Biomedical subjects

Stephen P Burns

Publications and source records attributed to Stephen P Burns.

At least 19 recordsLinked to original sources

PubMed2006

Role of creatinine clearance as a screening test in persons with spinal cord injury.

OBJECTIVES: To determine (1) the variability of annual creatinine clearance (C(Cr)) testing for subjects with chronic spinal cord injury (SCI) and (2) whether decisions to change neurogenic bladder management are made based on C(Cr) measurements. DESIGN: Retrospective chart review. SETTING: Inpatient Veterans Affairs SCI unit. PARTICIPANTS: The medical records of 70 men were consecutively selected for review from among 664 veterans enrolled in the SCI clinic. All patient charts had to have at least 5 C(Cr) tests performed within 10 years preceding the review. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Development of renal insufficiency and change in medical or bladder management of the patient, based on the results of the C(Cr) test. RESULTS: For individual patients, the results of 24-hour C(Cr) were highly variable from 1 evaluation to the next; the within-subject standard deviation (SD) for C(Cr) was 25.9mL/min. The within-subject SD for serum creatinine was 0.12mg/dL. For all comparisons of repeatability, variability, and reliability, serum creatinine was superior to C(Cr). No medical management decisions were made based on the result of the 24-hour creatinine clearance. Renal ultrasound results and postvoid bladder residuals were the major factors in changing medical management with regard to renal function preservation. CONCLUSIONS: The C(Cr) test has little value as a screening measure for renal disease in SCI patients because of its variability in serial testing.

Biomarkers↗

PubMed2006

Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders.

OBJECTIVE: Respiratory complications are a leading cause of death in persons with spinal cord injuries and disorders (SCI&D). We examined same-day and 60-day hospitalizations and 60-day mortality after acute respiratory illness (ARI) outpatient visits. DESIGN: A longitudinal study was conducted of 8775 ARI visits in the Veterans Health Administration (VA) (October. 1997-September 2002) by persons with SCI&D. ARIs included upper respiratory infections (URI), acute bronchitis, pneumonia, and influenza (P&I). RESULTS: URIs accounted for almost half of all (49%) visits. A total of 14.9% of patients with ARIs were hospitalized the same day; 30.8% were hospitalized within 60 days. Predictors of hospitalization included diagnosis of either P&I or acute bronchitis, comorbid illness, level of injury, age, and VA SCI center visit. Overall 60-day mortality was 2.9% but was 7.9% for pneumonia. Mortality was related to diagnosis (P&I: odds ratio [OR] = 9.80, 95% confidence interval [CI]: 6.27-13.33; acute bronchitis: OR = 2.00, 95% CI: 1.08-2.93), age (65+: OR = 3.96, 95% CI: 2.23-5.70), and comorbid conditions (OR = 1.94, 95% CI: 1.43-2.46). CONCLUSIONS: P&I and acute bronchitis were associated with increased VA hospitalization and mortality rates. The case fatality rate for pneumonia is higher for SCI&D than the general population. Level of injury predicted hospitalization but not death. Efforts to improve prevention and treatment of ARIs in persons with SCI&D are needed.

Aged↗

PubMed2005

Spinal cord infarction following cervical transforaminal epidural injection: a case report.

STUDY DESIGN: Case report. OBJECTIVE: A review of the literature about spinal cord infarction with epidural steroid injections and report of one case. SUMMARY OF BACKGROUND DATA: A 53-year-old man with a history of chronic cervical pain and multilevel degenerative disc disease with multiple posterior disc protrusions on cervical imaging. The patient received a left C6 tranforaminal injection for therapeutic pain relief, with fluoroscopic confirmation of left C6 nerve root sheath spread of injectable contrast. Approximately 10 to 15 minutes post-procedure, he noted weakness in his left arm and bilateral lower limbs. Initial cervical magnetic resonance imaging revealed no cord signal change, but a follow-up study 24 hours later demonstrated patchy increased T2 and short tau inversion recovery signal in the cervical cord from the odontoid to C4-C5 vertebral levels. This was consistent with a diffuse vascular infarct to the cervical cord, resulting in motor-incomplete tetraplegia. RESULTS: This is one of a few reported cases of spinal cord infarction after cervical epidural injections. No direct cord trauma occurred. Previously reported risk factors of spinal infarction, such as hypotension and large injectate volumes, were noncontributory in this case. CONCLUSIONS: Cervical epidural injections, despite careful localization, carry a risk of vascular infarction to the spinal cord, even in the absence of direct cord trauma. The etiology of these infarctions and identifying those patients at risk remain uncertain.

Anti-Inflammatory Agents↗

PubMed2005

Etiology and outcomes of veterans with spinal cord injury and disorders hospitalized with community-acquired pneumonia.

OBJECTIVE: To determine whether documentation of a causative organism for community-acquired pneumonia (CAP) is associated with outcomes, including mortality and length of stay (LOS), in hospitalized veterans with spinal cord injuries and disorders (SCI&D). DESIGN: Retrospective cohort study. SETTING: Patients with SCI&D admitted with CAP to any Veterans Affairs medical center between September 1998 and October 2000. PARTICIPANTS: Hospital administrative data on 260 patients with SCI&D and a CAP diagnosis. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: All-cause, 30-day mortality and hospital LOS. RESULTS: An organism was documented by International Classification of Diseases, 9th Revision , discharge codes in 24% of cases. Streptococcus pneumoniae and Pseudomonas aeruginosa accounted for 32% and 21%, respectively, of the identified bacterial pathogens. The overall mortality rate was 8.5%. No significant association was found between etiologic diagnosis of CAP and 30-day mortality. Lower mortality was associated with treatment at a designated SCI center (relative risk=.35; confidence interval, .12-.99). Pathogen-based CAP diagnosis was significantly associated with longer LOS (adjusted r 2 =.023, P =.024). CONCLUSIONS: There was no association between etiologic diagnosis of CAP and 30-day mortality among people with SCI&D. Documentation of CAP etiology was associated with the variance in LOS. Pneumococcal vaccination and antibiotic therapy with antipseudomonal activity may be particularly prudent in these patients given the high frequency of these pathogens among SCI&D patients with CAP.

Aged↗

PubMed2005

Break-technique handheld dynamometry: relation between angular velocity and strength measurements.

OBJECTIVES: To determine whether the muscle strength, as measured with break-technique handheld dynamometry (HHD), is dependent on the angular velocity achieved during testing and to compare reliability at different angular velocities. DESIGN: Repeated-measures study. Participants underwent HHD by using make-technique (isometric) and break-technique (eccentric) dynamometry at 3 prespecified angular velocities. Elbow movement was recorded with an electrogoniometer. SETTING: Inpatient spinal cord injury unit. PARTICIPANTS: Convenience sample of 20 persons with tetraplegia with weakness of elbow flexors or extensors. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Elbow angular velocity and muscle strength recorded during HHD. RESULTS: With the break technique, angular velocities averaging 15 degrees , 33 degrees , and 55 degrees /s produced 16%, 30%, and 51% greater strength measurements, respectively, than velocities recorded by using the make technique (all P < .006 for comparisons between successive techniques). The intraclass correlation coefficient for intrarater reliability was .89 or greater for all testing techniques. CONCLUSIONS: Greater strength is recorded with faster angular velocities during HHD. Differences in angular velocity may explain the wide range previously reported for break- versus make-technique strength measurements. Variation in angular velocity is a potential source of variability in serial HHD strength measurements, and for this reason the make technique may be preferable.

Biomechanical Phenomena↗

PubMed2005

Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury.

BACKGROUND/OBJECTIVES: The purpose of this study was to determine whether publication of the "Prevention of Thromboembolism in Spinal Cord Injury" clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy. METHODS: Data were abstracted from medical records of 134 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1), preimplementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing/outreach visits. RESULTS: Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively). CONCLUSIONS: The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.

Adult↗

PubMed2005

Creatine supplementation for weak muscles in persons with chronic tetraplegia: a randomized double-blind placebo-controlled crossover trial.

BACKGROUND AND OBJECTIVES: Creatine supplementation improves muscle strength in some patient populations with neurologic disorders. The purpose of this study was to determine whether creatine supplementation improves muscle strength and endurance in weak upper limb muscles in persons with tetraplegia, and whether it improves function. METHODS: Outpatients with tetraplegia and mild wrist extensor weakness were randomized to receive either creatine or placebo in a double-blind crossover design. During creatine supplementation, participants were loaded with 10 g orally twice per day for 6 days, then maintained on 5 g daily until undergoing testing. Main outcome measures, performed at baseline, after placebo, and after creatine supplementation, included maximal voluntary wrist extensor isometric contraction strength (MVC), endurance times for 5 submaximal wrist extensor contractions, and the Grasp and Release Test for hand function. RESULTS: Eight individuals (7 men, 1 woman) with tetraplegia met inclusion criteria and completed all study phases. The mean age of participants was 48 years, and 7 of 8 had C6 motor level injuries. There were no significant differences in MVC, endurance times, or hand function for creatine vs placebo. CONCLUSION: Creatine does not improve MVC and endurance of weak wrist extensors and does not improve hand function in individuals with tetraplegia.

Cervical Vertebrae↗

PubMed2005

Provider adherence to implementation of clinical practice guidelines for neurogenic bowel in adults with spinal cord injury.

BACKGROUND/OBJECTIVES: Clinical Practice Guidelines (CPGs) have been published on a number of topics in spinal cord injury (SCI) medicine. Research in the general medical literature shows that the distribution of CPGs has a minimal effect on physician practice without targeted implementation strategies. The purpose of this study was to determine (a) whether dissemination of an SCI CPG improved the likelihood that patients would receive CPG recommended care and (b) whether adherence to CPG recommendations could be improved through a targeted implementation strategy. Specifically, this study addressed the "Neurogenic Bowel Management in Adults with Spinal Cord Injury" Clinical Practice Guideline published in March 1998 by the Consortium for Spinal Cord Medicine METHODS: CPG adherence was determined from medical record review at 6 Veterans Affairs SCI centers for 3 time periods: before guideline publication (T1), after guideline publication but before CPG implementation (T2), and after targeted CPG implementation (T3). Specific implementation strategies to enhance guideline adherence were chosen to address the barriers identified by SCI providers in focus groups before the intervention. RESULTS: Overall adherence to recommendations related to neurogenic bowel did not change between T1 and T2 (P = not significant) but increased significantly between T2 and T3 (P < 0.001) for 3 of 6 guideline recommendations. For the other 3 guideline recommendations, adherence rates were noted to be high at T1. CONCLUSIONS: While publication of the CPG alone did not alter rates of provider adherence, the use of a targeted implementation plan resulted in increases in adherence rates with some (3 of 6) CPG recommendations for neurogenic bowel management.

Aged↗

PubMed2005

Hand-held dynamometry in persons with tetraplegia: comparison of make- versus break-testing techniques.

OBJECTIVE: To compare make and break techniques for hand-held dynamometry in persons with tetraplegia. We compared the interrater and intrarater reliability, the relative forces, and variability between examiner techniques. DESIGN: Two examiners with no previous hand-held dynamometry training performed hand-held dynamometry on the elbow flexors or extensors of 19 persons with upper limb weakness secondary to tetraplegia, using break and make techniques. Testing was performed in two sessions separated by 10 mins. Simultaneous recording from an electrogoniometer placed across the elbow was obtained for a subset of participants. RESULTS: Break and make techniques both showed intraclass correlation coefficients exceeding 0.9 for interrater and intrarater reliability. The maximum expected difference for 95% of repeated measurements was 3.5 kg, with hand-held dynamometry strength values that averaged 7-11 kg. Average break/make ratios ranged from 1.38 +/- 0.29 to 1.49 +/- 0.37. The electrogoniometric data showed that the two examiners used similar testing technique, and small variations in technique were not associated with significant differences in strength recordings. CONCLUSION: Make and break techniques for hand-held dynamometry both show high reliability over a short intersession period when performed by inexperienced examiners on weak elbow flexors and extensors.

Hand Strength↗

PubMed2005

Long-term treatment of sleep apnea in persons with spinal cord injury.

OBJECTIVE: Although numerous studies have documented a high prevalence of sleep apnea in persons with spinal cord injury, relatively little has been published regarding treatment of sleep apnea in this population. The purpose of this study was to describe long-term treatment outcomes and side effects of sleep apnea treatment in persons with spinal cord injury. DESIGN: Descriptive, postal mail survey to spinal cord injury individuals with sleep apnea followed by a Veterans Affairs Spinal Cord Injury Service. RESULTS: The response rate to the mailed survey was 54%, with complete surveys obtained from 40 individuals with spinal cord injury and sleep apnea. The majority of participants (93%) had been diagnosed with sleep apnea through routine clinical care, and patients had been diagnosed a mean of 4 yrs earlier. Continuous positive airway pressure was the most commonly used treatment. Continuous positive airway pressure was tried by 80% of patients, and of these, 63% continued to use continuous positive airway pressure, with mean usage 6.5 nights per week and 6.9 hrs per night. Continuous positive airway pressure was rated as beneficial in comparison with its side effects. The most common side effects were nasal congestion and mask discomfort. CONCLUSION: Many spinal cord injury individuals with sleep apnea become long-term users of continuous positive airway pressure and perceive a subjective benefit from the treatment.

Aged↗

PubMed2004

Whiplash: pathophysiology, diagnosis, treatment, and prognosis.

We have reviewed the literature relevant to pathophysiology, diagnosis, treatment, and prognosis of whiplash-associated disorder (WAD) since 1995 and provided a brief summary of literature pertaining to forces action on the head and neck during a motor vehicle accident. The scope of the current review is confined to the Quebec guidelines for WAD grades 1-3 but excludes grade 4 (neck complaints and fracture or dislocation). After excluding papers without scientific data and single case reports or case series with fewer than 20 patients, articles were reviewed for methodological quality. The diagnosis remains clinical. No imaging, physiological, or psychological study provides specific diagnostic criteria. In the acute period up to 2 weeks, soft collars or rest and work-leave do not shorten the duration of neck pain. Sick leave is reduced by high-dose methylprednisolone given within 8 h of injury, but confirmatory studies examining the cost-benefit relationship are needed. In the first 6 months, active as opposed to passive treatment results in improved outcomes. Specific exercise strategies have not been studied. For those with symptoms lasting more than 6 months, percutaneous radio-frequency neurotomy can provide pain relief for many months in those responding to blind local anesthetic facet blocks. Intra-articular corticosteroids are ineffective. Uncontrolled trials suggest that multimodal rehabilitation programs result in improved overall function. The overall prognosis for recovery has varied considerably across studies. Such variability is likely due to differences in case identification methods and whether outcome is assessed in terms of symptoms or the receipt of financial compensation for injury. The impact on prognosis of both collision- and patient-related factors is also reviewed.

Humans↗

PubMed2004

Measuring hand intrinsic muscle strength: normal values and interrater reliability.

BACKGROUND: The intrinsic muscles of the hand are of interest in spinal cord injury (SCI) and other myelopathies, because they are innervated by the most caudal cord segments innervating the upper limb. In addition, abnormalities of the peripheral nervous system, such as peripheral nerve entrapments, often affect hand intrinsic muscle strength of SCI patients. Therefore, measuring hand intrinsic strength may allow for early diagnosis of neurologic decline. METHODS: A method was developed for measuring strength of hand intrinsic muscles with a handheld myometer. With the use of a handheld myometer, this study examined the distribution of strength measurements for second-digit abductors, fifth-digit abductors, and thumb opposers in able-bodied participants and in individuals with weakness. The quantitative measurements were compared with manual muscle test scores and interrater reliability is described for these hand intrinsic strength measurements. Thirty-one able-bodied individuals participated (17 men, 14 women; mean age = 37.7 years). In addition, 24, patients with SCI participated (23 men, 1 woman; mean age = 53.5 years; 9 with paraplegia and 14 with tetraplegia as a primary diagnosis). The Bland-Altman method was used to test for interrater reliability. RESULTS: Mean strength of able-bodied participants was 5.0 kg for second-digit abduction, 3.1 kg for fifth-digit abduction, and 5.0 kg for thumb opposition, and the lower limits of normal were 3.0, 1.8, and 3.4 kg, respectively. The 95th percentile of interrater differences were 29.3% for second-digit abduction, 38.5% for fifth-digit abduction, and 43.7% for thumb opposition. CONCLUSION: Abnormal hand intrinsic strength should be suspected if values are lower than the 5th percentile values listed above or if strength change exceeds the 95th percentile for interrater differences shown above. These quantitative hand strength measurements may allow for earlier diagnosis of secondary neurologic complications and may aid in monitoring neurologic recovery in persons with SCI.

Adult↗

PubMed2004

Worsening myelopathy masked by peripheral nerve disorders.

BACKGROUND/OBJECTIVE: Peripheral nerve disorders--whether due to peripheral nerve entrapment or to polyneuropathy--can alter the signs of myelopathy, masking both the sensory loss and distal hyperreflexia. Diagnosis of worsening myelopathy may be missed when there is a coexisting peripheral nerve disorder. METHODS: This study is a case description and analysis of 3 consecutive cases identified over 2 years. RESULTS: Three cases were identified in which the diagnosis of worsening myelopathy was missed and treatment was delayed because neurologic decline was attributed to a coexisting peripheral nerve disorder. This report describes 2 cases of posttraumatic syringomyelia masked by superimposed peripheral nerve entrapments and 1 case of cervical myelopathy due to cervical spinal stenosis from ossification of the posterior longitudinal ligament masked by diabetic polyneuropathy. CONCLUSION: It is important to continually question whether the working diagnosis of peripheral nerve disorder explains the clinical findings, given neurologic decline; or whether a superimposed worsening myelopathy may coexist. Early diagnosis of worsening myelopathy is important, because prompt treatment of syringomyelia and myelopathy due to cervical spinal stenosis may yield better outcomes. Early diagnosis is aided by (a) considering alternative and multiple diagnoses, (b) assessing spinothalamic as well as posterior column sensation and assessing these sensory modalities for proximal as well as distal limbs, (c) assessing tendon hyperreflexia of proximal as well as distal limb muscles, and (d) utilizing electrodiagnostic tests that can identify myelopathy.

Adult↗

PubMed2003

Wheelchair configuration and postural alignment in persons with spinal cord injury.

OBJECTIVE: To determine whether postural alignment and shoulder flexion range differ for persons with spinal cord injury (SCI) seated in wheelchairs with standard configurations versus wheelchairs with posterior seat inclination and a low backrest set perpendicular to the floor. DESIGN: Prospective repeated-measures study. SETTING: Outpatient SCI clinic. PARTICIPANTS: Fourteen subjects with C6-T10 motor-complete SCI. INTERVENTIONS: Subjects sat in 3 manual wheelchairs: standard setup E&J Premier (S1), standard setup Quickie Breezy (S2), and test configuration Quickie TNT (T) with posterior seat inclination and a low backrest set perpendicular to the floor. MAIN OUTCOME MEASURES: Shoulder and neck alignment and pelvic tilt were determined from sagittal plane digital photographs at rest and with maximal vertical reach. RESULTS: At rest, T produced less shoulder protraction than either standard configuration (difference between the mean values, S1: 1.6 cm, P=.048; S2: 1.2 cm, P=.013). S1 and S2 showed a greater head-forward position than T (differences between the mean values, S1: 6.5 degrees, P=.008; S2: 6.3 degrees, P=.013). T allowed greater humeral flexion than S2 (difference between the mean values: 3.7 degrees, P=.036) and greater vertical reach above the seat plane than either conventional configuration (differences between the mean values, S1: 4.7 cm, P=.005; S2: 4.1cm, P=.002). The indirect pelvic tilt measurement showed a trend (P=.06) toward greater posterior pelvic tilt with S1 and S2. CONCLUSION: The alternate configuration produces more vertical postural alignment and greater reach ability versus the standard factory setup wheelchairs.

Adult↗

PubMed2003

The effect of inaccurate FIM instrument ratings on prospective payment: a study of clinician expertise and FIM rating difficulty as contributing to inaccuracy.

OBJECTIVE: To test whether clinician expertise and FIM instrument rating difficulty explain clinician overconfidence in FIM rating accuracy. DESIGN: Participants answered 60 true/false FIM questions and, for each question, completed a 6-category scale to assess confidence in the accuracy of their responses. Experts and novices, as well as hard and easy items, were identified through a Rasch analysis. The relation between confidence and accuracy was examined for these different groups. SETTING: Three urban medical centers. PARTICIPANTS: Fifty medical rehabilitation professionals, including physical therapists, occupational therapists, rehabilitation psychologists, speech pathologists, and rehabilitation nurses. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Observed proportion of correct responses to 60 true/false questions and responses from the 6-category confidence scale. RESULTS: The amount of overconfidence was mediated by the difficulty of the FIM task and the level of expertise of the clinical judge. CONCLUSIONS: Decreasing the level of overconfidence in FIM scoring is a promising avenue for improving the accuracy of functional assessment. Accurate assessment of functional status for case-mix group classification will be of even greater importance under the recently initiated Medicare prospective payment system.

Activities of Daily Living↗

PubMed2003

Prevalence of vitamin B12 deficiency in spinal cord injury.

OBJECTIVE: To assess the prevalence of vitamin B(12) deficiency in persons with spinal cord injury (SCI) or disease (SCD). DESIGN: Cross-sectional study with prospective blood collection and retrospective medical record review. SETTING: Regional Veterans Affairs SCI service. PARTICIPANTS: One hundred six adult men with chronic SCI or SCD and without other acute medical or surgical complications; most had SCI or SCD due to trauma or cervical spinal stenosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fasting blood samples were obtained at annual evaluation for serum B(12), folic acid, methylmalonic acid (MMA), and homocysteine. Serum levels were analyzed graphically and associated with patient variables by using statistical tests. RESULTS: The vitamin B(12) level was subnormal in 5.7% of subjects; of those, all had supranormal MMA levels, all were age 40 to 59, most had complete SCI, and 67% had symptoms suggestive of B(12) deficiency. Low-normal B(12) levels were associated with a high prevalence of supranormal MMA. Subjects with either subnormal B(12) or low normal B(12) with supranormal MMA, both suggestive of vitamin B(12) deficiency, comprised 13.3% of the total group of subjects. CONCLUSION: Vitamin B(12) deficiency is most common in middle-aged SCI or SCD persons with complete or near-complete spinal cord involvement (ie, American Spinal Injury Association class A-C injuries). Treatment with either parenteral or oral B(12) replacement may optimize health and prevent irreversible neuropsychiatric complications in those with subnormal and low-normal B(12) levels.

Adult↗

PubMed2003

Spinal cord injury providers' perceptions of barriers to implementing selected clinical practice guideline recommendations.

BACKGROUND/OBJECTIVE: Twelve focus groups were conducted at 6 Department of Veterans Affairs (DVA) Spinal Cord Injury (SCI) Centers. The purpose of these focus groups was to identify provider-perceived barriers to implementing selected recommendations of two clinical practice guidelines (CPGs)--Prevention of Thromboembolism in Spinal Cord Injury and Management of Neurogenic Bowel in Adults With Spinal Cord Injury--at their sites. METHODS: A total of 75 SCI direct-care staff (including physicians, nurses, dieticians, rehabilitation therapists, psychologists, and social workers) participated in the focus groups, which were conducted by trained focus group facilitators. Woolfs framework was used to classify perceived barriers into 1 of 4 categories: (a) lack of knowledge, (b) lack of agreement, (c) lack of ability, or (d) lack of systematic reminders for implementation. The "lack of ability" category was further expanded to reflect which specific aspect of the environment was seen as the obstacle: (a) patient, (b) provider, (c) SCI unit, (d) hospital or medical center, or (e) non-Veterans Affairs (VA) hospital setting. RESULTS: Providers disagreed with the recommendation to reinstitute prophylaxis in patients with nonacute SCI to prevent deep vein thrombosis and identified a number of system-level problems with providing appropriate prophylaxis. Providers identified patient reluctance to changing their bowel programs and difficulties in documenting changes in the patients' bowel program as obstacles to implementing the neurogenic bowel CPG. CONCLUSION: Based on this feedback, interventions were developed to address provider-perceived barriers. These interventions were implemented at 6 Veterans Affairs SCI Centers.

Adult↗

PubMed2003

Vitamin B12 deficiency in spinal cord injury: a retrospective study.

BACKGROUND/OBJECTIVE: Vitamin B12 (or cobalamin) deficiency is well known in geriatric patients, but not in those with spinal cord injury (SCI). This retrospective study describes vitamin B12 deficiency in SCI. METHODS: This study utilized a retrospective chart review of patients with SCI who had received serum vitamin B12 testing over the last 10 years. RESULTS: Probable vitamin B12 deficiency was noted in 16 patients with SCI. Twelve patients had subnormal serum vitamin B12 levels (< 220 pg/mL), whereas 4 patients had low-normal vitamin B12 levels (< 300 pg/mL) with neurologic and/or psychiatric symptoms that improved following vitamin B12 replacement. Classic findings of paresthesias and numbness often were not evident; such findings likely were masked by the pre-existing sensory impairment caused by SCI. Of the 16 SCI patients, 7 were ambulatory; 4 of the 7 presented with deterioration of gait. In addition, 3 of the 16 SCI patients presented with depression and fatigue, 2 had worsening pain, 2 had worsening upper limb weakness, and 2 had memory decline. Of the 12 patients with subnormal serum vitamin B12 levels, 6 were asymptomatic. Classic laboratory findings of low serum vitamin B12, macrocytic red blood cell indices, and megaloblastic anemia were not always present. Anemia was identified in 7 of the 16 patients and macrocytic red blood cells were found in 3 of the 16 patients. Only 1 of the 16 SCI patients had a clear pathophysiologic mechanism to explain the vitamin B12 deficiency (ie, partial gastrectomy); none of the patients were vegetarian. Twelve of the SCI patients appeared to experience clinical benefits from cyanocobalamin replacement (some patients experienced more than 1 benefit), including reversal of anemia (5 patients), improved gait (4 patients), improved mood (3 patients), improved memory (2 patients), reduced pain (2 patients), strength gain (1 patient), and reduced numbness (1 patient). CONCLUSION: It is recommended that physicians consider vitamin B12 deficiency in their patients with SCI, particularly in those with neurologic and/or psychiatric symptoms. These symptoms often are reversible if treatment is initiated early.

Adult↗