Spinal Cord Injury Care Research Articles

The State of Aging and Public Health for People with Spinal Cord Injury: Lost in Transition?

The population with spinal cord injury (SCI) is currently in an epidemiologic transition, characterized by increasing life span and a resultant change in health comorbidities. These health shifts, along with “life transitions” and aging experiences unique to people with SCI, require a specialized approach to aging with SCI. The purpose of this article is to provide a background to epidemiologic changes in the general population and in those with SCI. Then, a brief overview of the evidence base relevant to conditions associated with aging with SCI will be presented. By approaching SCI care with anticipatory knowledge of likely aging needs, health care professionals and consumers with SCI can better proactively address potential comorbidities and health decline and, using a coordinated approach, primary, secondary, and tertiary prevention and interventions can be implemented with the long-term goal of reducing morbidity, mortality, and improving health, wellness, and quality of life.

Historical perspective: Neurological advances from studies of war injuries and illnesses

Early in the 20th century during the Russo-Japanese War and World War I (WWI), some of the most important, lasting contributions to clinical neurology were descriptive clinical studies, especially those concerning war-related peripheral nerve disorders (eg, Hoffmann-Tinel sign, Guillain-Barré-Strohl syndrome [GBS]) and occipital bullet wounds (eg, the retinal projection on the cortex by Inouye and later by Holmes and Lister, and the functional partitioning of visual processes in the occipital cortex by Riddoch), but there were also other important descriptive studies concerning war-related aphasia, cerebellar injuries, and spinal cord injuries (eg, cerebellar injuries by Holmes, and autonomic dysreflexia by Head and Riddoch). Later progress, during and shortly after World War II (WWII), included major progress in understanding the pathophysiology of traumatic brain injuries by Denny-Brown, Russell, and Holbourn, pioneering accident injury studies by Cairns and Holbourn, promulgation of helmets to prevent motorcycle injuries by Cairns, development of comprehensive multidisciplinary neurorehabilitation by Rusk, and development of spinal cord injury care by Munro, Guttman, and Bors. These studies and developments were possible only because of the large number of cases that allowed individual physicians the opportunity to collect, collate, and synthesize observations of numerous cases in a short span of time. Such studies also required dedicated, disciplined, and knowledgeable investigators who made the most out of their opportunities to systematically assess large numbers of seriously ill and injured soldiers under stressful and often overtly dangerous situations.

Poster 44: Health-Related Consequences of Caregiving Identified by Caregivers of Persons With a Spinal Cord Injury

Objective: To describe the health-related consequences of caregiving in a sample of informal and formal caregivers of persons with a spinal cord injury (SCI). Design: This ongoing, federally-funded study employs a mixed-method approach to the collection, processing and analysis of data. Qualitative data comes from the transcribed in-depth interviews of study participants. Study participants also completed survey instruments measuring important outcomes, such as perceived stress, life satisfaction, and self-rated health/functioning. Setting: Community-based. Participants: Study participants included 39 informal caregivers and 20 formal caregivers. The former group included 23 unpaid family members and 16 independent contractors who were hired directly by the SCI care recipient. The latter group consisted of employees of home health agencies. Interventions: Not applicable. Main Outcome Measures: For this analysis quantitative measures included the following: Perceived Stress Scale (PSS), Satisfaction with Life Scale (SWLS), and a measure of health functioning (SF-12, v2). Qualitative outcomes consisted of narrative themes related to caregiver workload; stress; perceived impact of caregiving on health, and quality of life. Results: Informal caregivers reported higher mean PSS and SWLS scores and a lower mean SF-12 score than did formal caregivers. For both caregiver groups, descriptive statistics revealed moderately strong negative relationships between perceived stress and satisfaction with life and between stress and health functioning. Content analysis of coded transcripts produced a wide range of stressors linked to SCI caregiving. Informal caregivers most often cited the physical and emotional demands of caregiving. Formal caregivers most often cited poor wages and lack of health insurance benefits. A substantial number of participants in both caregiver groups cited health-related consequences of caregiving (fatigue, physical aches and pains, and deleterious effects on chronic conditions. Conclusions: This presentation triangulates quantitative data with narrative material to provide an understanding of the linkages between the demands of SCI caregiving and its health-related consequences for informal and formal caregivers.

SCIRehab Project Series: The Psychology Taxonomy

Context: The integration of psychologists as members of the rehabilitation team has occurred in conjunction with the evolution and adoption of interdisciplinary teams as the standard of care in spinal cord injury (SCI) rehabilitation. Although the value of psychological services during rehabilitation is endorsed widely, specific interventions and their association with patient outcomes have not been examined adequately.Objective: To address this shortcoming, psychologists from 6 SCI centers collaborated to develop a psychology intervention taxonomy and documentation framework.Methods: Utilizing an interactive process, the lead psychologists from 6 centers compiled an inclusive list of patient characteristics assessed and interventions delivered in routine psychological practice at the participating rehabilitation facilities. These were systematically grouped, defined, and compared.Results: The resulting taxonomy became the basis of a documentation framework utilized by psychologists for the study. The psychology taxonomy includes 4 major clinical categories (assessment, psychotherapeutic interventions, psychoeducational interventions, and consultation) with 5 to 10 specific activities in each category.Conclusions: Examination of psychological interventions and their potential association with positive outcomes for persons who sustain SCI requires the development of a taxonomy. Results of these efforts illustrate similarities and differences in psychological practice among SCI centers and offer the opportunity to blend research and clinical practice in an innovative approach to evidence-based practice improvement. The established taxonomy provides a basic framework for future studies on the effect of psychological interventions.

Rehabilitation of pediatric spinal cord injury: From acute medical care to rehabilitation and beyond

Spinal Cord Injury (SCI) in the pediatric population is an uncommon but potentially devastating entity that may be unfamiliar to many practitioners. Because its treatment requires a long-term, well-planned, integrated approach, understanding the natural history, treatment, and common comorbidities of pediatric SCI is crucial for all physicians caring for these children. We present a review of the current literature on this topic to discuss the current standard of medical and rehabilitation care of pediatric SCI patients. Studies for this review article were obtained by a thorough PubMed search, including but not limited to the terms "spinal cord injury," "SCI," "spinal rehabilitation," and "pediatric spinal injury." Frequently referenced articles of particular prominence in the field were also reviewed. Studies were included primarily to illustrate specific clinical situations in this overview article. Studies were reviewed by the authors (JG and HK) and clinically important details were incorporated into the review. Not applicable. Pediatric SCI, while relatively uncommon, is a life-changing event for affected children and their families, physically, medically, and economically. Providing multidisciplinary care, as well as early and extensive rehabilitation, translates into superior outcomes. However, more research remains necessary to identify tactics for better community integration and increased educational, financial, and social success.

The Bors Award: Legacy of Ernest H. J. “Pappy” Bors, MD

After World War II, military hospitals in the US were inundated with veterans paralyzed by spinal cord injury. Their complications spanned specialties and subspecialties including pulmonary medicine, orthopedics, neurology, urology, dermatology, surgery and some yet to be developed. Care was hindered by a health care delivery structure based on specialty and a lack of cohesive approach to their complex medical and social problems. Not only did the structure need overhauling, clinicians were needed to care for these “hopeless cripples” and research was needed to find ways to address their many needs in a climate of little support and even less recognition. Even the patients, hardened warriors, often bitter, with no hope for recovery, needed to be convinced that there was a better way. Only a dedicated, aggressive and persistent professional could hope to make any headway in such a difficult situation. In 1944, Ernest H.J. Bors, MD, joined the staff of Hammond General Army Hospital. As assistant chief of urology, Dr Bors was urology consultant to the hospital's Spinal Cord Injury Care Section (1,2). Caring for these most needy veterans inspired him to develop a comprehensive way to oversee all of their needs. Not only did Dr Bors become the foremost expert on neurourology in spinal cord injury, he developed a holistic multidisciplinary approach that formed the foundation for modern SCI centers. His success with his SCI ward attracted the attention of the War Department, which opened the first SCI Center in the nation at Birmingham General Army Hospital (now the Long Beach VA Hospital), and placed Dr Bors in charge. Soon he had 220 patients under his care and disciplinary problems that further complicated the administrative, medical and surgical issues involved in managing this large, innovative unit. The frustrations and responsibilities sometimes overwhelmed Dr Bors, who was known for his crusty, ‘tough love' demeanor. But his equally tough patients, eventually numbering more than 2,500, recognized his underlying deep love and dedication and called their champion, “Pappy”. They called themselves the S.O.B.s (Survivors of Birmingham) and in 1970, more than 700 of them turned out for Pappy Bors' retirement party in Los Angeles—a fitting tribute to a true pioneer in the field of spinal cord injury. Since 1994, the Journal of Spinal Cord Medicine has offered an annual award in Pappy's honor—The Ernest Bors Award for Scientific Development, because throughout a career spent fighting for basic resources while caring for thousands of patients many considered ‘hopeless cases', Dr Bors made research and publication a priority. “You learn at the bedside,” he said, and from there, he devised better ways to manage SCI complications by developing protocols for treatment and rehabilitation. He shared his innovative techniques in more than 140 scientific papers and in a major textbook, co-authored by Estin Comarr, MD, Neurological Urology, Physiology of Micturition, Its Neurological Disorders and Sequelae. More than 35 years later, this remains the authoritative text in this field. The Bors Award memorializes this pioneer who “carried the torch of care and research and opened the way for better care” of all individuals with SCI (3) by recognizing the achievement of young investigators and supporting their ongoing efforts. The winning authors represent the spectrum of spinal cord injury research (see box). The guidelines for the Bors Award are published in each issue. Entries are judged by a panel of editors convened by the Editor. The winner is invited to present the paper at the annual conference and receives recognition and a cash prize. The Editorial Board encourages students, fellows and residents to share in the legacy of Dr Bors by seeking answers to problems faced by individuals with SCI and sharing their findings with the readers of the Journal of Spinal Cord Medicine.

A Pioneer in Optimism: The Legacy of Donald Munro, MD

Since 1983, American Paraplegia Society has invited noted experts in spinal cord medicine and research to present the Donald Munro Memorial Lecture (1). These invited lecturers enrich our knowledge while honoring the pioneer in spinal cord medicine known as the ‘father of paraplegia’ (2-5). Munro was born in Boston in 1889 to a prominent family. His father was a well known surgeon and his mother was the daughter of Dr. E.R. Squibb, founder of the pharmaceutical company. Of Scottish descent, Munro claimed an ancestor who was captured by Cromwell at the Battle of Worcester in 1652 and deported to America. In 1695, the Munroes established a tavern in Lexington, Massachusetts, which remains standing as historical landmark of the American Revolution. Munroe Tavern was used by Lord Hugh Percy as the British headquarters and infirmary during the Battle of Lexington in 1775 (6,7). A graduate of Harvard College and Harvard Medical School, Munro studied medicine and surgery in Boston, Chicago and Philadelphia, and served as a surgeon in the Army Medical Corps in France during World War I. After the war, he joined the surgical staff of Boston City Hospital where he specialized in neurosurgery in a career that would span 36 years at the hospital. When the neurosurgery service began caring for individuals with spinal cord injuries (SCI), which at the time carried a mortality rate of 80%, Munro developed a special interest in their comprehensive care. His 10-bed unit, established in 1936, showed that with thoughtful and attentive care, patients lived longer and better lives (2,3). Munro achieved noteworthy outcomes by incorporating physical rehabilitation including bowel and bladder management and physical and occupational therapy, and by addressing patients' complex socioeconomic needs (2,3,8). His small unit became the model for SCI care in the United States. Munro's work influenced the Veterans Administration to establish SCI Centers around the US to care for wounded soldiers. His practices formed the basis for multidisciplinary, holistic care for people with SCI and inspired other dedicated pioneers such as Ernest Bors, Estin Comarr, John Young and Erich Krueger (9-11). His many published articles and books broke new ground in every aspect of the management of people living with the consequences of SCI (5). It has been said that Munro is “best remembered as a pioneer in optimism” for people with a condition long considered hopeless (11). Over the past 16 years, the Donald Munro Memorial Lectureship has traced the advancements in our field from basic care of SCI complications to research applications involving neuroscience and the latest technologies—evidence that Munro's legacy of optimism continues to offer hope to individuals with SCI and inspire professionals in spinal cord medicine.​medicine. Donald Munro, MD, 1889–1973.

The Comarr Memorial Award for Distinguished Clinical Service: The Legacy of A. Estin Comarr, MD

Since 1993, the American Paraplegia Society has acknowledged exceptional dedication and achievement in the clinical care of individuals with spinal cord injury (SCI) with the A. Estin Comarr Memorial Award for Distinguished Clinical Service. A pioneer in medical care, education, and clinical research in our field, Dr Comarr's legacy honors all of you who have dedicated your careers to improving the lives of people with SCI. Born in Chicago in 1915, Comarr attended the University of Southern California and Chicago Medical School. He trained in Cleveland hospitals, specializing in urology. In 1945, after serving as a battalion surgeon in the Third Armored Division in World War II, he joined the staff of Birmingham General Hospital in Van Nuys, California (now the Long Beach VA Hospital) (1,2). There began his long and fruitful collaboration with neurourologist Ernest Bors, MD, another pioneer in the care of veterans paralyzed by SCI (2–5). Dr Comarr (photo) contributed to the formation of paraplegia centers, which provided specialty care for veterans disabled by SCIs sustained in World War II. With the founding of these centers, the Veterans Administration “actually lit the torch for research and comprehensive care of these patients,” Dr Comarr emphasized. Before the VA's commitment, people with SCIs were “condemned to death from various complications…” (6). Post-World War I, 60% of these individuals died within 3 years of their injury (6), noted Comarr and Eltorai, while others were left to cope with serious complications with little hope for improvement. It was not until the mid-1930s that neurosurgeon Donald Munro, MD, inspired others by organizing the first ward dedicated to the holistic care of patients with SCI at Boston City Hospital, showing the medical establishment that with attentive care and targeted research, people with SCI could live longer lives of better quality (2). In addition to caring for patients with complex medical issues, Dr Comarr was dedicated to research and professional education. He authored or co-authored textbooks, chapters, and more than 120 articles in the field of spinal cord medicine. His seminal text, co-authored with Dr Bors more than 35 years ago, “Neurological Urology, Physiology of Micturition, its Neurological Disorders and Sequelae”, remains a standard today (7). He also lectured widely on the management of medical complications, especially urological. A founding member of APS, Dr Comarr was the society's first president (1954) and first honorary member. He also served as president in 1955 and 1967. Fittingly, in 1983, Dr Comarr delivered the first Donald Munro Memorial Lecture, which was established by APS to recognize Dr Munro's fundamental contributions to the modern model of SCI care (8). Today, we continue to recognize Dr Comarr's contributions to spinal cord medicine with this eponymous award while acknowledging the professionals who carry his legacy into a future now bright with promise and hope. I can think of no better closing than the words of Dr Comarr's widow, Ruth, on the occasion of the 50th Anniversary of APS (2): “I hope my husband's legacy will find continuance in all your combined efforts. With the advent of new medicines and the like, which did not exist in Estin's time, I know you will make great strides in the future.”

Functional and Clinical Outcomes of Telemedicine in Patients With Spinal Cord Injury

Dallolio L, Menarini M, China S, Ventura M, Stainthorpe A, Soopramanien A, Rucci P, Fantini MP, on behalf of the THRIVE Project. Functional and clinical outcomes of telemedicine in patients with spinal cord injury. Objective To compare the 6-month outcomes of telerehabilitation intervention with those of standard care for spinal cord injury (SCI). Design Multicenter randomized controlled trial. Setting Home, nursing, or unspecialized hospital care provided after discharge from a spinal cord unit. Participants Adult patients with nonprogressive, complete, or incomplete SCI discharged for the first time from the spinal cord unit to their homes (Belgium and Italy) or to their homes or another facility (England). Interventions All patients received the standard care they would have normally received after discharge from the spinal cord unit. In addition, patients in the telemedicine group received 8 telemedicine weekly sessions in the first 2 months, followed by biweekly telemedicine sessions for 4 months. Main Outcome Measures Functional status at 6 months, clinical complications during the postdischarge period, and patient satisfaction. Results No significant differences in the occurrence of clinical complications were found between the study groups. A higher improvement of functional scores in the telemedicine group was found only at the Italian site: FIM total score 3.38±4.43 (controls) versus 7.69±6.88 (telemedicine group), FIM motor score 3.24±4.38 (controls) versus 7.55±7.00 (telemedicine group; P<.05). Items contributing to this difference were grooming, dressing upper body, dressing lower body, and bed/chair/wheelchair transfer. Higher satisfaction with care was reported by patients in the telemedicine group across all sites. Conclusions Our study provides some of the first quantitative evidence, based on results from 1 site, that telerehabilitation may offer benefits to patients discharged from a spinal cord unit compared with standard care in terms of functional improvement. Further research is warranted to confirm or disprove this finding.

Poster 52: The Need for Mechanical Ventilation and the Occurrence of Extubation Failure in Patients With Traumatic Spinal Cord Injury

Objective: To determine factors associated with the need for mechanical ventilation and the occurrence of subsequent extubation failure in patients with acute traumatic spinal cord injury (SCI). Design: Retrospective cohort study. Setting: Acute SCI care unit. Participants: All consecutive SCI patients at risk for mechanical ventilation who were admitted from December 1995 to September 2007. Interventions: Not applicable. Main Outcome Measure: Need for mechanical ventilation and the occurrence of subsequent extubation failure. Potential predictors of intubation and extubation failure included age, sex, Charlson Comorbidity Index score, American Spinal Injury Association Impairment Scale (AIS) grade, and level and cause of SCI. Results: There were 113 patients with acute cervical (85%) or thoracic SCI (82 men, 31 women; age range, 17–96y; mean age, 54y). Most patients sustained moderately severe SCI (AIS grades C or D, 76%) following falls (43%) or motor vehicle collisions (34.5%). Patients who required mechanical ventilation (n=14) had significantly more severe SCI (P<.001) than patients without mechanical ventilation. Extubation failure occurred in 3 patients. Patients who experienced extubation failure had significantly more severe SCI (P=.013) than patients who were successfully extubated. Conclusions: Our results indicate that 12% of SCI patients require mechanical ventilation, of whom 21% experience extubation failure. Motor and sensory complete SCI is a risk factor for mechanical ventilation and for extubation failure after a successful spontaneous breathing trial.

China multicenter study of sentinel node biopsy substituting axillary node dissection: CBCSG-01 trial

To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI).Longitudinal, observational multisite study of a single-arm, nonrandomized cohort.SCI centers in the Veterans Health Administration (n=7).Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI).IPS SE for 24 months.Competitive employment.Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients.Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

The provision of culturally appropriate care for individuals with spinal cord injuries

Britain is one of the most ethnically diverse countries in Europe, and most spinal cord injury units admit patients from other countries for rehabilitation. Nurses in spinal cord injury care will, therefore, encounter patients from a range of cultural backgrounds. This article defines and discusses the concepts of culture, race and ethnicity in relation to the care of those with spinal cord injuries. The impact of these concepts on quality and equality in nursing care is identified. The article suggests how to provide culturally appropriate care for people with spinal cord injury from diverse cultural backgrounds, by avoiding cultural stereotypes and taking an individualized approach to care.

Neurological and Functional Outcomes Associated with SCI Rehabilitation

Modern spinal cord injury (SCI) care is purported to involve treatment in specialized centers with an interdisciplinary team of health care professionals providing care as early as possible following injury. Care is delivered throughout the rehabilitation process with appropriate discharge to the community characterized by ongoing outpatient care and follow-up. This article is intended to describe the evidence that exists for aspects of this model of SCI care. Specifically, we examined the evidence for specialized versus general care, early versus late hospital admission, and follow-up care. A second objective of the article is to describe relevant findings of the most common outcomes within the rehabilitation context. We have summarized the outcomes of length of stay, neurological status, and functional status over the rehabilitation stay and examined the interrelationships among these outcomes.

Sir Ludwig Guttmann: The father of spinal cord injury care in the UK

Sir Ludwig Guttmann (1899–1980) has been described as the father of spinal cord injury care in the UK. This article traces events in his life that culminated in the opening of the National Spinal Injuries Centre at Stoke Mandeville Hospital. His vision that people with spinal cord injury could survive and eventually return to an independent and fulfilling life revolutionized spinal cord injury management in the UK. The effects of this on nursing care and the foundation of competitive sport for disabled people are discussed.

Assessment of upper limb in tetraplegia: Considerations in evaluation and outcomes research

This article briefly discusses several measurement tools for evaluating the upper limb of persons with tetraplegia. Muscle strength testing and electrodiagnostics are discussed as they relate to technique and usefulness for clinical trials. Standardized measures of hand function are reviewed; their limitations for clinical trials during acute spinal cord injury (SCI) care are acknowledged and their strengths for interventional studies and clinical trials during chronic phases of SCI care are defined. Recommendations are set forth for incorporating the International Classification for Surgery of the Hand in Tetraplegia motor and sensory examinations as adjuncts to the International Standards for Neurological Classification of SCI motor and sensory examinations and for further developing electrodiagnostic techniques as measurement tools for acute clinical trials. The Grasp and Release Test is described and recommended for clinical trials involving persons in the chronic stages of SCI. Lastly, we note that much work remains in the development, validation, and clinical deployment of an assessment of upper-limb function in SCI.

Spinal Cord Injury-Past, Present, and Future

Summary: This special report traces the path of spinal cord injury (SCI) from ancient times through the present and provides an optimistic overview of promising clinical trials and avenues of basic research. The spinal cord injuries of Lord Admiral Sir Horatio Nelson, President James A. Garfield, and General George Patton provide an interesting perspective on the evolution of the standard of care for SCI. The author details the contributions of a wide spectrum of professionals in the United States, Europe, and Australia, as well as the roles of various government and professional organizations, legislation, and overall advances in surgery, anesthesia, trauma care, imaging, pharmacology, and infection control, in the advancement of care for the individual with SCI.

Health Care Costs for Patients With Chronic Spinal Cord Injury in the Veterans Health Administration

Background/Objective: Recurring annual costs of caring for patients with chronic spinal cord injury (SCI) is a large economic burden on health care systems, but information on costs of SCI care beyond the acute and initial postacute phase is sparse. The objective of this study was to establish a frame of reference and estimate of the annual direct medical costs associated with health care for a sample of patients with chronic SCI (ie, >2 years after injury).Methods: Patients were recruited from 3 Veterans Health Administration (VHA) SCI facilities; baseline patient information was cross-referenced to the Decision Support System (DSS) National Data Extracts (NDE) to obtain patient-specific health care costs in VHA. Descriptive statistical analysis of annual DSS-NDE cost of patients with SCI (N = 675) for fiscal year (FY) 2005 by level and completeness of injury was conducted.Results: Total (inpatient and outpatient) annual (FY 2005) direct medical costs for 675 patients with SCI exceeded $14.47 million or $21,450 per patient. Average annual total costs varied from $28,334 for cervical complete SCI to $16,792 for thoracic incomplete SCI. Two hundred thirty-three of the 675 patients with SCI who were hospitalized over the study period accounted for a total of 378 hospital discharges, costing in excess of $7.19 million. This approximated a cost of outpatient care received of $7.28 million for our entire sample.Conclusions: The comprehensive nature of health care delivery and related cost capture for people with chronic SCI in the VHA provided us the opportunity to accurately determine health care costs for this population. Future SCI postacute care cost analyses should consider case-mix adjusting patients at high risk for rehospitalization.

‘An ailment not to be treated’: Tracing the development of spinal cord injury management

Spinal cord injury was first described by the Ancient Egyptians who concluded that it was ‘an ailment not to be treated’. This attitude to spinal cord injury continued through succeeding centuries as a number of physicians described the pathology and consequences. Nursing input was not a feature of spinal cord injury management. In the 20th century the foundations of modern spinal cord injury care were laid out by pioneers such as Donald Munroe in the USA and Sir Ludwig Guttmann in the UK, during the Second World War. The nursing role in spinal cord injury care has developed since those days, but there is scope for nurses to develop that role further as new challenges are presented.

Poster 14: Sponsorship and Initial Rehabilitation Outcomes in Spinal Cord Injury

Objective: To examine sponsorship for acute care of spinal cord injury (SCI) across various periods, characteristics, and outcomes. Design: Multicenter longitudinal study. Setting: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. Participants: 12,576 patients receiving initial hospital care from 23 MSCIS between 1986 and 2004. Interventions: Not applicable. Main Outcome Measures: Length of stay (LOS) and discharge disposition. Results: Private insurance was the most common sponsor, providing at least partial support for 41.6% of patients.

Prevention of Venous Thromboembolism in High-Risk Patients

The prevention of venous thromboembolism (VTE) in patients recovering from major trauma, spinal cord injury (SCI), or other critical illness is often challenging. These patient groups share a high risk for VTE, they often have at least a temporary high bleeding risk, and there are relatively few thromboprophylaxis trials specific to these populations. A systematic literature review has been conducted to summarize the risks and prevention of VTE in these three groups. It is concluded that routine thromboprophylaxis should be provided to major trauma, SCI and critical care patients based on an individual assessment of their thrombosis and bleeding risks. For patients at high risk for VTE, including those recovering from major trauma and SCI, prophylaxis with a low molecular weight heparin (LMWH) should commence as soon as hemostasis has been demonstrated. For critical care patients at lower thrombosis risk, either LMWH or low-dose heparin is recommended. For those with a very high risk of bleeding, mechanical prophylaxis should be instituted as early as possible and continued until pharmacologic prophylaxis can be initiated. The use of prophylactic inferior vena caval filters is strongly discouraged because their potential benefit has not been shown to outweigh the risks or substantial costs. Implementation of thromboprophylaxis in these patients requires a local commitment to this important patient safety priority as well as a highly functional delivery system, based on the use of pre-printed orders, computer prompts, regular audit and feedback, and ongoing quality improvement efforts.