RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI

1. RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI Suzanne Groah, MD, MSPH Mark Nash, PhD Alexander Libin, PhD Jessica Ramella-Roman, PhD Manon Schladen, MSE, EdS NSCIA and ILRU Grant # H133B090002

2. RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI Suzanne Groah, MD, MSPH Mark Nash, PhD Alexander Libin, PhD Jessica Ramella-Roman, PhD Manon Schladen, MSE, EdS NSCIA and ILRU Grant # H133B090002

3. RRTC Staff Center Director Suzanne Groah, MD,MSPH Alexander Libin, PhD Manon Schladen, MSE, EdS Inger Ljungberg, MPH Alison Lichy, DPT Brenda Triyono, BS Emily Ward, MS Miriam Spungen, BS Eric Larson Jessica Romella-Roman, PhD, MSEE Mark Nash, PhD Cynthia Pineda, MD, FAAPMR

4. Allen Taylor, MD Kurt Johnson, PhD Brenda Gilmore, BFA Mark Loeffler, MA Shannon Minnick Ms. Wheelchair MD Other Staff (Picture not available) Nawar Shara, PhD Patricia Burns, MS Eleutevio Ballwis, BSN Jasmine Martinez, DO Armando Mendez, PhD Tom Burnett, MS Sydney Jacobs, MA Robert Marsteller Katherine Westie, PhD

5. Summary of Proposed RRTC • Research focus • Cardiometabolic risk and cardiovascular disease • Obesity • Pressure ulcers

6. Summary of Proposed RRTC • Training focus • Consumers - focus on the underserved and non-English speaking • Health care professionals - including non-rehabilitationists • State of the Science Conference

7. Importance of the Problem • Cardiovascular disease is a leading cause of death in long-term SCI • Overweight and obesity (especially around the abdomen) • Diabetes and pre-diabetes • High blood pressure • Abnormal cholesterol levels • Other - inflammation

8. Importance of the Problem • Pressure ulcers (PU) are the most common medical complication in people surviving at least 1-year post injury • Frequency may be on the increase • Turning and repositioning recommendations are NOT supported by evidence • When PU’s occur in the hospital, they are now considered a “Never Event”

9. Importance of the Problem • 14-17% of people in the US have a pressure ulcer at any given time • 27-40% of people with SCI will experience skin breakdown during their acute hospitalization • Another 15% develops skin breakdown within the first year of injury

10. Skin Health • Skin pressure causes • Decreased oxygenation to the skin • Decreased blood flow to the skin • Cascade of events leading to skin damage

11. Skin Health After SCI • When pressures were applied to the skin of other hospitalized patients without SCI, people with SCI were found to have greater changes in skin blood flow • When pressures were applied to the buttocks during sitting, people with SCI had greater changes in blood flow than people without SCI

12. Prevention of Skin Breakdown • Repositioning • Standard of care: turn in bed every 2 hours • Recommendation is NOT supported by evidence • In fact, tissue damage may begin to occur within 1-2 hours • Inflammatory response evident at 2 hours in one position

13. Prevention of Skin Breakdown • Pressure reliefs • No consensus on pressure relief • Frequency • Duration • Type • PVA Guidelines state: • “a weight shift every 15-30 minutes is recommended to allow the skin to be replenished with oxygen….”

14. Prevention of Skin Breakdown • Pressure reliefs every 15 minutes…..is this enough?

15. Prevention of Skin Breakdown • British researchers looked at data from their seating clinic • 15-30 second pressure lifts or pushups were ineffective at improving buttock skin oxygenation • American researchers looked at different pressure relief protocols • Found that it takes 200-250 seconds for blood flow to return to normal during a pushup

16. Measuring Skin Health • Difficult, if not impossible, to do in the seated position • Laser doppler • Measures blood flow • But cannot be done during sitting • Pulse oximetry • Measures oxygenation of the blood • But cannot be done during sitting • Pressure measurements

17. Measuring Skin Health • New behavioral intervention will be comprised of two parts: (1) clinician’s observation of pressure relief practice based on a method caller behavioral mapping, and (2) data-driven guidelines for patients aimed at improving individual pressure relief practices through developing self-management skills

18. Measuring Skin Health • We need a system that can measure pressure, blood flow AND oxygenation • This needs to be done in the sitting position

19. Project R3:Skin Microvascular and Metabolic Response to Sitting and Pressure Relief Maneuvers in People with Spinal Cord Injury Principal Investigator (PI): Suzanne Groah, MD, MSPH Co-Principal Investigators (Co-PIs): Alexander Libin, PhD & Jessica Ramella-Roman, PhD Project Coordinator: Alison Lichy, DPT, PT, NCS

20. Objectives • To establish metabolic parameters of the skin during sitting and pressure reliefs • To determine if a self-management intervention will improve performance of pressure reliefs

21. R3 Methods • Design: Randomized Controlled Trail • Setting: NRH • Participants:46 subjects with SCI

22. R3 Criteria for Entry into Study • SCI within the past six months; • Use a permanent manual wheelchair as their primary means of mobility; • Be able to perform wheelchair pushups for pressure relief; • Not have an existing PU over buttocks, but could have had a previous PU; and • Be 18 years of age or older.

24. Methods • First probe, proof of concept, generates accurate SO2 measurement. • Used for testing and calibration.

25. Behavioral Intervention Randomization: After the baseline assessment, participants will be randomized into equal control or intervention groups. Control Group: The control group will be provided feedback from the microvascular baseline assessment informing them about their pressure and microvascular responses as well as their pressure relief frequency and technique as measured via the PRESS. They will be instructed by the Study PT to perform pressure reliefs every 15 minutes for 1 minute, per guidelines. Intervention Group: In addition to being provided feedback from the microvascular baseline assessment, the intervention group will be enrolled in a 3-month self-management program consisting of 3 interactive modules as follow.

26. Behavioral Intervention 3-month self-management program 1) An interactive PU prevention educational module via both DVD and 24/7 online access. In coordination with Training Project 1 (Year 1), a DVD-based educational guide on pressure relief techniques will be developed and produced in both DVD and online formats. 2) PU self-management skill-building using phone-based motivational interviewing. Research staff members will develop a protocol for motivational interviewing utilizing findings from our previous work on secondary conditions and peer-mentoring for persons with SCI. 3) Bi-weekly monitoring of participants' adherence to PU management guidelines.

27. R3 Outcome Measures • Baseline Data Collection • Demographic Data • Baseline Microvascular Assessment

28. R3 Outcome Measures • Baseline Data Collection • Skin Care Self-Management • The Skin Care Self Efficacy Scale • The Pressure Relief Behavior Mapping Instrument (PRES) • Observation and recording of pressure relief behavior • SCI Health Related Quality of Life (HRQL) • Subjective satisfaction with health-related quality of life

29. Training* Project Overview • 3 Projects • T1 – Consumer-focused • Director, Alex Libin, PhD • Co-Director, Manon Schladen, EdS • Coordinator, Inger Ljungberg, MPH • T2 – Clinician-focused • Director, Cindi Pineda, MD FAAR • Co-Director, Manon Schladen, EdS • Coordinator, Inger Ljungberg, MPH • T3 – State-of-the-Science Conference • Director, Suzanne Groah, MD MSPH * What we mean by “training” • Activities that promote understand and application of the knowledge our RRTC will produce

30. Objectives • Overarching Objective: Translate findings of RRTC research to practice for both consumers and health care providers • Supporting Objectives: • Define and present the state of knowledge about positioning and the risk of pressure ulcers in people with SCI • “What is the optimal positioning to prevent skin breakdown?” Systematic Review • Explore what knowledge and information formats and delivery mechanisms are most useful and acceptable to our consumer and clinician audiences • Build capacity to support the health and well-being of persons with SCI (consumer living, clinical practice, research discovery) • Technology development

31. Integrated Approach to Research and Training Systematic Review User Studies Key points of support and interaction

32. Sensor Development Learning Materials R3 Intervention • Consumers: • Barriers to performing pressure reliefs? (Equipment? Social?) • Contexts for learning skin self-management? (PCP facilitated?) • Preferred information formats? (Print? Mulitmedia?) • Preferred information delivery? (Internet? DVD? IPOD/Mobile?) • Impact of health literacy? Medical terminology? Basic reading skills? Revised materials, intervention best practices Quality Plan Systematic Review User Studies What (does the literature say) is the optimal positioning to prevent skin breakdown? Clinicians: Contexts for learning about skin health in SCI? (CME? GME?) Preferred learning formats? (Traditional? Online? Simulation?) Enhancement of information credibility? Importance? (Evidence-based?) Ability to put knowledge in practice? (Health System constraints?) Revised materials, Recommendations for Actionable practice Learning Materials Evaluation

33. How To Videos • Peer Modeling • Task

34. Identity

35. T3: State of the Science Conference 2-day, fully accessible During 3rd year of grant period Include professionals and consumers Include track on optimizing rehabilitation research design and analyses

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