Comparison of Rates of Hospitalization and Emergency Department Visits Using Self-Report and South Carolina Administrative Billing Data Among a Population-Based Cohort With Spinal Cord Injury.

OBJECTIVE: To compare self-report and South Carolina administrative billing data documentation of emergency department (ED) visits and hospitalizations in the past 12 months among a population-based cohort of persons with spinal cord injury (SCI). DESIGN: Cross-sectional study. SETTING: SCI surveillance system in South Carolina. PARTICIPANTS: Persons (N=605) sustaining a traumatic SCI between January 1, 1998 and December 31, 2011 in South Carolina who, at the time of study assessment, were adults, were >1 years postinjury, and had not made a complete recovery. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Hospitalizations and ED visits in the past 12 months. RESULTS: There was a significantly higher rate of reporting >1 hospitalizations in the past year for self-report (36%) as compared with South Carolina administrative billing data (26%) (P<.001), but not for >1 ED visits (48% vs 45%; P=.11). Decreased physical health and increased injury severity were associated with higher reporting rates of hospitalization. Physical health and injury severity were predictive of both self-report and South Carolina administrative billing data of hospitalizations, whereas years postinjury and race were also predictors of South Carolina administrative billing data hospitalizations. CONCLUSIONS: Our comparison of self-report and South Carolina administrative billing data hospitalizations and ED visits showed a significantly higher rate of reporting of hospitalizations using self-report, specifically among those with poor physical health and higher injury severity. Future work should look at different ways of asking about health care utilization and compare with South Carolina administrative billing data documentation to identify the best ways to assess through self-report.

Lifetime prevalence of chronic health conditions among persons with spinal cord injury.

OBJECTIVE: To assess lifetime prevalence of 7 chronic health conditions (CHCs) among a cohort of adults with chronic traumatic spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Rehabilitation hospital. PARTICIPANTS: Adults with SCI who were ≥18 years of age, were ≥1 year postinjury, and had residual neurologic effects impeding full recovery (n=1678). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: CHCs were measured using questions from the Behavioral Risk Factor Surveillance System for diabetes (not including gestational), heart attack (also called a myocardial infarction), angina or coronary artery disease, stroke, hypertension (not including during pregnancy), high blood cholesterol, or cancer. RESULTS: Of participants, 49.5% reported having at least 1 CHC, with 23.2% reporting ≥2 CHCs. The most frequently reported CHC was high cholesterol (29.3%) followed by hypertension (28.7%) and diabetes (11.8%). Although the prevalence of CHCs significantly increased with increasing age, only hypertension and cancer were significantly associated with years postinjury. Four CHCs (diabetes, coronary artery disease, hypertension, high cholesterol) were significantly related to mobility status as measured by injury level and ambulatory status. However, after controlling for age, years postinjury, sex, and race, mobility status became nonsignificant in relation to coronary artery disease, but it remained significantly associated with diabetes, hypertension, and high cholesterol. CONCLUSIONS: Clinicians should be aware of the risk of CHCs in persons with SCI and should screen for these conditions and regular maintenance activities related to SCI.

It's All of the Above: Benefits of Working for Individuals with Spinal Cord Injury.

BACKGROUND: The majority of research on employment among persons with spinal cord injury (SCI) focuses on the employment rate at a given point in time to the exclusion of quality employment outcomes. OBJECTIVE: To identify the employment outcomes of greatest importance as defined by those with SCI who have worked since injury. METHODS: A qualitative approach was used with 6 focus groups at 2 sites (Minnesota and Georgia). Participants (N = 44) were a minimum of 10 years after injury and had been employed at some point after SCI. We identified participants through a 40-year longitudinal study of SCI and a community resource. A combination of homogeneous (race/ethnic minority group, female group) and heterogeneous groups were convened. A semi-structured interview format queried participants about personal, environmental, and policy-related factors that impacted obtaining, maintaining, and advancing in employment. RESULTS: Seven overlapping themes were identified under the 2 broad categories of compensation and subjective well-being: (1) salary and what it can support, (2) health insurance and other fringe benefits, (3) promotions and recognition, (4) social connection and support, (5) job satisfaction and enjoyment from working, (6) making a difference and helping others, and (7) psychological and emotional health. CONCLUSION: The results indicate several common themes among persons with SCI who have successful employment histories, suggesting that the benefits of employment are multifaceted and go beyond monetary compensation.

Risk behaviors related to cigarette smoking among persons with spinal cord injury.

INTRODUCTION: Smoking, while detrimental to health in any population, has greater health implications for those with spinal cord injury (SCI) because of additional risks posed by SCI. The aims of this study were to document smoking status after SCI and to assess relationships between smoking status with injury severity and alcohol/pain medication use. METHODS: Participants (n = 1,076) were identified from a large rehabilitation hospital in the southeastern part of the United States. Eligibility criteria included (a) traumatic SCI resulting in residual impairment, (b) adult, and (c) 1+ years postinjury. Previous and current cigarette smoking and quitting attempts were assessed. Relationships were assessed between smoking status (current, former, and never), alcohol use, and pain medication use. RESULTS: Of participants (72% male, M age = 49.6 years, M = 16.1 years since SCI), 49.2% had never smoked, 28.2% were former smokers, and 22.6% were current smokers. Of current smokers, 39.2% attempted quitting in the past year and 77.2% had ever tried to quit. Only 29.9% of those who ever tried to quit sought professional help. Ambulatory persons, regardless of injury level, were 2.32 times more likely to be current smokers than nonambulatory persons with a high-level cervical injury. Lower socioeconomic status, binge drinking, and misuse of pain medication all predicted current smoking. CONCLUSIONS: Smoking prevalence among persons with SCI is largely consistent with the general population. Additionally, we found smoking to be associated with other risk behaviors (binge drinking and prescription medication misuse) and differs by injury severity. Future studies should assess smoking interventions, which may differ by injury severity.

Accelerated death rate in population-based cohort of persons with traumatic brain injury.

OBJECTIVES: To determine the influence of preexisting heart, liver, kidney, cancer, stroke, and mental health problems and examine the influence of low socioeconomic status on mortality after discharge from acute care facilities for individuals with traumatic brain injury. PARTICIPANTS: Population-based retrospective cohort study of 33695 persons discharged from acute care hospital with traumatic brain injury in South Carolina, 1999-2010. MAIN MEASURES: Days elapsing from the dates of injury to death established the survival time (T). Data were censored at the 145th month. Multivariable Cox regression was used to examine the independent effect of the variables on death. Age-adjusted cumulative probability of death for each chronic disease of interest was plotted. RESULTS: By the 70th month of follow-up, rate of death was accelerated from 10-fold for heart diseases to 2.5-fold for mental health problems. Adjusted hazard ratios for diseases of the heart (2.13), liver-renal (3.25), cancer (2.64), neurological diseases and stroke (2.07), diabetes (1.89), hypertension (1.43), and mental health problems (1.59) were highly significant (each with P < .001). Compared with persons with private insurance, the hazard ratio was significantly elevated with Medicaid (1.67), Medicare (1.54), and uninsured (1.27) (each with P < .001). CONCLUSION: Specific chronic diseases strongly influenced postdischarge mortality after traumatic brain injury. Low socioeconomic status as measured by the type of insurance elevated the risk of death.

Household income and subjective well-being after spinal cord injury: a longitudinal study.

BACKGROUND: Studies regarding subjective well-being (SWB) after spinal cord injury (SCI) are increasing in recent years, but little has been contributed to the relationship between income and SWB. OBJECTIVE: By using longitudinal data, we want to identify (1) the overall trend in SWB over a 10-year period; (2) the association between household income and SWB at baseline; (3) the variation of the trajectory of SWB over 10 years among different household income groups; and (4) the variation of change rates of SWB over 10 years among different household income groups. METHODS: We conducted a cohort study, including 434 participants who completed 3 measurements in 1998, 2003, and 2008. They were identified from outpatient records of 2 midwestern hospitals and a southeastern specialty hospital. RESULTS: People with lower household income experienced more life problems and less life satisfaction at the baseline measurement. During the 10-year period, their health problems and environmental barriers significantly increased compared to persons with higher income. Increasing vocational satisfaction was the only favorable change for the lower income group. CONCLUSIONS: There were consistent disparities in SWB related to income, and these typically persisted over time. Therefore, with the exception of vocational satisfaction, few changes may be anticipated in SWB that would narrow the gap between high and low income.

Allostatic load and spinal cord injury: review of existing research and preliminary data.

OBJECTIVE: To introduce allostatic load (AL) as a framework for measuring stress-related outcomes after spinal cord injury (SCI) by identifying the number and nature of biomarkers investigated in existing studies and by generating preliminary data on AL in 30 persons with traumatic SCI. METHODS: This systematic review and pilot study were conducted at a medical university in the southeastern United States. A review of literature published between 1993 and 2012 identified studies using 2 or more of 5 classes of AL biomarkers. We then collected data on 11 biomarkers (n = 30) from self-selected participants using physical exams and blood and urine specimen collection. These included waist to hip ratio, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein cholesterol, dihydroepiandrosterone, glycosylated hemoglobin, C-reactive protein, interleukin-6, and cortisol, norepinephrine, and epinephrine normalized by 12-hour creatinine. RESULTS: We were unable to identify any studies investigating AL biomarkers from each of the 5 areas or any studies specifically proposing to investigate AL. AL scores were relatively low, with metabolic indicators being the most elevated and neuroendocrine the least elevated. CONCLUSIONS: AL is a promising, yet underutilized, construct that may be feasibly assessed after SCI.

Ambulation and complications related to assistive devices after spinal cord injury.

OBJECTIVE: To evaluate long-term health outcomes including pain intensity, pain interference, and fatigue among ambulatory persons with spinal cord injury (SCI). DESIGN: Prospective cohort study. SETTING: Data were analyzed at a major medical university in the southeast USA. PARTICIPANTS: Participants included 783 ambulatory adults with SCI of traumatic origin, who were at least 1-year post-injury. Participants were identified through three sources of records at a large specialty hospital in the southeastern USA. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Pain intensity and interference (Brief Pain Inventory) and fatigue (Modified Fatigue Impact Scale Abbreviated Version 5). RESULTS: Examining assistive devices used for ambulation, 66% of the population used at least one device. In the logistic model, wheelchair and cane usage were significantly related to the outcomes after controlling for age, gender, and race. Wheelchair usage 50% of the time or less was significantly related to pain intensity (odds ratio (OR) 2.05, 95% confidence interval (CI) = 1.39-3.03), pain interference (OR 2.11, 95% CI = 1.43-3.12), and fatigue (OR 1.99, 95% CI = 1.12-1.43). Additionally, unilateral cane use was significantly related to the outcomes; pain intensity (OR 1.86, 95% CI = 1.35-2.56), pain interference (OR 2.11, 95% CI = 1.52-2.93), and fatigue (OR 2.49, 95% CI = 1.52-4.08). CONCLUSIONS: Among ambulatory persons with SCI, increased pain intensity, pain interference, and fatigue are associated with minimal wheelchair usage (50% or less) and less supportive assistive device (unilateral cane) usage.

Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research.

BACKGROUND: To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies. OBJECTIVE: Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention. METHODS: We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research. CONCLUSIONS: The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.

Risk of Fall-Related Injuries among Ambulatory Participants with Spinal Cord Injury.

BACKGROUND: With medical and rehabilitation advances, many people are able to regain or maintain ambulation after spinal cord injury (SCI). However, those who are ambulatory may be at increased risk for falls. OBJECTIVE: To assess the relationships between walking devices and behaviors, including alcohol use, prescription medication use, and exercise, with falls among persons with SCI who are ambulatory. METHODS: A total of 515 adults with chronic SCI who were able to ambulate provided self-report of their use of assistive devices for ambulation, prescription medication use, alcohol use, exercise, and falls resulting in injury (FRI). RESULTS: At least 1 FRI was reported by 20.3% of participants in the past year. Ambulatory participants who reported using a wheelchair as their primary mode of mobility were less likely to have an FRI than those who reported walking more than using a wheelchair. Those with perceived poor balance were 2.41 times more likely to have an FRI than those without poor balance. Those who reported less exercise than other persons with a comparable SCI severity were 2.77 times more likely to have an FRI than those reporting the same or more amount of exercise. Pain medication misuse also was associated with higher odds of an FRI. CONCLUSIONS: Health care providers should be aware of the risk for FRI among those who are ambulatory. They should assess and consider not only ambulatory ability, but also behaviors, including prescription medication use and exercise, when recommending ambulation techniques.

Behavioral factors related to fatigue among persons with spinal cord injury.

OBJECTIVE: To examine behavioral risk factors in relation to fatigue after spinal cord injury (SCI), specifically cardiovascular-related behaviors, prescription medication use, and alcohol and cigarette use. DESIGN: Cross-sectional. SETTING: A medical university in the southeastern United States. PARTICIPANTS: Adults (N=2245) at least 1 year post-SCI from a large specialty hospital in the Southeast responded to a mail-in survey. INTERVENTION: Not applicable. MAIN OUTCOMES MEASURE: The Modified Fatigue Impact Scale-5-item version was used to assess disabling fatigue. RESULTS: Of participants, 8.3% had disabling fatigue, 45.3% reported fatigue rarely to never impacted their life, and 46.4% reported having some fatigue. Persons who reported having less exercise than others with a similar injury level were 2.49 times as likely to have disabling fatigue as persons who reported more exercise. Those with a fair or poor diet were also more likely to have disabling fatigue. Use of prescription medication to treat pain was associated with disabling fatigue, as was being CAGE positive. Among nonbehavioral variables, race and injury severity were significantly associated with disabling fatigue. CONCLUSIONS: We identified several behavioral predictors of disabling fatigue, including cardiovascular risk factors, prescription medication use, and alcohol use. These factors are important because they are able to be modified and could be potential factors for prevention or intervention.

Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury.

OBJECTIVE: To assess the associations of race and socioeconomic status (SES) with pressure ulcers (PUs) after accounting for health care access among persons with spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Large specialty hospital in the southeastern United States. PARTICIPANTS: Persons with traumatic SCI who (1) had residual effects from their injury, (2) were 18 years or older at the time of the survey, and (3) were a year or more postinjury at the time of survey (N=2549). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Outcomes were measured by a mail-in survey: having a current PU (yes vs no), having a PU in the past year with or without reduced sitting time (no PU, no reduced sitting time, month or less, ≥5wk), and having at least 1 PU surgery since SCI onset (yes vs no). RESULTS: Of participants, 39.3% reported a PU in the past year, 19.9% had a current PU, and 21.9% reported having had surgery for a PU since their SCI onset. While race was preliminarily associated with each PU outcome, it became nonsignificant after controlling for SES and health care access. In each analysis, household income was significantly associated with PU outcomes after controlling for demographic and injury factors and remained significant after accounting for the health care access factors. Persons with lower income had higher odds of each PU outcome. Health care access was not consistently related to PU outcomes. CONCLUSIONS: Even after accounting for health care access, household income, a measure of SES, remained significantly associated with PU outcomes after SCI; however, race became nonsignificant.

Association between reliance on devices and people for walking and ability to walk community distances among persons with spinal cord injury.

OBJECTIVE: To identify and describe the frequency of reliance on assistive devices and/or people for ambulating distances and stair climbing. DESIGN: Survey. SETTING: A total of 429 adults with traumatic spinal cord injury who were able to walk at least 10 m were identified through inpatient and outpatient hospital databases at a specialty hospital in the southeast United States. OUTCOME MEASURE: Data were collected using a self-report questionnaire including items related to distances walked and devices used for ambulation. RESULTS: Participants best able to ambulate community distances were those who were independent with ambulation and those who used one cane or crutch. Reliance on people or use of a walker was associated with walking shorter distances. Regression analysis indicated reliance on devices or people for walking predicted variation in ability to ambulate community distances after controlling for demographic and injury characteristics. CONCLUSION: This study suggests that reliance on devices or a person for assistance is important to consider when assessing potential for achieving functional community ambulation.

Health, secondary conditions, and life expectancy after spinal cord injury.

OBJECTIVE: To evaluate the association of health status, secondary health conditions, hospitalizations, and risk of mortality and life expectancy (LE) after spinal cord injury (SCI). DESIGN: Prospective cohort study. SETTING: Preliminary data were collected from a specialty hospital in the Southeastern United States, with mortality follow-up and data analysis conducted at a medical university. PARTICIPANTS: Adults with traumatic SCI (N=1361), all at least 1-year postinjury at the time of assessment, were enrolled in the study. There were 325 deaths. After elimination of those with missing data on key variables, there were 267 deaths and 12,032 person-years. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The mortality status was determined by routine follow-up using the National Death Index through December 31, 2008. A logistic regression model was developed to estimate the probability of dying in any given year using person-years. RESULTS: A history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized within the past year were all predictive of mortality. LE estimates were generated using the example of a man with noncervical, nonambulatory SCI. Using 3 age examples (20, 40, 60y), the greatest estimated lost LE was associated with chronic pressure ulcers (50.3%), followed by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and the diagnosis of probable major depression (18%). Symptoms of infections were associated with a 6.7% reduction in LE for a 1 SD increase in infectious symptoms. CONCLUSIONS: Several secondary health conditions represent risk factors for mortality and diminish LE after SCI. The presence of 1 or more of these factors should be taken as an indicator of the need for intervention.

Current trends in venous thromboembolism among persons hospitalized with acute traumatic spinal cord injury: does early access to rehabilitation matter?

OBJECTIVE: To determine the incidence of venous thromboembolism (VTE) among patients with traumatic spinal cord injury (TSCI) in acute care settings that is attributable to extended length of stay (LOS), insurance status, and access to rehabilitation. DESIGN: Population-based, retrospective cohort study. SETTING: Levels I through III and undesignated trauma centers. PARTICIPANTS: Patients with acute TSCI (N=3389) discharged from all acute care hospitals in South Carolina from 1998 through 2009, and a representative sample of patients with TSCI (n=186) interviewed 1 year later. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: VTE while in acute care. RESULTS: Annual incidence of TSCI is 67.2 per million in the state of South Carolina, while the cumulative incidence of VTE is 4.1%. Patients with TSCI who developed VTE were nearly 4 times more likely (odds ratio [OR], 3.98; 95% confidence interval [CI], 2.57-6.17) to have been those who stayed 12 days or longer in acute care after adjusting for covariates. The adjusted mean LOS in acute care was 32.0 days (95% CI, 27.7-37.2) for patients with TSCI who had indigent insurance versus 11.3 days (95% CI, 4.9-17.6) for Medicare, and 18.5 days (95% CI, 14.5-22.5) for commercial insurance after adjusting for VTE, disposition, and year of discharge. Only 20% of the persons under indigent care received rehabilitation from accredited rehabilitation facilities in contrast to 60% under commercial insurance. CONCLUSIONS: Fewer patients with TSCI under indigent care received postacute rehabilitation compared with Medicare or commercial insurance. Insurance status remains a major barrier to timely transfer to rehabilitation, leading to protracted LOS in acute care with increased risk of VTE.

Income and risk of mortality after spinal cord injury.

OBJECTIVE: To evaluate the association of household income and formal education with risk of mortality after spinal cord injury (SCI). DESIGN: Cohort study. SETTING: Twenty hospitals designated as Model SCI Systems of care in the United States. PARTICIPANTS: Adults (N=8027) with traumatic SCI, seen in one of the Model SCI Systems, who had at least 1 follow-up assessment between 1995 and 2006. All participants were at least 1 year postinjury at the time of assessment. There were 57,957 person-years and 1036 deaths. The follow-up period started with the first assessment between 1995 and 2006 and went until either the date of death or March 2009. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mortality status was determined by routine follow-up supplemented by using the Social Security Death Index. A logistic regression model was developed to estimate the chance of dying in any given year. RESULTS: Educational status and income were significantly predictive of mortality after adjusting for age, sex, race, and severity of injury. Compared with those with household income of $75,000 or greater, the odds of mortality was greater for those who had income between $25,000 and $75,000 (1.61) and still higher for those with less than $25,000 a year (2.41). Life expectancy differed more as a function of household income than the economic subscale of the Craig Handicap Assessment and Reporting Technique. CONCLUSION: There was a clear gradation in survival based on familial income (high, middle, low), not just an effect of the lowest income.

Vocational interests after recent spinal cord injury: comparisons related to sex and race.

OBJECTIVE: To compare vocational interests as a function of sex and race among persons with recent spinal cord injury (SCI), because previous research used almost exclusively white men. Limited research from nearly 2 decades ago suggested SCI selectively occurs to men whose vocational interests are consistent with the Realistic theme of the Holland typology, indicative of a preference for activities and occupations requiring physical strength and dexterity. DESIGN: The Strong Interest Inventory (SII) was completed an average of 50 days after SCI onset. SETTING: Data were collected at a specialty hospital and analyzed at a medical university. PARTICIPANTS: Adults with traumatic SCI (N=500) were assessed during inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The SII, a 317-item measure of vocational interests. RESULTS: Although the findings for white men were consistent with elevation of the Realistic theme when compared with the reference group, the interests of women and black participants were substantially different. Women scored highest on Social, Enterprising, and Conventional themes compared with the reference group. Black participants reported significantly higher elevations than whites on 5 themes (all except Realistic), with elevations on the Social, Enterprising, and Conventional themes exceeding standardized norms. The Artistic and Investigative themes were least descriptive of the overall sample. CONCLUSIONS: Rehabilitation professionals should be aware of likely differences in patterns of vocational interests as a function of race and sex, and use vocational interests as a means of facilitating postinjury adaptation.

The relationship between prescription medication use and ability to ambulate distances after spinal cord injury.

OBJECTIVE: To investigate the relationship between prescription medication use for pain and spasticity and ambulation distances while controlling for pain severity, injury severity, age, sex, and race in participants with spinal cord injury (SCI). DESIGN: Secondary analysis of survey data. SETTING: Specialty hospital in the Southeast United States. PARTICIPANTS: Adults (N=407) with traumatic SCI identified through inpatient and outpatient hospital databases. INTERVENTION: Not applicable. MAIN OUTCOMES MEASURES: A questionnaire measured prescription medication use, ambulation distance, and other demographic data. A composite score of four 10-point scales from the Brief Pain Inventory was used to measure pain severity. Multinomial logistic regression was used to calculate the odds ratio (OR) of ambulation distance using 1000 ft or more as the reference group. RESULTS: Persons with SCI who were heavy prescription medication users (defined as weekly or daily use for pain or spasticity) were more likely to be limited to distances less than 150 (OR, 2.82; 95% confidence interval [CI], 1.57-5.04) and 150 to 999 ft (OR, 2.52; 95% CI, 1.45-4.39). CONCLUSION: Heavy prescription medication use for pain and spasticity was related inversely to a person's ability to achieve community ambulation distances of 1000 ft or more.

Posttraumatic stress disorder and spinal cord injury.

OBJECTIVES: To identify the prevalence of posttraumatic stress disorder (PTSD) after spinal cord injury (SCI) in a sample averaging over 2 decades postinjury at assessment. Related objectives are to confirm the factor structure, compare subscales with those reported in a nonclinical sample, and identify the relationship of PTSD with depression. DESIGN: Survey. SETTING: A medical university in the Southeastern United States. PARTICIPANTS: Participants were initially identified through specialty hospitals in the Midwest and Southeastern United States. A cohort of adults (N=927) with traumatic SCI of at least 1 year duration at enrollment in 2002 to 2003 and a minimum of 7 years at the time of assessment completed the study materials. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: PTSD was measured by the Purdue Posttraumatic Stress Disorder Scale-Revised, and depression was measured by the Patient Health Questionnaire 9-item. RESULTS: PTSD was reported by less than 10% of the participants. Item endorsement decreased as a function of years postinjury, primarily because of low rates of endorsement among those 21 or more years postinjury. Confirmatory factor analysis did not result in an acceptable fit for subscales, item sets, or factors previously reported in the literature. Participants scored higher than a nonclinical sample (reported in the literature) on the arousal and avoidance subscales but lower on the re-experiencing subscale. Item endorsement were lower for the first set of items that relate directly to the SCI itself, with the highest item endorsement for "have difficulty remembering important aspects of event." PTSD rarely occurred in the absence of a depressive disorder. CONCLUSIONS: PTSD does not appear to be highly prevalent in long-term SCI survivors, and endorsement of items related to re-experiencing and even recalling the injury are rare. Because SCI often is accompanied by mild traumatic brain injury, difficulty recalling the event may have an organic rather than psychologic component.

The relationship of pressure ulcers, race, and socioeconomic conditions after spinal cord injury.

OBJECTIVE: To identify risks factors associated with pressure ulcers (PrU) after spinal cord injury (SCI) by examining race and indicators of socioeconomic status (measured by income and education). We hypothesize African Americans will have a greater risk for PrUs than whites, but this relationship will be mediated by the 2 socioeconomic status indicators. DESIGN: Cohort study. SETTING: A large rehabilitation hospital in the southeastern US. PARTICIPANTS: 1466 white and African American adults at least 1-year post-traumatic SCI. OUTCOME MEASURES: (a) PrUs in the past year, (b) current PrU, (c) surgery to repair a PrU since injury. RESULTS: In preliminary analyses, race was significantly associated with having a current PrU and with having surgery to repair a PrU since injury. In multivariable analyses, the relationships of PrU with having a current PrU and with having surgery to repair a PrU were both mediated by income and education such that the relationships were no longer significant. Lower income was associated with increased odds of each PrU outcome. After controlling for other variables in the model, education was associated with increased odds of having a current PrU. CONCLUSION: These findings help clarify the relationships between race and socioeconomic status with PrUs after SCI. Specifically, a lack of resources, both financial and educational, is associated with worse PrU outcomes. These results can be used by both providers and policy makers when considering prevention and intervention strategies for PrUs among people with SCI.