIONS: This study provides evidence that individuals receiving intensive peer mentoring during and after rehabilitation for SCI/D demonstrate greater gains in self-efficacy over time and have fewer days of unplanned rehospitalization in the first 180 days postdischarge. More research is needed to examine the long-term effects of this intervention on health care utilization and the relation between improved health and patient-reported quality of life outcomes.