'When the bedbugs come, that's another problem': exploring the lived experiences of bedbug infestations among low-income older adults and service providers who support them.

AIMS: Older adults in low-income housing communities are more vulnerable to bedbug infestations. Prior research, however, has predominately focused on the effectiveness of integrated pest-management strategies, with little attention given to the lived experiences of tenants struggling with infestations. We used a qualitative approach to explore what it is like to live with and treat bedbug infestations from the perspectives of low-income older adults and service providers. METHODS: Participants included low-income older adults (n = 58) and service providers (n = 58) who offer supports directly in the buildings. Semi-structured qualitative interviews and focus groups were used to explore the challenges of preparing and treating units for bedbugs, and examine how bedbugs impact access to support services. RESULTS: Bedbugs were a widespread issue, and underlying physical, mental, social, and financial challenges made it difficult for older tenants to prepare their units and access treatment. Tenants also faced bedbug stigma from community services, as many were unwilling to provide services in infested units. Although some service providers utilized strategies to minimize exposure, many were concerned these strategies created additional stigma. CONCLUSION: Our findings highlight an urgent need to increase public health funding to support older adults with the costs of bedbug elimination and to enhance pest-management strategies through partnerships with health and social service agencies to improve outcomes for older adults.

A Depiction of Rehabilitation Patients 65 Years and Younger With Dysvascular Lower Extremity Amputation.

BACKGROUND: The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascular amputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges. OBJECTIVES: To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation. METHODOLOGY: A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, comorbidities, and discharge outcomes. FINDINGS: One hundred and forty-three patients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was 5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20). CONCLUSIONS: Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The guidelines were developed 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 developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation. CONCLUSIONS: The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: Recommendations for treatment.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: To develop the first Canadian clinical practice guidelines for treatment of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The CanPainSCI Working Group reviewed the evidence for different treatment options and achieved consensus. The Working Group then developed clinical considerations for each recommendation. Recommendations for research are also included. RESULTS: Twelve recommendations were developed for the management of neuropathic pain after SCI. The recommendations address both pharmacologic and nonpharmacologic treatment modalities. CONCLUSIONS: An expert Working Group developed recommendations for the treatment of neuropathic pain after SCI that should be used to inform practice.

The CanPain SCI Clinical Practice Guideline for Rehabilitation Management of Neuropathic Pain after Spinal Cord: recommendations for model systems of care.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: The project objectives were to develop the first Canadian recommendations on a model of care for the management of at- and below-level neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: On the basis of a review of the Accreditation Canada standards, the Steering Committee developed questions to guide the CanPainSCI Working Group when developing the recommendations. The Working Group agreed on recommendations through a consensus process. RESULTS: The Working Group developed five recommendations for the organization of neuropathic pain rehabilitation care in people with SCI. CONCLUSIONS: The Working Group recommendations for a model of care for at- and below-level neuropathic pain after SCI should be used to inform clinical practice.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: screening and diagnosis recommendations.

STUDY DESIGN: Clinical practice guidelines. OBJECTIVES: To develop the first Canadian clinical practice guidelines for screening and diagnosis of neuropathic pain in people with spinal cord injury (SCI). SETTING: The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada. METHODS: The CanPainSCI Working Group reviewed evidence to address clinical questions regarding screening and diagnosis of neuropathic pain after SCI. A consensus process was followed to achieve agreement on recommendations and clinical considerations. RESULTS: Twelve recommendations, based on expert consensus, were developed for the screening and diagnosis of neuropathic pain after SCI. The recommendations address methods for assessment, documentation tools, team member accountability, frequency of screening and considerations for diagnostic investigation. Important clinical considerations accompany each recommendation. CONCLUSIONS: The expert Working Group developed recommendations for the screening and diagnosis of neuropathic pain after SCI that should be used to inform practice.

Loss of Work Productivity and Quality of Life in Patients With Autoimmune Bullous Dermatoses.

BACKGROUND: Little is known about quality of life and work productivity in autoimmune bullous dermatoses (AIBDs). OBJECTIVE: To determine the impact of AIBDs on quality of life and work productivity. METHODS: An observational cross-sectional study took place between February and May 2013 at an AIBD tertiary referral centre. Ninety-four patients were included. All participants completed the Dermatology Life Quality Index and the Work Productivity and Activity Impairment-Specific Health Problem questionnaires. RESULTS: Responders to treatment had less impairment (P<.001) than nonresponders. Patients with severe AIBD had significantly more impairment that those with mild (P<.001) and moderate (P=.002) AIBD. Greater impairment was associated with higher percentage of work missed. Those with a higher Dermatology Life Quality Index score had greater work impairment and overall activity impairment (P=.041, P=.024). Nonresponders had increased impairment while working (P<.001), overall work impairment (P<.001), and activity impairment (P<.001). Severely affected patients had worse impairment in all Work Productivity and Activity Impairment Questionnaire domains. CONCLUSIONS: AIBD has the potential to be a large burden on ability to work and quality of life. Larger studies are needed to clarify how these domains change over time and whether or not they improve with treatment.

Use of screening to recruitment ratios as a tool for planning and implementing spinal cord injury rehabilitation research.

STUDY DESIGN: Descriptive report. OBJECTIVES: To describe screening to recruitment (S:R) ratios and discuss their use for planning and implementing research among individuals with spinal cord injury (SCI) . SETTING: Toronto, Ontario, Canada. METHODS: We calculated S:R ratios for SCI research by study methodology and nature of the exposure/intervention for 25 studies previously conducted in a tertiary SCI rehabilitation facility. Study methodologies included ten randomized controlled trials (RCTs), nine cohort studies and six panel studies. Exposures included seven rehabilitation interventions, and three drug studies, ten telephone interviews/chart abstractions (TI/CA) and five surveys. A S:R ratio was calculated for each study methodology, and exposure type, by dividing the number of consenting individuals who underwent screening by the number of eligible recruited participants enrolled in the study. RESULTS: In terms of design, RCTs had the highest median S:R ratio (3:1), followed by cohort studies (2:1) and panel studies (2:1). In terms of intervention type, drug studies had the largest median S:R ratio (5:1), followed in descending order by rehabilitation studies (2:1), TI/CAs studies (2:1) and surveys (2:1). CONCLUSIONS: Reported S:R ratios varied substantially with study methodology and the associated study intervention exposure. Awareness of S:R ratios may assist researchers in estimating recruitment timelines, personnel needs and study budgets for a required sample size based on the planned study methodology and intended study exposure. We advocate for the routine reporting of S:R ratios to inform the success of future SCI research.

An evidence-based review on the influence of aging with a spinal cord injury on subjective quality of life.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify changes in subjective quality of life (QoL) as one ages with a spinal cord injury (SCI). SETTING: Vancouver, Canada. METHODS: Electronic databases were searched for studies reporting on age-related QoL changes over time. Data from relevant studies were transcribed into data extraction forms and analyzed by years post injury (YPI) and chronologic age. Each study was assigned a level of evidence based on a modified Sackett scale. RESULTS: In all, 21 studies, each with a low level of evidence, were included for review. The results indicated that regardless of chronologic age, individuals with relatively new SCI have the potential to improve their QoL. Among individuals with advanced YPI, overall QoL is consistently reported as good or excellent over time, however, with variations in different QoL domains. CONCLUSION: The QoL of individuals aging with a SCI has the potential to improve, and remain high and stable over time. As the identified studies provide low levels of evidence, more longitudinal research with greater methodological and measurement rigor is needed to corroborate the findings and conclusions of this review.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

An evidence-based review of aging of the body systems following spinal cord injury.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review evidence on aging of the body systems after spinal cord injury (SCI). SETTING: Toronto, Ontario and Vancouver, British Columbia, Canada. METHODS: Electronic databases (MEDLINE/PubMed, CINAHL, EMBASE and PsycINFO), were searched for studies published between 1980 and 2009. The search was augmented by reviewing the reference lists of relevant papers. Non-intervention studies that were longitudinal or cross-sectional with able-bodied controls that were at minimum matched on chronological age were included for review. Levels of evidence were assigned to the study design using a modified Sackett scale. RESULTS: Of the 74 studies selected for inclusion, 16 were longitudinal in design. The hypothesis that SCI represents a model for premature aging is supported by a large proportion of level 5 evidence for the cardiovascular and endocrine systems, level 2, 4 and 5 evidence for the musculoskeletal system, and limited level 5 evidence for the immune system. Only a few level 4 and 5 studies for the respiratory system were found. The evidence on the genitourinary system, gastrointestinal system, and for skin and subcutaneous tissues provide level 4 and 5 evidence that premature aging may not be occurring. The evidence on the nervous system does not provide evidence of premature aging as a result of SCI. CONCLUSIONS: Premature aging appears to occur in some systems after SCI. Additional longitudinal studies are required to confirm these findings.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Understanding age effects associated with changes in secondary health conditions in a Canadian spinal cord injury cohort.

STUDY DESIGN: Longitudinal cohort. OBJECTIVES: To determine whether changes in secondary health conditions (SHC) associated with spinal cord injury (SCI) were effectively modeled from a longitudinal or cross-sectional perspective, and whether the changes in SHCs were attributable to age or years post-injury (YPI). SETTING: Toronto Rehabilitation Institute, Lyndhurst Centre. METHODS: Telephone survey methods were used to collect data on (1) demographics, (2) impairment, (3) health status, and (4) self-reported SHCs at two time intervals (1995-1997; 2003-2004) from 344 adults with SCI. Generalized estimating equations were applied to model the longitudinal and cross-sectional effects. RESULTS: Health status decreased over time (P<0.0005), whereas the number of SHCs increased (P<0.0001). Regardless of age or YPI, the longitudinal component of aging better predicted SHC occurrence and was associated with spasticity [odds ratio, OR=1.055 (95% confidence interval, CI, 1.018 to 1.093, P<0.01)], kidney problems [OR=1.154 (95% CI, 1.084 to 1.229, P<0.0001)], cardiac problems [OR=1.168 (95% CI, 1.060 to 1.286, P<0.01)], high blood pressure [OR=1.121 (95% CI, 1.058 to 1.188, P<0.0001)], chronic pain [OR=1.058 (95% CI, 1.021 to 1.096, P<0.01)], and arthritis/joint pain [OR=1.113 (95% CI, 1.075 to 1.152, P<0.0001)]. CONCLUSION: Within a relatively short period of time, persons with SCI experienced substantive declines in health. The findings suggest that a longitudinal perspective is more sensitive for predicting the risk of self-reported SHCs than a cross-sectional one.

Predicting life satisfaction after spinal cord injury in a Canadian sample.

STUDY DESIGN: Cross-sectional, survey. OBJECTIVES: To extend current theoretical models predicting life satisfaction post-spinal cord injury (SCI). Our primary model predicting life satisfaction as measured by the Satisfaction with Life Scale (SWLS) examined demographic characteristics, elements of the International Classification of Functioning and subjective and objective measures of health. A second model was developed to examine factors that are associated with successful community participation as measured by the Reintegration to Normal Living Index (RNL). In addition, the effects of psychological distress and chronic pain on life satisfaction and community participation were examined. SETTING: Toronto Rehabilitation Institute, Spinal Cord Rehabilitation Program, Lyndhurst Centre. METHODS: Prospective data collection via semi-structured telephone interview on an established SCI Canadian sample. RESULTS: In predicting life satisfaction, our model accounted for 35.3% of the variance with demographic characteristics, objective and subjective health, and community participation significantly contributing to the model. In particular, psychological complications, current health rating and community participation were the only variables that made significant contributions in predicting life satisfaction. With regards to community participation, the presence of psychological complications and number of medical complications were associated with decreased reintegration. Increased time since injury onset, higher health ratings and being employed were positively related to RNL. CONCLUSION: It would appear that factors involving functional decline and aging are associated with lower participation but not life satisfaction. Further, models predicting quality of life should incorporate measures of psychological functioning.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.