Evaluation of a Bowel and Bladder Health Management Program for Individuals With Spinal Cord Injury (SCI)

Background and Overview

This study will evaluate the efficacy of a newly developed self-management program, Health
Mechanics, to develop and improve bladder and bowel management skills among persons with new
and chronic SCI. Program participation is expected to prevent bladder and bowel related
medical complications (e.g., constipation, leakage), leading to enhanced social participation
and QOL. Health Mechanics was designed by the study PI, Dr. Meade, between 2007 and 2009 with
funding from the Paralyzed Veteran's of America Education Foundation to assist persons with
SCI develop and transfer the necessary skills to keep their bodies healthy while managing the
many aspects of SCI care.

This study will investigate the effectiveness of a telehealth version of Health Mechanics to
enhance self-management skills related to neurogenic bladder and bowel management in an
attempt to prevent associated complications and improve QOL. The study makes a unique
contribution to rehabilitation by emphasizing the concepts of personal responsibility and
control over one's health and life as a whole. By selecting a telehealth approach (here
defined as telephone-based) for program implementation, the investigators also attempt to
address the high cost of care delivery and lack of health care access to underserved
populations with SCI living in remote areas of the State of Michigan.

The Health Mechanics program is designed based on the needs and strengths of individuals with
SCI while being responsive to identified gaps and challenges of health care provision in this
population. The program focuses on enhancing skills, encouraging positive health behaviors
and empowering people within their own environments, recognizing that people have different
resources and abilities. For this study, the Health Mechanics program has been adapted to
specifically focus on bladder and bowel management related concerns and to be administered
via telephone, thus better addressing the needs of the rural population and
transportation-related challenges.

By teaching skills to better manage bladder and bowel health, this self-management program
should not only reduce the occurrence of complications but it should also result in higher
levels of social integration and QOL. Since the skills taught - attitude, self-monitoring,
problem-solving, communication, organization and stress management - will be addressed in the
context of performing the behaviors necessary to enhance bladder and bowel health, we expect
them to generalize into other areas such that improvements in these skills result in better
overall health and participation.

Purpose and Objectives

The proposed study's overall purpose is to evaluate the effects of Health Mechanics in
preventing bladder and bowel complications and to improve QOL. The program specifically
targets newly injured individuals for early prevention of complications, as well individuals
with chronic injuries for later treatment and prevention of complications. Objectives are: 1)
to improve self-management skills, including problem-solving, knowledge of health behaviors,
and attitude about disability; 2) to increase adherence to recommended bladder and bowel
management behaviors; 3) to improve bladder and bowel health and related QOL; and 4) to
determine the extent that program improvements in terms of skills acquired are sustained over
time. Short-term refers to 3 and 6 months assessments while long-term refers to the 12 month
assessment. All hypotheses posit that, following the intervention, differences will exist
such that participants in the Health Mechanics program will perform better than the control
group (an assessment of between group differences) and that these differences will be
sustained over time (an assessment of within and between group differences). It is expected
that individuals with new injuries will improve over time regardless of group assignment,
while individuals with chronic injuries are stabilized prior to admission to the study.
Because of these naturally occurring differences in trajectory, we will be examining within
and between group differences.

Research Hypotheses

H1: Program participants will show greater improvements in problem solving skills, healthy
attitudes about disability and knowledge of SCI management skills than will the control
group; these improvements will be sustained over time within and between groups.

H2: Program participants will have greater adherence to recommended bladder and bowel
management behaviors than the control group; these improvements will be sustained over time
within and between groups.

H3: Program participants will have fewer bladder and bowel complications than the members of
the control group; these differences will be maintained over time within and between groups.

H4: Program participants will have higher levels of QOL than the control group; these
differences will be sustained over time within and between groups.

Inclusion Criteria for all groups:

- having a traumatic spinal cord injury

- being at least 18 years old

- having neurogenic bowel and/or bladder

- being community-living

- English-speaking

Additional inclusion criteria for new injury onset groups:

- completing inpatient rehabilitation for new SCI at University of Michigan Health
System

Additional inclusion criteria for chronic injury groups:

- having an SCI for at least one year before enrollment

- expressing moderate to occasional bowel and/or bladder issues on the secondary
conditions scale with associated distress

Exclusion Criteria for all groups:

- cognitive deficits and psychiatric conditions that render persons unable to
independently direct or perform their own care

Additional Exclusion Criteria for chronic injury groups:

- current episode of severe depression as evidenced by scoring 20 or higher on the PHQ-9

- current suicidality or suicidal ideation