Ambulation and Secondary Complications after SCI

1. Thank you for joining us!Our webcast, ‘Ambulation and Secondary Conditions after SCI,’ will begin at 12:00PM EDT.

2. Ambulation and Secondary Complications after SCI Lee L. Saunders, PhD Medical University of South Carolina May 22, 2014

3. Acknowledgement • The contents of this presentation were developed under grants from the Department of Education, NIDRR grant numbers H133B090005, H133G090059, and H133G050165 and a grant from the National Institutes of Health (NIH), 1R01 NS 48117. However, those contents do not necessarily represent the policy of the Department of Education or NIH, and you should not assume endorsement by the Federal Government.

4. Collaborators • James S. Krause, PhD (Principal Investigator) • Sandra S. Brotherton, PhD, PT (Co-I) • Sara Kraft, DPT (Co-I) • David C. Morrisette, PhD, PT (Co-I) • Student Contributors: • Nicole D. DiPiro, MS • Ryan K. Kohout, MD

5. Objectives • Identify the relationship between prescription medication use and ability to ambulate distances after SCI. • Identify secondary complications related to assistive walking devices after SCI. • Identify the relationship of assistive walking devices and fall-related injuries after SCI.

6. Background • Traumatic spinal cord injury (SCI) is a severe disabling condition that occurs suddenly and generally results in permanent sensory and motor loss. • Frequently leads to secondary health conditions that are particularly devastating as they restrict participation, reduce quality of life (QOL), and diminish life expectancy.

7. Background • The proportion of persons with incomplete SCI has increased in recent years, most likely due to a number of factors, including improved techniques for emergency management.(NSCISC, 2013) • There are a substantial number of individuals with incomplete SCI and lower-level lesions who retain or redevelop the ability to walk to differing degrees.(Morganti, Scivoletto, Ditunno, Ditunno, & Molinari, 2005; New, 2005; Wirz et al., 2005)

8. Background • Ambulation has been associated with many positive improvements in both physical health and subjective well being.

9. Preliminary Studies • Persons with SCI who are ambulatory have shown: • Higher risk of subsequent injury (Krause, 2004) • Higher risk of falls (Brotherton et al., 2006) • Among those ambulatory, persons dependent on others for assistance in walking have shown: • Higher levels of pain interference and prescription pain medication use (Krause et al., 2007a) • Greater risk of a depressive disorder, however this relationship was mediated by pain interference (Krause et al., 2007b)

10. Purpose • While studies have shown short-term benefits of gait training for people with SCI, some research suggests there may be unforeseen long-term adverse consequences of ambulation. • The purpose of this research study was to identify variations in ambulation after SCI based on use of assistive devices and/or reliance on people for ambulation, functionality of ambulation (distances), and their association with secondary conditions.

11. Methods • IRB approval through MUSC. • Participants were part of a larger longitudinal study of health outcomes after SCI. • Identified through records of a large rehabilitation hospital in the Southeastern US. • Inclusion criteria: • 18+ years at assessment • 1+ years post-injury • Traumatic SCI with residual impairment

12. Participants • Those who reported at least some ambulation were included: • Are you able to walk at all? Yes/No • Overall of 1,689 participants, 31.3% reported being ambulatory (n=529). • Those responding yes were asked a series of follow-up questions regarding: • Distance, assistive devices, portion of time spent ambulating around the home and community • Secondary health conditions

13. Ambulation Questions

14. Participant Demographics

15. RESULTS

16. Reliance on Devices and People for Walking and Ability to Walk Community Distances Brotherton, S.S., Saunders, L.L., Krause, J.S., & Morrisette, D.C. (2012). Association between reliance on devices and people for walking and ability to walk community distances among individuals with spinal cord injury. Journal of Spinal Cord Medicine, 35(3), 156-161.

17. Reliance on Devices • Purpose: To identify and describe maximum walking distances and the reliance on assistive devices and/or people. • Distances: • Maximum Walking Distance • 10m, 150ft, 1000ft • Able to climb stairs • Yes/No • Devices • Walker, cane(s), crutch(es), long leg brace(s), short leg brace(s) people

18. Ambulation • 4.3% could not walk 10 meters (~33 ft) • 20.6% could walk 10 meters (but not 150 ft) • 27.8% could walk 150 ft (but not 1000 ft) • 47.3% could walk 1000 feet • 72.1% could walk up a flight of 12-14 stairs

19. Ambulation • Home • 71.5% walk a majority of the time • 5.7% walk/wheel 50/50 • 22.8% wheel a majority of the time • Community • 68.8% walk a majority of the time • 4.3% walk/wheel 50/50 • 26.8% wheel a majority of the time

20. Reliance on Devices • 33.4% did not use devices or people to assist in ambulation • 30.2% used one device or a person • 22.7% used 2 • 13.7% used 3+

21. Reliance on Devices • 25.1% used a walker • 20.6% used a crutch(es) • 34.1% used a cane(s) • 6.8% used a long leg brace(s) • 21.7% used a short leg brace(s) • 11.3% used another person for assistance

22. Relationship between Prescription Medication Use and Ability to Ambulate Distances Kohout, R., Saunders, L.L., & Krause, J.S. (2011). The relationship between prescription medication use and ability to ambulate distances after spinal cord injury. Archives of Physical Medicine and Rehabilitation, 92, 1246-1249.

23. Prescription Medication and Distances • To investigate the association of prescription medication for spasticity and pain with maximum ambulatory distance. • Primary Outcome: Maximum walking distance • <150m, <1000ft, 1000ft+

24. Prescription Medication and Distances • Primary Predictor • Prescription medication use for pain or spasticity • Minor – never, sometimes • Heavy – weekly, daily • Control Variables • Gender (male, female) • Race (white, black) • Injury level (cervical, non-cervical) • Pain severity (Brief Pain Inventory Score)

25. Prescription Medication and Distances

26. Prescription Medication and Distances

27. Conclusions • Heavy prescription medication use for pain and spasticity was inversely related to a person’s ability to achieve community ambulation distances of 1000ft or more. • Results may provide insight for clinicians involved in medication management for those with SCI.

28. Ambulation and Secondary Complications Related to Devices after SCI Saunders, L.L., Krause, J.S., DiPiro, N.D., Kraft, S., & Brotherton, S. (2013). Ambulation and secondary complications related to devices after spinal cord injury. Journal of Spinal Cord Medicine, 36(6), 652-659.

29. Devices and Secondary Complications • Purpose: To assess pain intensity, pain interference, and fatigue among persons with SCI who are ambulatory. • Primary outcomes: • Pain Intensity (Brief Pain Inventory) • Pain Interference (Brief Pain Inventory) • Fatigue (Modified Fatigue Impact Scale)

30. Devices and Secondary Complications • Primary Predictors: • Wheel chair use (None, 50% or less, 51% or more) • Assistance from people (yes, no) • Long leg braces (0, 1, 2) • Short leg braces (0, 1, 2) • Cane (0, 1, 2) • Crutches (0, 1, 2) • Walker (yes, no)

31. Devices and Secondary Complications *controlling for age, gender and race

32. Devices and Secondary Complications

33. Conclusions • Among ambulatory persons with SCI, increased pain intensity, pain interference, and fatigue is seen among those with minimal wheelchair users (1-50%) as well as those who reported use of assistive devices that provide less support during ambulation.

34. Pain and Fatigue as Mediators of the Relationship between Mobility Aid Usage and Depressive Symptomatology Dipiro, N. D., Saunders, L. L., Brotherton, S., Kraft, S., & Krause, J. S. (2014). Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI. Spinal Cord, 52, 316-321.

35. Pain, Fatigue, Depression • Purpose: To test a mediational model where pain (intensity and interference) and fatigue mediate the relationship between use of mobility aids and moderate to severe depressive symptomatology. • Primary Outcomes: • Patient Health Questionnaire-9 (PHQ-9) scores of 10+ were used to indicate moderate to severe depressive symptomatology.

36. Pain, Fatigue, Depression • Predictor Variables • Injury level (C1-C4, C5-C8, Non-cervical) • Race (white, non-white) • Gender (male, female) • Age& time post-injury • Assistive devices (cane, crutch, leg brace, walker, people) • Wheelchair usage (<50%, 50%, 50-99%, always) • Pain intensity (BPI) • Pain interference (BPI) • Fatigue (Modified Fatigue Impact Scale)

37. Pain, Fatigue, Depression *controlling for injury level, race, gender, age, time post-injury

38. Conclusions • Only use of people for ambulation and using a wheelchair less than 50% of the time were related to depression symptoms. Other devices were not significantly associated with depressive symptoms. • The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while alwaysusing a wheelchair is associated with lower odds. • Pain and fatigue mediate the relationship between usage of those assistive devices and depressive symptomatology.

39. Fall-related Injuries Saunders, L.L., DiPiro, N., Krause, J.S., Brotherton, S., & Kraft, S. (2013). Risk of fall related injuries among ambulatory participants with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 19(4), 259-266.

40. Fall-related Injuries • Purpose: To assess the relationships between walking devices and health behaviors with fall-related injuries (FRI) among persons with SCI who are ambulatory. • Primary outcome: FRI in the past year • “In the past year, how many falls have you had that resulted in an injury serious enough to receive medical care in a clinic, emergency room, or hospital?” • Dichotomized as Yes/No

41. Fall-related Injuries • Predictor variables: • Maximum walking distance • % time spent walking at home • % time spent walking in community • Walk slower compared to people without disability • Poorer balance compared to people without disability • Assistive devices (people, walker, cane/crutch/braces) • Exercise • Alcohol use • Pain medication misuses

42. Fall-related Injuries • 20.3% reported at least 1 FRI in the past year • Among those reporting FRI • 56.3% reported 1 • 20.8% reported 2 • 8.3% reported 3 • 14.6% reported 4+

43. Fall-related Injuries *controlling for demographics

44. Fall-related Injuries • Health care providers should be aware of the risk for FRI among those who are ambulatory. • Not only should ambulatory ability be taken into account but also health behaviors, including pain medication use.

45. Conclusions • These analyses demonstrated there are groups of people, among those who are ambulatory with SCI, who are at increased risk for secondary conditions. • This was especially seen among persons who reported using a wheelchair, but used it less than half of the time. • Clinicians should be aware of the risks of secondary health conditions among persons with SCI who are ambulatory. • We found increased risks also among those who frequently use prescription medications for pain and/or spasticity.

46. Future Research • Assess changes in ambulation status and the relationship of those changes with secondary health conditions. • As we saw increased risks among those who used wheelchairs, but used them minimally, we should assess transition from ambulation to wheelchair use. • Look at broader outcomes, including QOL and participation.

47. Contact Us • Lee Saunders: saundel@musc.edu • Website: http://www.longevityafterinjury.com