Literature Review & Critique: Health Outcomes, Health Behaviors, and Spinal Cord Injury
Michelle A. Meade, PhD
ABSTRACTS
Krause, J. (1996). Secondary conditions and spinal cord injury: A model for prediction and prevention. Topics in Spinal Cord Injury Rehabilitation, 2(2). 58-70.
Rehabilitation professionals are becoming increasingly concerned about the long-term consequences of spinal cord injury. After SCI, individuals are vulnerable to a wide array of secondary conditions, including skin sores, urinary tract infections, and respiratory complications. Two conceptual models are outlined in this article to better identify risk factors for secondary conditions and early mortality after SCI. The general risk factor model outlines three levels of risk factors to secondary conditions and mortality. The bi-dimensional risk behavior model breaks down risk behaviors along positive and negative dimensions. Several implications for prevention are outlined.
Elliott, T. R., Bush, B. A., Chen, Y. (2006). Social problem-solving abilities predict pressure sore occurrence in the first three years of spinal cord injury. Rehabilitation Psychology 51(1), 69-77.
Objective: To test the hypothesis that social problem-solving abilities of persons with recent-onset spinal cord injury would be predictive of pressure sore occurrence in the first three years following discharge from initial inpatient rehabilitation.
Design: A prospective study of persons with recently incurred SCI and their subsequent pressure sore evaluations over a three-year period in annual clinic evaluations.
Setting: Inpatient SCI rehabilitation center and outpatient clinic.
Participants: 188 persons with recent-onset SCI approaching discharge from initial inpatient SCI rehabilitation, with outpatient pressure sore evaluations for those who returned for pressure sore evaluations.
Main Outcome Measure : Pressure sore occurrence as determined in annual outpatient evaluations conducted over the first three years of SCI.
Results: Two separate statistical models indicated that social problem-solving abilities significantly contributed to the prediction of pressure sore occurrence.
Conclusions: Social problem-solving abilities are implicated in the development of pressure sores. Persons with ineffective problem-solving abilities may be at risk for pressure sores; these individuals might require strategic monitoring and training from clinical programs.
Latimer, A. E., Ginis, K., Martin, A., Arbour, K. P. (2006). The efficacy of an implementation intention intervention for promoting physical activity among individuals with spinal cord injury: A randomized controlled trial. Rehabilitation Psychology, 51(4), 273-280.
Objective: To evaluate the efficacy of an eight-week implementation intention intervention for promoting physical activity among individuals with spinal cord injury. [That is, the study tested if making specific plans to exercise (implementation intention)––including identifying times, places and types of exercise––increased physical activity to a greater degree than simply forming intentions, for example, verbally agreeing to exercise and listing possible types of physical activities for exercise (activity intention).]
Study Design : Randomized clinical trial.
Method : Participants were randomly assigned to an implementation intention intervention (n = 26) or control (n = 28) condition and were asked to engage in 30 minutes of moderate to heavy intensity physical activity three times per week.
Results: Participants who formed implementation intentions followed through with their physical activity intentions, engaging in more physical activity than participants in the control condition. Participants in the intervention condition also experienced sustained motivation and greater confidence to schedule physical activity compared with participants in the control condition.
Implications: These findings suggest a role for implementation intentions in health promotion programs for people with spinal cord injury.
COMMENTARY
We all know that individuals with SCI are at increased risk for secondary conditions––including pressure ulcers, depression, urinary tract infections, and chronic pain; and the list goes on. As clinicians, we work under the assumption that secondary conditions can be prevented or minimized with appropriate management including performing health maintenance behaviors and compensatory strategies. Many studies link secondary conditions in individuals with SCI to a range of demographic factors such as the associations between increasing age and greater time since injury with UTI’s, pressure sores, spasticity, and pain; but psychological, social and behavioral factors are less frequently examined. As this is our bread-and-butter, I think it’s important that we are aware of some of what’s out there on this topic. It is for this reason that I decided to take a closer look at what the literature has to say about health behavior for individuals with SCI. Only one of these articles was referenced in the AASCIPSW reading list, the others I pulled out of my own personal files and a quick review on PsychInfo.
The first of the articles mentioned takes the broadest view of the issue. In it, Krause articulates the General Risk Factor model as a way of predicting how different types of variables influence the development of secondary conditions, and ultimately contribute to premature death for individuals with chronic SCI. This model posits that secondary conditions such as pressure sores and urinary tract infections are related to behavioral, psychological, environmental and biological factors with varying degrees of proximity. The health-related behaviors are categorized on two independent dimensions––positive, health-promoting behaviors like the timely performance of weight shifts and eating nutritious food; and negative, self-destructive behaviors like alcohol abuse and cigarette smoking. Biologic factors refer to an individual’s biological determinants such as metabolism and genetic inheritance, biographical factors such as gender, race, and age, and injury-related factors, for instance, the level and severity of injury, time since injury, and age at injury. Psychologic factors refer to the social and psychological factors like cognitive ability, problem-solving capacity, and adjustment level; and individual social characteristics, such as marital status. In contrast, “environment” refers to the resources and traits of both the physical and social environment including the accessibility of the environment and the physical and financial resources available.
I like this article, and this model, as it provides a macro-level framework to begin to consider the range of factors that we––as clinicians––implicitly know are important. The general risk factor model can be used to put theories of health behavior change, such as the transtheoretical model, the Health Belief Model, or the cognitive-behavioral theories mentioned in the other articles, within a context appropriate for individuals with SCI. For example, consider exercise as an example of a health behavior of exercise. The types of exercise that are likely feasible for an individual with SCI depend on level of injury (biologic factors) and resources (environment) available, including types of equipment, social support, transportation, and socioeconomic status. The individual’s motivation, feelings of self-efficacy, perceived control and ability to problem-solve or plan how they will participate in exercise would be considered psychologic factors. These would interact with one another and influence the performance (intensity and frequency) of exercise. The health behavior itself would influence the development of secondary conditions like obesity or cardiovascular disease and, ultimately, the life expectancy of the individual. The article does not provide data or advanced statistical techniques to support it, and I’m not sure that the relationship among the factors is as unidirectional as presented here. Krause, however, does present a logical argument for it based on results of past studies.
The study by Elliott and colleagues uses a prospective design to determine the relationship between demographic and cognitive-behavioral characteristics with health outcomes. Standardized instruments and physician examination are used to assess variables of interest. The statistical techniques and models used to investigate the relationships among the variables are complex but well explained. Variables of interest were first entered into a generalized estimating equation (GEE) to examine the predictive ability of social problem solving. A secondary analysis then used structural equation modeling to examine the relationship among the predictor variables, which also included demographic characteristics and injury severity. Results support the importance of social problem-solving in predicting the development of pressure sores while unchangeable demographical characteristics are assigned a more secondary role. No other psychological characteristics or constructs that might influence or overlap with social problem-solving, such as depression, were assessed or included in the model.
Finally, the study by Latimer and colleagues used the gold-standard of clinical research––the randomized clinical trial––and presents a great example of a psychological theory in action. Azjen’s theory of planned behavior is applied within this trial to determine if an intervention that assists participants in developing implementation intentions for physical activity will increase the self-reported occurrence of physical activity, and perceived control of being able to perform those activities. Participants were never seen in person but were recruited from across the United States and Canada; the interventions themselves, both experimental and control, were implemented by phone, mail and e-mail. While there are some limitations inherent in this methodology––for example, participants must have e-mail and the assessment of activity is based on self-report––it is also what makes this type of intervention efficacious with regard to cost and time and feasible for large-scale implementation and the translation of research into practice. Questions of the validity of measurements are reduced, in large part, by the use of standardized instruments, as opposed to a survey instrument created specifically for the study. Specifically, physical activity was assessed using the Physical Activity Recall Assessment for Individuals with SCI (PARA-SCI), which has adequate test-retest reliability and demonstrated construct validity.
Taken together, these studies made me hopeful that we are advancing as a science. While most articles focus on correlational relationships and theoretical findings that do little to move the field, these studies increase our understanding of how we, as clinicians, can work more effectively either in designing programs or treating an individual.
Michelle A. Meade, PhD, is an associate professor in the Physical Medicine and Rehabilitation Department at Virginia Commonwealth University, Richmond, Virginia.