5.9. SCI Comprehensive Preventative Health Evaluation
Critical Functions. Critical functions of the SCI Comprehensive Preventive Health Evaluation include health promotion, prevention, early identification and treatment of complications related to lifestyle, aging, and living with a SCI/D. Annual comprehensive preventive health evaluations must be offered at SCI Centers by a multidisciplinary team trained in SCI/D care.
Evaluation Scope. The scope of the evaluation is comprehensive and includes:
Elements of health promotion and disease prevention defined for the general Veteran, and
SCI/D specific elements. NOTE: Health promotion and disease prevention elements are addressed by VHA, and are not listed here due to their periodic revision. As standards of care are developed or modified for the general Veteran population, they will be implemented in the SCI/D System of Care in the same manner as in other VA primary care sites.
Evaluation Elements. The SCI/D specific evaluation includes the following elements:
Medical History and Physical Examination. In addition to the standard medical history and physical examination, the SCI/D specific evaluation must minimally include evaluation of: integumentary (e.g. pressure ulcers), cardiovascular (e.g. postural hypotension, autonomic dysreflexia, cardiovascular risk factors), pulmonary (e.g. impaired cough, pneumonia, and respiratory failure), gastrointestinal (e.g., neurogenic bowel), endocrine (e.g., low testosterone), genitourinary (e.g. neurogenic bladder), metabolic (e.g., diabetes), musculoskeletal, and neurologic systems. The risk for secondary problems and co-morbid conditions following SCI/D is considerable in many of these systems. For example, the integumentary system undergoes anatomical and physiologic changes after SCI/D resulting in increased risk for pressure ulcers. The risk of cardiovascular disease is considerable since Veterans with SCI/D are paralyzed and less able to participate in physical activities. The physiology of the urinary and gastrointestinal systems are altered thereby resulting in high risks of complications, such as the development of stones, urinary tract infections, incontinence, and obstipation.
Integumentary System. The risk for pressure ulcer development and recurrence is high in Veterans with SCI/D. All Veterans with impaired sensation or mobility must have an annual comprehensive assessment of risk factors, a review of prevention strategies, a thorough inspection of skin/body wall, and recommendations for pressure ulcer prevention shared with the Veteran (i.e., a pressure ulcer prevention plan).
Cardiovascular Screening. Cardiovascular screening is particularly important in the SCI/D population since persons with SCI/D often have increased risk factors for cardiovascular disease (e.g., inactivity, obesity, hypercholesterolemia, tobacco use, hypertension). In higher level spinal cord injuries (i.e., tetraplegia) coronary artery disease, angina, and cardiac ischemia may not manifest with chest pain due to sensory impairment, and lack of intact cardiac afferents (particularly in injuries above the neurological level of T2). Cardiovascular risk factors are frequently present in younger adults with SCI/D as compared with the general population (e.g., inactivity as a result of paralysis, early onset of diabetes mellitus).
Cardiovascular risk factor assessment should include hypertension screening with annual blood pressure measurement. A fasting lipoprotein profile should be obtained regularly for all Veterans with SCI/D. Since mobility deficits, lack of physical activity, and obesity are common following SCI/D, screening for dyslipidemia may be more frequent than VA/DOD and National Cholesterol Education Program guidelines. At a minimum, Veterans with SCI/D, normal lipid profiles, and less than three non-lipid cardiovascular (CV) risk factors (non-lipid CV risk factors, age 35 years or older for males, age 45 years or older for females, family history of premature cardiovascular disease, hypertension, smoking, diabetes mellitus, abdominal obesity, male gender) should be screened once every 5 years. Veterans with SCI/D with abnormal values and/or more than three non-lipid cardiovascular risk factors warrant annual testing, and should be counseled and treated in accordance with VA/DOD national guidelines.
Evaluation and treatment of Veterans with SCI/D who have ischemic heart disease should follow VA/DOD Clinical Practice Guidelines. In Veterans with tetraplegia, symptoms and signs of ischemic heart disease may be subtle or absent. Cardiac ischemia may not result in chest pain. A 12-lead electrocardiogram should be obtained in all individuals with tetraplegia age 35 years and older. Electrocardiogram is also mandatory for all symptomatic individuals or if there is any question of cardiac disease.
Autonomic Dysreflexia. Evaluation, education, and treatment for autonomic dysreflexia should be performed as clinically indicated following the recommendations of the clinical practice guideline, Acute Management of Autonomic Dysreflexia, Consortium for Spinal Cord Medicine. This condition can represent a medical emergency; recognizing and treating the earliest signs and symptoms can avoid dangerous sequelae of severely elevated blood pressure in Veterans with SCI/D with neurologic injuries at T6 and higher. The annual evaluation offers a time to review problems with autonomic dysreflexia, patient knowledge, and ensuring that medications for acute treatment are available and renewed.
Orthostatic hypotension. Many Veterans with SCI/D have symptomatic orthostatic hypotension. Assessment, education, and treatment may include recommendations for change in fluid intake, compressive stockings, abdominal binder, and medications.
Respiratory Complications. Respiratory complications are one of the leading causes of death and morbidity when living with SCI/D. Evaluation and treatment should follow the clinical practice guideline Respiratory Management following SCI, Consortium for Spinal Cord Medicine.
Pulmonary function tests and chest x-ray should be obtained when clinically indicated and in high-risk patients (e.g., high tetraplegia, ventilator dependency, phrenic pacers, asthma, Chronic Obstructive Pulmonary Disease (COPD).
The prevalence of sleep-disordered breathing in persons with chronic tetraplegia is 25 to 40 percent. The prevalence is likely elevated in persons with chronic paraplegia as well as acute SCI/D. Patients with signs and symptoms of sleep disordered breathing, such as severe snoring or excessive daytime sleepiness without another cause, must undergo diagnostic evaluation. Full polysomnography with electroencephalographic monitoring is the most sensitive test for diagnosing sleep disordered breathing. Nocturnal pulse oximetry may be adequate for detecting severe cases; however, a normal study does not rule out sleep disordered breathing, particularly if performed with a standard oximeter.
Annual seasonal influenza vaccine is recommended for all persons with SCI/D, unless there are specific contraindications. For those patients who will not be seen during the influenza vaccination season, every effort needs to be made to contact patients and inform them about resources in the community, and document receipt of vaccination in the medical record. H1N1 influenza vaccination will follow evolving recommendations.
Pneumococcal vaccination is recommended for all persons with SCI/D, unless there are specific contraindications. A single revaccination is recommended if more than 5 years have elapsed since receipt of the first vaccination. The recommendations for revaccination may change and need to follow recommendations of the Advisory Committee on Immunization Practices (ACIP).
Gastrointestinal system. There may be many gastrointestinal complications that result from SCI/D including neurogenic bowel, peptic ulcer disease, impaction, diarrhea, and incontinence. Many of these complications may result in hospitalization or can be life-threatening. Complaints of symptoms related to gastrointestinal dysfunction are some of the most common following SCI/D, and they result in a negative impact on quality of life.
Neurogenic bowel. Evaluation, education, and treatment of neurogenic bowel needs to follow the clinical practice guideline, Neurogenic Bowel Management in Adults with SCI, Consortium for Spinal Cord Medicine. A screening assessment of neurogenic bowel function and related problems needs to be done annually.
People with SCI/D have an increased prevalence of cholelithiasis. Diagnostic tests to visualize the gall bladder (abdominal ultrasound or computed tomography) need to be obtained in Veterans with SCI/D who have altered, or no sensation overlying the gall bladder (approximately the T8 neurologic level) at least once every 5 years or more frequently as clinically indicated. If gall bladder afferents and/or afferents in the overlying peritoneum are impaired, symptoms of acute cholecystitis may be subtle or absent.
Genitourinary system. Some of the most common complications that follow SCI/D are related to a neurogenic bladder. Assessment, education, and treatment of the neurogenic bladder should follow the clinical practice guideline, Bladder Management for Adults with Spinal Cord Injury, Consortium for Spinal Cord Medicine. Complex and recurrent problems need to be assessed and treated in the SCI Centers (e.g., assessment of hydronephrosis and nephrolithiasis: diagnostic tests such as cystoscopy and urodynamics).
The annual evaluation of the genitourinary system needs to include:
Urinalysis, culture and sensitivity;
Serum creatinine and Blood Urea Nitrogen (BUN); and
Annual assessment of upper tract function should include an anatomical test (e.g., abdominal ultrasound) and/or an evaluation of function (e.g., creatinine clearance, renal scan). Diagnostic tests such as computed tomography (CT) and intravenous pyelogram should be ordered only when clinically indicated.
Indwelling catheterization may result in long-term complications such as bladder cancer. Surveillance using cystoscopy, cytology, and random bladder biopsy should be performed on a regular basis at the SCI Center.
Urodynamics need to be done at the SCI Center when objective information on voiding function and intravesicular pressures is needed. Indications for urodynamics includes recent onset of SCI/D, deterioration in renal function, anatomical changes in the upper tract (e.g., hydronephrosis), recurrent autonomic dysreflexia of unknown etiology, and urinary incontinence in the absence of urinary tract infection. A standard medical history and physical examination (evaluating symptoms and signs) is not sensitive in screening for high intravesicular pressures.
Annual digital rectal exam is recommended for all men with SCI/D at ages consistent with those recommended by the American Cancer Society, American Urological Association, and VHA Health Promotion and Disease Prevention Programs. Annual counseling regarding the advantages and disadvantages of prostate specific antigen testing should also be discussed.
Each Veteran with SCI/D who uses intermittent catheterization should be offered and provided enough catheters so a new catheter can be used at each catheterization.
Abnormalities of Carbohydrate and Lipid Metabolism. Abnormalities of carbohydrate and lipid metabolism are common in Veterans with SCI/D in all age groups. Annual evaluation of fasting serum glucose is recommended for all Veterans with SCI/D. Follow-up and treatment of diabetes should follow VA/DOD guidelines. Dilated eye exam in accordance with VA/DOD guidelines should be performed.
Musculoskeletal Disorders. Many musculoskeletal disorders after SCI/D are common and disabling. Due to increased forces and repetition (e.g., upper limbs used for transfers and wheelchair propulsion), extreme positions (e.g., during uneven transfers), altered biomechanics (e.g., gait pattern due to weakness), and instrumentation of the spine, peripheral joint and spine pathology are common. Quantitative assessment of upper limb function and treatment should follow clinical practice guideline, Preservation of Upper Limb Function Following SCI, Consortium for Spinal Cord Medicine.
The evaluation of spine pain is a particular challenge in Veterans with SCI/D. A thorough history, physical examination, and if indicated, imaging studies should be performed in all persons with the new onset of, or significant changes in neck or back pain; evaluating for instrumentation problems, instability, neuropathic arthropathies, syringomyelia, radiculopathy, and spinal stenosis.
Osteoporosis and fracture due to decreased bone mineral content and bone mineral density have been demonstrated in persons with SCI/D. All correctable factors that exacerbate osteoporosis need to be reviewed and treated (i.e., vitamin D, calcium, hyperthyroidism, hypogonadism). Fall prevention must be reviewed and include evaluation of intrinsic factors (cognitive impairment), sedating medications, and extrinsic factors (wheelchair set-up). Other risk factors need to also be assessed and corrected (e.g., unsafe transfers, excessively zealous range of motion).
Seating and postural abnormalities are common after SCI/D. Screening for problems needs to be done annually. Treatment by experienced therapists in the SCI Center and use of seat mapping must be conducted when indicated.
Neurologic Complications. Common neurologic complications (e.g., spasticity, pain) need to be evaluated and treated when clinically indicated. The International Standards for Neurological Classification of Spinal Cord Injury should be used and documented for patients with traumatic SCI/D during each annual evaluation for early detection of neurologic decline. An accepted, standardized assessment tool should be used to assess and document the neurologic status in Veterans with atraumatic SCI/D annually (e.g., International Standards for Neurological Classification of Spinal Cord Injury, Kurtzke Expanded Disability Status Scale for multiple sclerosis).
Chronic Pain. Chronic pain following SCI/D is common. Thorough evaluation and comprehensive management should be done at initial presentation, annually, and if there is new pain or change in symptoms.
Rehabilitation Functional Assessment. A rehabilitation functional assessment that includes activities of daily living (ADL), transfers, proper wheelchair pushing techniques, and other aspects of mobility needs to be performed annually.
Dietary and Nutritional Assessment. An annual dietary and nutritional assessment needs to be performed annually since the SCI/D population has a higher prevalence of obesity, and disorders of carbohydrate and lipid metabolism.
Review and Renewal of Medications. Review and renewal of medications and supplies must be performed annually.
Dental Evaluation. A dental evaluation needs to be made available to patients with SCI/D. Follow-up care for issues identified by the evaluation, need to be provided when VHA eligibility criteria for dental services are met.
Psychological, Social, and Vocational Needs. Psychological, social, and vocational needs related to vocational rehabilitation potential and/or readiness, social role participation, quality of life, behavioral health status, chemical dependency and/or use, living environment, life care planning, and attendant training needs must be evaluated annually.
Review of Prosthetic Equipment. Review of prosthetic equipment needs, function, and safety must be reviewed annually.
Comprehensive Preventive Health Evaluation Findings. The comprehensive preventive health evaluation findings must be documented, summarized with recommendations for follow- up care, and shared with Veterans with SCI/D.