RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI Suzanne Groah, MD, MSPH Mark Nash, PhD Alexander Libin, PhD Jessica Ramella-Roman,

RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI

Suzanne Groah, MD, MSPHMark Nash, PhD

Alexander Libin, PhDJessica Ramella-Roman, PhDManon Schladen, MSE, EdS

NSCIA and ILRUGrant # H133B090002

RRTC on Secondary Conditions in the Rehabilitation of Individuals with SCI

Suzanne Groah, MD, MSPHMark Nash, PhD

Alexander Libin, PhDJessica Ramella-Roman, PhDManon Schladen, MSE, EdS

NSCIA and ILRUGrant # H133B090002

RRTC Staff

Center Director Suzanne Groah,

MD,MSPH

Alexander Libin, PhD

Manon Schladen, MSE, EdS

Inger Ljungberg, MPH

Alison Lichy, DPT

Brenda Triyono, BS

EmilyWard, MS

Miriam Spungen, BS

Eric Larson Jessica Romella-Roman,

PhD, MSEE

Mark Nash, PhD

Cynthia Pineda, MD,

FAAPMR

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

AllenTaylor, MD

Brenda Gilmore, BFA

Mark Loeffler, MA

Shannon MinnickMs. Wheelchair

MD

Kurt Johnson, PhD

Summary of Proposed RRTC• Research focus

– Cardiometabolic risk and cardiovascular disease– Obesity– Pressure ulcers

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

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

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”

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

Skin Health

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

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

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

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….”

Prevention of Skin Breakdown

• Pressure reliefs every 15 minutes…..is this enough?

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

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

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

Measuring Skin Health

• We need a system that can measure pressure, blood flow AND oxygenation

• This needs to be done in the sitting position

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, MSPHCo-Principal Investigators (Co-PIs): Alexander Libin, PhD

& Jessica Ramella-Roman, PhD Project Coordinator: Alison Lichy, DPT, PT, NCS

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

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

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.

Methods• First probe, proof of concept,

generates accurate SO2 measurement.

• Used for testing and calibration.

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.

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.

R3 Outcome Measures• Baseline Data Collection

– Demographic Data– Baseline Microvascular Assessment

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

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

Objectives• Overarching Objective: Translate findings of RRTC research to practice for

both consumers and health care providers

• Supporting Objectives:

1. Define and present the state of knowledge about positioning and the risk of pressure ulcers in people with SCI 1. “What is the optimal positioning to prevent skin breakdown?”

Systematic Review2. Explore what knowledge and information formats and delivery

mechanisms are most useful and acceptable to our consumer and clinician audiences

3. Build capacity to support the health and well-being of persons with SCI (consumer living, clinical practice, research discovery)1. Technology development

Integrated Approach to Research and Training

Key points of support and interaction

Systematic Review

User Studies

Systematic Review

Sensor Development

Learning Materials

Learning Materials

User Studies

R3 Intervention

Quality Plan

Evaluation

What (does the literature say) is the optimal positioning to prevent skin breakdown?

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?

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, intervention best practices

Revised materials,Recommendations forActionable practice

How To Videos

• Peer Modeling

•Task

Identity

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

Thank you!!!

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