Methods for classifying obesity in spinal cord injury: a review.

STUDY DESIGN: Narrative review. OBJECTIVES: Review methods used to measure and classify obesity in individuals with spinal cord injuries (SCI). Outline the strengths and weaknesses of each method used to measure obesity in individuals with SCI. SETTING: International. METHODS: PubMed was used to identify articles before 2016. Search terms ('obesity' or 'weight status' and 'spinal cord injury'). Filters: adults, English and human. Studies were retained that (1) included participants, 18 years or older, with SCI; (2) took place in inpatient, outpatient or community-based settings and (3) measured obesity status. Unique methods for classifying individuals with SCI as obese were identified and examples are presented. RESULTS: Methods identified for classifying obesity were as follows: World Health Organization body mass index (BMI) cutoff⩾30 kg m-2, BMI cutoff ⩾25-29 kg m-2, and SCI-specific BMI cutoff ⩾22 kg m-2, waist circumference cutoff (women >102 cm, men >88 cm), percent body fat cutoffs ⩾25% using bioelectrical impedance analysis and dual-energy X-ray absorptiometry, computerized tomography scan visceral fat area ⩾100 cm2 and percentage of ideal body weight. CONCLUSIONS: BMI is the most widely used measure of obesity in the SCI literature. Although some studies identified alternative cutoffs or other metrics, there is no standardized obesity classification in SCI. However, research is needed to determine and validate obesity classification specific to SCI due to physiological changes that occur following injury. We recommend that researchers and clinicians proceed with caution and use methodology based on the purpose of measurement.

Abuse assessment screen-disability (AAS-D): measuring frequency, type, and perpetrator of abuse toward women with physical disabilities.

An interview questionnaire was presented to a multiethnic sample of 511 women, age 18-64 years, at public and private specialty clinics to determine the frequency, type, and perpetrator of abuse toward women with physical disabilities. The four-question Abuse Assessment Screen-Disability (AAS-D) instrument detected a 9.8% prevalence (50 of 511) of abuse during the previous 12 months. Using two standard physical and sexual assault questions, 7.8% of the women (40 of 511) reported abuse. The two disability-related questions detected an additional 2.0% of the women (10 of 511) as abused. Women defining themselves as other than black, white, or Hispanic (i.e., Asian, mixed ethnic background) were more likely to report physical or sexual abuse or both, whereas disability-related abuse was reported almost exclusively by white women. The perpetrator of physical or sexual abuse was most likely to be an intimate partner. Disability-related abuse was attributed equally to an intimate partner, a care provider, or a health professional. This study concludes that both traditional abuse-focused questions and disability-specific questions are required to detect abuse toward women with physical disabilities.

Practical considerations in the performance of physical examinations on women with disabilities.

There are over 28 million women with disabilities in the United States (1). This includes women with mobility and self-care limitations of varying degrees. Many of these women have difficulty obtaining comprehensive, accessible, and dignified physical examinations. Additionally, patients and clinicians are often misinformed about issues pertaining to healthcare needs of women with disabilities (2). This article outlines strategies to overcome physical barriers and gaps in knowledge, and proposes creative solutions for common problems encountered during the performance of the basic physical examination of a woman who has disabilities. It discusses the reality of sexually transmitted disease, promotes awareness of abuse in the population of women with disabilities, and offers guidelines physicians can follow in assisting their patients in resolving this abuse.

Accessibility of primary care physicians' offices for people with disabilities. An analysis of compliance with the Americans With Disabilities Act.

OBJECTIVE: To determine if primary care physicians are in compliance with the Americans With Disabilities Act of 1990 (ADA) and to what extent offices of primary care physicians are usable for persons with disabilities. DESIGN: Cross-sectional survey. SETTING: Members listed in the Harris County (Texas) Medical Society roster. SUBJECTS: Sixty-two general practitioners, family practitioners, internists, and obstetrician-gynecologists. MAIN OUTCOME MEASURE: A 15-page questionnaire with 57 items and 136 variables. RESULTS: Eleven (18%) of the primary care physicians in this study were unable to serve their patients with disabilities in the last year for reasons that could be interpreted as noncompliant with the ADA. Two physicians (3%) had offices that patients with disabilities could not enter because of physical barriers, and 1 physician (2%) had inaccessible equipment. Fourteen physicians (22%) were improperly referring patients with disabilities although they generally treat such patients. In measuring the level of compliance with regard to structural features that enhance the accessibility of the physicians' offices, only 8 (13%) had a low level of compliance. Thirty-nine (63%) of the physicians supplied auxiliary aids and services to their patients with disabilities. The most common aid was printed materials. CONCLUSIONS: A substantial portion of primary care physicians' offices are not in compliance with the ADA, and some informational tools will be required to inform physicians about the nondiscriminatory requirements of the statute.

Prevalence of abuse of women with physical disabilities.

OBJECTIVE: Emotional, physical, and sexual abuse of women with physical disabilities is a problem largely unrecognized by rehabilitation service providers. This article documents the prevalence of abuse of women with physical disabilities compared to women without physical disabilities. DESIGN: Case-comparison study using written survey. Data were analyzed using chi 2 analyses and the Mann-Whitney U Wilcoxon rank sum W tests. SETTING: General community. PARTICIPANTS: A sample of 860 women, 439 with physical disabilities and 421 without physical disabilities, was compiled from women responding to a national sexuality survey. MAIN OUTCOME MEASURES: The women were asked if they had ever experienced emotional, physical, or sexual abuse. If they answered yes, they were asked to identify the perpetrator(s) of the abuse and when the abuse began and ended. RESULTS: Sixty-two percent of both groups of women had experienced some type of abuse at some point in their lives. Of women who had experienced abuse, half of each group had experienced physical or sexual abuse. Husbands or live-in partners were the most common perpetrators of emotional or physical abuse for both groups. Male strangers were the most common perpetrators of sexual abuse for both groups. Women with physical disabilities also were more likely to be abused by their attendants and by health care providers. Thirteen percent of women with physical disabilities described experiencing physical or sexual abuse in the past year. CONCLUSIONS: Women with physical disabilities appear to be at risk for emotional, physical, and sexual abuse to the same extent as women without physical disabilities. Prevalence of abuse by husbands or live-in partners in this study is similar to estimates of lifetime occurrence of domestic violence for women living in the United States. Women with physical disabilities are more at risk for abuse by attendants or health care providers. They are also more likely to experience a longer duration of abuse than women without physical disabilities.

Breast and cervical cancer screening among women with physical disabilities.

OBJECTIVE: This article reports findings from the National Study of Women with Physical Disabilities about rates of screening for breast and cervical cancer and factors associated with regular screening in a large sample of women with a variety of physical disabilities and a comparison group of women without disabilities. DESIGN: Case-comparison study using written survey. Data were analyzed using measures of central tendency, chi 2 analysis, logistic regression, and risk using odds ratios. SETTING: General community. PARTICIPANTS: A total of 843 women, 450 with disabilities and 393 of their able-bodied friends, aged 18 to 65, who completed the written questionnaire. The most common primary disability type was spinal cord injury (26%), followed by polio (18%), neuromuscular disorders (12%), cerebral palsy (10%), multiple sclerosis (10%), and joint and connective tissue disorders (8%). Twenty-two percent had severe functional limitations, 52% had moderate disabilities, and 26% had mild disabilities. MAIN OUTCOME MEASURES: Outcomes were measured in terms of frequency of pelvic exams and mammograms. RESULTS: Women with disabilities tend to be less likely than women without disabilities to receive pelvic exams on a regular basis, and women with more severe functional limitations are significantly less likely to do so. No significant difference was found between women with and without disabilities, regardless of severity of functional limitation, in receiving mammograms within the past 2 years. Perceived control emerged as a significant enhancement factor for mammograms and marginally for pelvic exams. Severity of disability was a significant risk factor for noncompliance with recommended pelvic exams, but not mammograms. Race was a significant risk factor for not receiving pelvic exams, but not mammograms. Household income and age did not reach significance as risk factors in either analysis. CONCLUSIONS: Women with physical disabilities are at a higher risk for delayed diagnosis of breast and cervical cancer, primarily for reasons of environmental, attitudinal, and information barriers. Future research should focus on the subpopulations that were not surveyed adequately in this study, women with disabilities who have low levels of education or income, or who are of minority status.

Sexual functioning among women with physical disabilities.

OBJECTIVE: Three a priori hypotheses were tested: (1) There are significant differences in sociosexual behaviors of women with physical disabilities compared with women without disabilities; (2) the sexual functioning of women with disabilities is significantly related to age at onset of disability; (3) psychological factors explain more of the variance in the sexual functioning of women with physical disabilities than do disability, social and environmental factors. DESIGN: Case-comparison study using written survey. SETTING: General community. PARTICIPANTS: The questionnaire was mailed to 1,150 women with physical disabilities who were recruited as volunteers or through independent living centers. Each woman gave a second copy of the questionnaire to an able-bodied female friend, which comprised the comparison group. The response rate was 45%, with 475 cases and 425 comparisons eligible to participate. The most common disability type was spinal cord injury (24%), followed by polio (18%), muscular dystrophy (11%), cerebral palsy (11%), multiple sclerosis (10%), joint disorders (7%), and skeletal abnormalities (5%). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Sexual-functioning, consisting of four factors: (1) sexual desire, (2) sexual activity, (3) sexual response, (4) sexual satisfaction. RESULTS: Highly significant differences were found in level of sexual activity (p = .000001), response (p = .000009), and satisfaction (p=.000001) between women with and without disabilities. No significant differences were found between groups on sexual desire. Severity of disability was not significantly related to level of sexual activity. CONCLUSIONS: Psychological and social factors exert a strong impact on the sexual functioning of women with physical disabilities. Further investigations is needed of the effect of social environment on development of self-esteem and sexual self-image, and how these influences affect levels of sexual functioning in women with physical disabilities.

Demonstrating a model approach to independent living center-based assistive technology services.

This project examined the effectiveness of an assistive technology preventive maintenance service for consumers. Sixteen independent living centers that offer mobility equipment repair services for consumers were surveyed. Thirty-seven consumers and 22 vendors supplying mobility equipment and repair services within the Houston area were interviewed. Problems identified included lack of available services to maintain mobility equipment in good working order, no centralized information and evaluation system, denials of needed equipment by third party payers, and high equipment costs. A collaborative effort between the Independent Living Research Utilization Research and Training Center on Independent Living at The Institute for Rehabilitation and Research in the Texas Medical Center, and the Houston Center for Independent Living designed and implemented a model preventive maintenance service--The Wheelchair Maintenance Clinic. Evaluation after the first year of operating the clinic showed 111 service visits were delivered to 50 consumers. Consumers reported high levels of satisfaction with the service.

Personal assistance: its effect on the long-term health of a rehabilitation hospital population.

After discharge from a rehabilitation hospital, persons with severe disabilities may not be able to maintain health effectively without adequate personal assistance with activities of daily living. Techniques of qualitative analysis were used to assess interview results based on the observations of 41 physicians, physical therapists, occupational therapists, social workers, and nurses in five rehabilitation hospitals. A positive relationship was found between the adequacy of personal assistance and the ability of individuals disabled primarily by stroke, spinal cord injury, or traumatic brain injury to maintain good physical and mental health. The most commonly cited health problem was skin breakdown, followed by urinary tract infections, pulmonary infections, and contractures. Inadequate personal assistance also led to extended hospital stays, threats to safety, poor nutrition, and poor personal hygiene. Reliance on family alone for assistance was considered inadequate, common adverse effects including burnout, family role changes, and economic strain. Persons with the best health combined assistance by relatives and unrelated persons. Recommended is the establishment of a comprehensive system capable of coordinating service delivery from home health agencies, independent living centers, and rehabilitation hospitals.

Relationships between independent living centers and medical rehabilitation programs.

A survey of independent living centers (ILCs) and medical rehabilitation programs (MRPs) with cooperative relationships was conducted to (1) document the extent and kinds of relationships that exist and (2) identify factors that are reported to impede or facilitate those relationships. A questionnaire was mailed to 83 ILCs that are listed in the ILRU Registry of Independent Living Programs and that reported having a relationship with one or more MRPs. Subsequently, another questionnaire was sent to the MRPs with which each ILC reported having a relationship. Usable questionnaires were received from 46 ILCs. In descending order, the most frequently reported relationships were (1) making referrals to or supplying information about MRPs, (2) providing peer counseling services, and (3) conducting training in daily living skills for medical rehabilitation patients. Mean ratings of satisfaction with the various kinds of relationships were relatively high. The three most frequently endorsed barriers to stronger relationships were conflicting approaches or styles of service delivery, funding of services, and conflicting program philosophies. Using information from a database describing ILCs, it was found that ILCs with MRP relationships served significantly more consumers than centers not having such relationships. According to results provided by 25 MRPs, patients with spinal cord injury most frequently received services by staff members of ILCs, with peer counseling being the most frequently provided service.

Psychosocial independence and functional abilities: their relationship in adults with severe musculoskeletal impairments.

Personality traits, functional abilities, and demographic characteristics of 61 persons with severe musculoskeletal impairments were examined using a personality factors questionnaire, the Barthel Index, and a demographic questionnaire. Subjects were grouped by high or low scores on the personality factors scale (psychologic independence) and an independent living scale (social independence). Data were analyzed using correlations, chi-squares, analyses of variance, factor analyses, and discriminant analyses. Subjects with high psychologic independence tended to live in less restrictive settings, had fewer communication problems, and spent less time in comprehensive rehabilitation facilities. Those with high social independence tended to be married; have assertive, self-assured, and self-sufficient personalities; more education; and more earned income. Both groups of highly independent persons tended to have hired attendants, good health, and more transportation options. They were outgoing, predominantly female, and tended to perceive themselves as independent. Functional abilities were not significantly related to levels of psychologic and social independence.