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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 46-50

Spinal cord injury in organizational setup - A hospital based descriptive study


1 Officer Commanding, Station Health Organisation, Jalandhar, Punjab, India
2 Commandant, 92 Base Hospital, Srinagar, Jammu and Kashmir, India
3 Dir Health, DGAFMS Office, New Delhi, India
4 Department of Community Medicine, NC Medical College, Panipat, Haryana, India

Date of Submission16-Oct-2018
Date of Acceptance24-Feb-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Wg Cdr Gurpreet Singh
Officer Commanding, Station Health Organisation, Jalandhar - 144 005, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_67_18

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  Abstract 


Introduction: There is dearth of data on Spinal Cord Injury (SCI) from developing countries where ironically, special focus is required. Aims and Objectives: To study SCI in an organisational set up. Material and Methods: An observational, cross sectional study at a tertiary care rehabilitation centre was conducted. Patients who had injury during service were included. Questionnaire and case records were used to collect socio-demographic variables, cause, level, severity and duration of injury and clinical, functional and psychological status. Organisational support was estimated for pre-hospitalisation services, inpatient welfare measures and post-hospitalisation rehabilitative services. Results: A total of 157 patients participated. Median age at time of injury was 27 years with 89.2% injuries within 18 - 37 years of age. Trauma was underlying cause in 94.3%. Most common level of injury was thoracic (37.6%) and majority (66.9%) were paraplegic. RTA was most common (42.6%) traumatic cause and Tuberculosis among non-traumatic causes(66.6%). Scores suggestive of stress disorder were present in 13%. Pre-hospitalization health facilities were available to 79.6%. Majority (59.2%) had access to health facilities within two hours. Personal assistance was available to 88.5% and 66.9% undertook rehabilitation course. Conclusion: Health education with emphasis to trauma prevention in young is required. Social security measures need to be replicated by all organisations, both public and private in the country.

Keywords: Functional status, organizational support, psychological status, rehabilitation, spinal cord injury


How to cite this article:
Singh G, Prakash R, Bhatti VK, Mahen A. Spinal cord injury in organizational setup - A hospital based descriptive study. J Mar Med Soc 2019;21:46-50

How to cite this URL:
Singh G, Prakash R, Bhatti VK, Mahen A. Spinal cord injury in organizational setup - A hospital based descriptive study. J Mar Med Soc [serial online] 2019 [cited 2019 Sep 22];21:46-50. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/46/260672




  Introduction Top


Spinal cord injury (SCI) is a rare catastrophe, but it leads to an expensive life-altering state requiring specialized intensive rehabilitation.[1],[2],[3],[4],[5] In India, the average annual incidence of SCI is 15,000 with a prevalence of 0.15 million.[6] According to the World Health Organization (WHO), the incidence of SCI is increasing in developing countries including India, and the health-care burden due to SCI is expected to be similar to that in the developed world.[7]

The sudden occurrence of SCI leading to functional limitations around the peak of the productive age group poses a major public health challenge.[5] The mortality risk due to SCI shows wide variation within as well between regions and countries, and depend largely on availability and accessibility of prehospital medical care, acute management, and rehabilitation services.[4],[8]

SCI poses a difficult management dilemma. At present, there is a lack of definitive cure to SCI and thus efforts aim at prevention of secondary complications and rehabilitation.[6] These services include the provision of employment services, personal assistants, peer group support, physiotherapy, occupational rehabilitation courses, counseling, psychological support. In combat casualty care scenarios, prompt availability and accessibility for causality evacuation to a hospital setting assume additional importance toward SCI patients. Rehabilitative measures which are initiated at the site of injury and are provided throughout the rest of life constitute key components of services required for recovery from impaired abilities and to further achieve optimal social participation.[9],[10]

There is a dearth of data regarding various issues in the management of SCI from developing countries where ironically, special focus is required.[11],[12] The present study was carried out to study the clinicoepidemiological profile of SCI patients in a tertiary care rehabilitation center and organizational support provided to SCI patients in an established setup.


  Materials and Methods Top


The present study was a descriptive, cross-sectional study carried out over a period of 1 year (May 2013–April 2014) at a tertiary care SCI and rehabilitation center providing care to veterans as well as serving soldiers and their dependents. Ethics clearance was obtained from the Institutional Ethics Committee before the start of the study. Informed consent was obtained from all the study participants. Considering low prevalence and feasibility, all SCI patients undergoing rehabilitation, who had an injury while in service were included. Patients on life support and/or who were unable to provide response to the questionnaire were excluded. Further, the organizational setup provided acute as well as long-term rehabilitative care to serving soldiers and their dependents. However, dependents undergoing treatment/rehabilitation were not included in the present study. An interviewer-administered structured questionnaire was designed and pilot tested. Data were collected for age at the time of injury, the cause of injury, associated injuries, level, severity and duration of injury, and clinical, functional, and psychological status. Organizational support to SCI patients was estimated in domains of prehospitalization services, inpatient welfare measures, and posthospitalization rehabilitative services.

Prehospitalization services were ascertained on basis of availability of health-care services before reaching a hospital. Accessibility to hospitalization services was also assessed. Time taken to reach health-care facility post-SCI within 2 h was considered an indicator of accessibility to hospital care in accordance with guidelines to essential trauma care[13] and evacuation using ambulance/stretcher in the presence of a trained health-care worker including Battle Field Nursing Assistants as an indicator for the availability of prehospital health-care services. Inpatient organizational support was estimated in terms of cashless provision of wheelchair/assistive devices, medication and surgeries, and personal assistance being provided by the organization. However, the pilot study revealed that among the decided variables as indicators of organizational support, all indicators other than personal assistance were provided to every SCI patient. Thus, the presence of personal assistance by the organization was evaluated as an indicator of inpatient organizational support.

Clinically, a patient was said to be having “paraplegia” if there was a loss of varying degrees of control of the lower limbs and trunk without the involvement of the upper limbs. In case functional loss involved the neck, trunk, and upper and lower limbs, it was classified as “tetraplegia.” Severity of injury was classified on basis of completeness of lesion. In case of the absence of both motor and sensory loss in anal sensations, the injury was classified as complete. The injury was classified as incomplete when either of the sensations was present.[4]

Functional status of SCI patients was assessed in activities of daily living (ADL) as described by the WHO. Eight activity domains were studied which included activities for feeding, grooming, dressing upper body, dressing lower body, transfers, wheelchair propulsion, and bowel and bladder functions. The SCI patients were evaluated for each domain and based on the performance of the patient, each domain was categorized as being “independent,” “requires assistance,” or “dependent.” The patient was said to be “independent” when he was able to carry out the activity without human assistance, with or without assistive technologies. In case, SCI patient was able to carry out the task with partial assistance by another individual; it was classified as “requires assistance.” Finally, when the patient was unable to carry out the activity even with partial assistance and required complete assistance from another individual, the functional status was categorized as “dependent.” Comprehensive functional status in ADL was classified as independent when five or more individual activity domains were found to be independent and as a dependent when activity was independent in <5 activity domains.

The impact of SCI on the psychological status of SCI patients was assessed using questions adapted from “Impact of Event Scale-Revised.”[14],[15] A total of 22 questions or item responses were asked to assess the subjective stress due to SCI. The scale also permitted assessment of intrusion (intrusive thoughts, nightmares, intrusive feelings and imagery, and dissociative-like re-experiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, and heightened startle) in a SCI patient due to injury per se. Each question was provided with five options representing “not at all,” “a little bit,” “moderate,” “quite a bit,” and “extreme” which were graded with a score of 0, 1, 2, 3, and 4, respectively.

Posthospitalization services were considered to be present when SCI patient was vocationally rehabilitated with at least one of the rehabilitation course being undertaken. Postadministration of the questionnaire, case records were perused. The collected data were entered in Excel and analyzed using SPSS version 21.0 (Chicago, IL, USA). Median (interquartile range [IQR]) and number (%) was calculated for descriptive statistics.


  Results Top


A total of 157 SCI patients participated in the study. Median age at the time of injury was 27 years (IQR 23–31 years) and median duration since injury was 6 years (IQR 2–22 years). Trauma was the underlying cause of injury in 94.3% of patients. The most common level of injury was thoracic (37.6%) followed by cervical (36.3%). Complete injury was present in 84% of patients. Majority of patients (66.9%) were paraplegic [Table 1].
Table 1: Patient characteristics (n=157)

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Among traumatic injuries, the most common cause of injury was road accident (RTA) (42.6%) followed by falls (29.1%) [Figure 1]. Among patients with traumatic SCI (n = 148), associated injuries were seen in 86 (58.1%) patients. Among those having associated injuries, “head-and-face trauma” was most common (35.1%) [Figure 2]. Among nontraumatic SCI patients, tuberculosis was found to be the most common cause (66.6%).
Figure 1: Traumatic causes of spinal cord injury (n = 148) (frequency, %). RTA: Road traffic accident

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Figure 2: Associated injuries in traumatic spinal cord injury (n = 148)

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Details of functional status among paraplegics and tetraplegics are represented in [Table 2]. Psychological status of the study participants is represented in [Figure 3]. “A little bit” of intrusion was seen in 58.6% patients. “Not at all” of avoidance behavior was present in 32.5%, whereas hyperarousal was seen in 35.0%. Scores suggestive of stress disorder were seen in 13% of SCI patients.
Table 2: Distribution according to functional status

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Figure 3: Psychological status of spinal cord injury patients

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Organizational support to SCI patients is represented in [Table 3]. Prehospitalization health-care facilities were available to 79.6% of patients. The majority (59.2%) had access to health-care facilities within 2 h following injury. Personal assistance was available to 88.5% and rehabilitation course was being undertaken by 66.9%.
Table 3: Organizational support to spinal cord injury patients (n=157)

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  Discussion Top


The present study documents hospital-based profile of SCI patients along with a high level of organizational support to the affected individuals. Personal assistance was provided by the organization to the majority of SCI patients in addition to universal provision of infrastructure, assistive devices and inpatient cashless tertiary care and rehabilitative services. This is in contrast to the reported nonavailability of medical and rehabilitation services in public health-care system in developing countries like India.[12] This high level of organizational support can be explained by the presence of social security measures which are being provided during as well as after employment to every member of the organization to which study participants belonged.

In the present study, the availability of prehospitalization services, as well as accessibility to hospital care, was found for the majority of patients, being an organizational setup. Key prehospitalization care involves the correct positioning of the body and immobilization of the spinal column of SCI patient during resuscitation as well as during transport.[8] Despite these facts, studies report inappropriate positioning as well as varied modes of transfer of SCI patients. This includes being brought recumbent in the back seat of a car or bringing the patient in smaller vehicles, which are often too small to permit the correct position as well as immobilization of the SCI patient. In a study carried out in India, saloon car was reported to be the most common mode of transportation apart from the use of commercial buses and open trucks.[16] Another study on SCI injuries from the country found the use of an ambulance in 23% of SCI cases only, with the majority of patients being transported by vehicles unsuitable for positioning and transfer of SCI patients.[17] Further, the access to health-care facilities post-SCI is more apt in prevailing health-care facilities in developing countries as the medical and rehabilitative services are minimal, availability of quality assistive devices is limited and opportunities to participate in all areas of personal and social life are constrained.[12] Ideally, patients should arrive at tertiary care centers within 2 h of injury.[13] In a study carried out by Rosińczuk-Tonderys et al. among 130 SCI patients, only 5.4% of patients reached health-care facility within 2 h.[18] Chacko et al. in their study in 1986 found that less than half (44%) of SCI patients in their series had access to tertiary health-care facilities within 24 h of SCI.[16] In another study, Singh et al. in 2003 found 81% of patients have access to health-care facilities within 6 h and 90.3% within 24 h of SCI.[17]

In the present study, age at the time of injury was found to be similar to various country-level data which also report the age of 20–39 years to be the most common age of SCI.[5],[16],[17] Furthermore, trauma was the cause of SCI in 94.3% of the study participants which is similar to the trends reported from across the globe.[5] In the present study, associated injuries were seen in 58.1% of traumatic spinal cord injury (TSCI) patients with head-and-face trauma as the most common associated injury (35.1%). This was similar to a study by Lida et al. on the association of head injuries with TSCI which report one-third of patients with SCI with moderate or severe head injuries.[19] However, in a study carried in the state of Haryana in India, associated injuries were reported in 28% of SCI patients.[17] The variations in the proportion of TSCI patients with associated injuries may be partly explained by the varying distribution pattern of the cause of injuries among the study populations. The thoracic level was found to be the most common level of lesion (37.6%) closely followed by cervical injury (36.3%). This was similar to the study findings by Brito et al. which report thoracic segment to be the most common site (37.9%) followed by cervical (25.4%) and lumbar (25.4%).[5] However, Chacko et al. found the cervical spine to be the most common level involved followed by the thoracic spine and lumbar spine.[16]

The strengths of the present study are the high number of patients who participated in the study as compared to the previous observational studies being carried in the country on the topic. Further, the study looks into a gap of knowledge regarding estimates of organizational support being made available to critical care patients such as SCI in the established setup. All the patients were personally interviewed, and clinical data sheets and records were matched with the findings to avoid observation bias for the accuracy of the facts. However, despite the use of objective scales and efforts to accurately collect the data, the presence of bias inherent in the study design such as recall bias cannot be ruled out.


  Conclusion and Recommendations Top


The present study provides an insight into SCI in armed forces as well as organizational support to SCI patients in an established setup. Incorporation of social security measures in the form of infrastructure, inpatient cashless health care and rehabilitative services, assistive devices, and personal assistance needs to be replicated by the majority of organizations in the country. Further, future work on SCI should include the development of a national database/registry on SCI.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Status Report on Road Safety: Time for Action. World Health Organization. Available from: https://www.books.google.co.in/. [Last accessed on 2019 Jan 15].  Back to cited text no. 1
    
2.
Craig A, Tran Y, Lovas J, Middleton J. Spinal cord injury and its association with negative psychological states. Int J Psychosoc Rehabil 2008;12:115-21.  Back to cited text no. 2
    
3.
Post MW, Dallmeijer AJ, Angenot EL, van Asbeck FW, van der Woude LH. Duration and functional outcome of spinal cord injury rehabilitation in the Netherlands. J Rehabil Res Dev 2005;42:75-85.  Back to cited text no. 3
    
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World Health Organization. International Perspectives on Spinal Cord Injury. World Health Organization. Available from: https://www.who.int/disabilities/policies/. [Last accessed on 2019 Jan 16].  Back to cited text no. 4
    
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Brito LM, Chein MB, Marinho SC, Duarte TB. Epidemiological evaluation of victims of spinal cord injury. Rev Col Bras Cir 2011;38:304-9.  Back to cited text no. 5
    
6.
Rehabilitation Council of India. Spinal Cord Injury. Available from: http://www.rehabcouncil.nic.in/writereaddata/spinal.pdf. [Last accessed on 2019 Jan 16].  Back to cited text no. 6
    
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Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003;81:646-56.  Back to cited text no. 7
    
8.
Kolli S, Inman C, Chowdhury J. From the age of the pyramids to the superfast world – What has changed in the management of spinal injuries? Clin Med (Lond) 2012;12:57-8.  Back to cited text no. 8
    
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Lamontagne ME, Gagnon C, Allaire AS, Noreau L. Effect of rehabilitation length of stay on outcomes in individuals with traumatic brain injury or spinal cord injury: A systematic review protocol. Syst Rev 2013;2:59.  Back to cited text no. 9
    
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Trieschmann RB. Spinal Cord Injuries: Psychological, Social, and Vocational Rehabilitation. Demos Medical Publishing. Available from: https://www.books.google.co.in/. [Last accessed on 2019 Jan 16].  Back to cited text no. 10
    
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Allotey P, Reidpath D, Kouamé A, Cummins R. The DALY, context and the determinants of the severity of disease: An exploratory comparison of paraplegia in Australia and Cameroon. Soc Sci Med 2003;57:949-58.  Back to cited text no. 11
    
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Hagen EM. Still a need for data from developing countries on traumatic spinal cord injury. Neuroepidemiology 2013;41:86-7.  Back to cited text no. 12
    
13.
World Health Organization. Guidelines for Essential Trauma Care. World Health Organization. Available from: https://www.who.int/violence_injury_prevention/publications/. [Last accessed on 2019 Jan 16].  Back to cited text no. 13
    
14.
Christianson S, Marren J. The Impact of Event Scale - Revised (IES-R). Medsurg nursing: Official Journal of the Academy of Medical-Surgical Nurses 2012;21321-2.  Back to cited text no. 14
    
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Hyer K, Brown LM. The impact of event scale – Revised: A quick measure of a patient's response to trauma. Am J Nurs 2008;108:60-8.  Back to cited text no. 15
    
16.
Chacko V, Joseph B, Mohanty SP, Jacob T. Management of spinal cord injury in a general hospital in rural India. Paraplegia 1986;24:330-5.  Back to cited text no. 16
    
17.
Singh R, Sharma SC, Mittal R, Sharma A. Traumatic spinal cord injuries in Haryana: An epidemiological study. Indian J Community Med 2003;28:184-6.  Back to cited text no. 17
  [Full text]  
18.
Rosińczuk-Tonderys J, Załuski R, Gdesz M, Lisowska A. Spine and spinal cord injuries – Causes and complications. Adv Clin Exp Med 2012;21:477-85.  Back to cited text no. 18
    
19.
Lida H, Tachibana S, Kitahara T, Horiike S, Ohwada T, Fujii K. Association of head trauma with cervical spine injury, spinal cord injury, or both. J Trauma-Injury, Infect, and Crit Care 1999;46:450-2.  Back to cited text no. 19
    


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    Tables

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