Primary Care

Health Issues

The final section of this review presents articles discussing the most common health concerns experienced by people with SCI in the community, and those issues most typically seen in primary care. This section is made up of 13 surveys of patients and providers, aiming to increase awareness of the nature and scope of health concerns typically experienced by people living in the community with spinal cord injuries. Table 4 summarizes the health issues and information needs of individuals with SCI when they seek primary care.

Table 4. Health Issues of Key Importance in Primary Care, including Physician Knowledge

Author Year; Country Score Research Design Total Sample Size	Methods	Outcome
McDermott et al. 2005 USA Case Control Level 3 N=3636 (1552 with disability, 35 SCI)	Population: 35 SCI (8 female, 12 with paraplegia, 23 with tetraplegia). Treatment: No treatment. Purpose: Computerized medical records from rural and urban primary care settings from 1990 to 2003 and companion paper records were reviewed. Outcome Measures: Determine the rate of depression among individuals with disabilities, comparing both within the disability group (e.g., different diagnosis) and to the control group.	1. Patients with disabilities have significantly higher rates of depression (p=0.019). 2. 28.6% of people with SCI were found to be depressed. 3. Patients with trauma (SCI and TBI) had significantly earlier onset of depression compared to controls (p=0.0007). 4. By age 50, 16-17% of patients with trauma had depression. 5. By age 60, 45% of patients with trauma had depression compared to 18% of controls.
Evans et al. 2010 USA Retrospective Cohort Level 3 N=1277	Population: 1277 veterans with SCI with acute respiratory infection (ARI); 57.1% paraplegia, 64.3% incomplete injury, mean age 59.1, mean YPI 20.3 yrs. Purpose: follow-up survey of 2006 study of SCI outpatients. Treatment: new antibiotic prescription within 3 days of ARI. Outcome Measures: Survey on long term outcome of traumatic SCI, health-care utilization, subsequent outpatient visit or hospitalization.	1. 53.2% of patients with ARI were prescribed an antibiotic. 2. 47.0% had subsequent outpatient visit within 30 days. 3. No significant difference in health care utilization for those prescribed antibiotic. 4. Patients without chronic respiratory condition were fine without additional antibiotic prescription.
Patel et al. 2017 Canada Retrospective Cohort Level 3 N=19	Population: Patients with SCI presented in an interprofessional primary care mobility clinic. Purpose: To determine how frequently different secondary health conditions SCI patients present with in a primary care clinic and the patients’ most common complaints. Treatment: No treatment. Outcome Measures: Frequency of patients who presented with a certain medical condition or had a certain complaint.	1. The most frequent secondary health conditions are depression/anxiety (37%), osteoporosis/osteopenia (26%) and hypertension (21%). 2. The most common referral for people with SCI present were pain (23%) or bowel/bladder issues (13%) or erectile dysfunction (10%).
McColl et al. 2015 Canada and Australia Pre-post Level 4 N=125	Population: 49 primary care physicians. Purpose: To determine whether sending weekly ‘Actionable Nuggets’ (short messages related primary care for SCI patients) to physicians improve their knowledge of SCI treatment. Treatment: No treatment. Outcome Measures: Self-rated physician knowledge of SCI primary care, usefulness and acceptability of ‘Actionable Nuggets’.	1. Primary care physicians identified the top five most important issues associated with SCI to be: bladder care, skin care, office accessibility and bowel care. 2. Areas that they were most knowledgeable were the areas of depression, cardiac disease and pain. Areas they were least knowledgeable were autonomic dysreflexia, office accessibility, skin breakdown and sexual and reproductive health. 3. After 20 weeks of sending weekly SCI ‘Actionable Nuggets’, self-rated physician knowledge went from 58% to 75%. 4. 53% of physicians have stated that they have changed their practice after receiving ‘Actionable Nuggets’.
Smith et al. 2014 Canada Pre-post Level 4 N=49	Population: 49 family physicians. Purpose: To determine physicians’ satisfaction with the ‘Actionable Nuggets’ (short messages related to primary care for SCI patients). Treatments: No treatment. Outcome Measures: Survey asking physicians on the effects of the ‘Actionable Nuggets’.	1. 15% of participants stated that their practice is or will be changed or improved because of the ‘Actionable Nuggets’. 2. 57% of participants stated that they learned something new because of the ‘Actionable Nuggets’. 3. Top 5 module topics that were completed included: epidemiology of SCI, screening for cardiovascular disease risk, autonomic dysreflexia, pharmacological management of neuropathic pain in SCI and management of musculoskeletal pain.
Goetz et al. 2005 USA Pre-post Level 4 N=4432	Population: 4432 participants (3% F); age: 47-69 yrs. Treatment: Targeted dissemination & implementation of neurogenic bowel Clinical Practice Guideline. Purpose: to determine whether adherence to clinical guidelines could be improved through a targeted implementation strategy. Outcome Measures: Adherence to CPG before implementation (T1), after publication (T2) and after dissemination and implementation strategies (T3).	1. Overall adherence to recommendations did not change between T1 and T2. 2. Statistically significant increase in adherence for 3 of 6 recommendations from T2 to T3 (p<0.001). 3. Publication alone did not alter adherence, targeted implementation increased adherence for 3 of 6 recommendations.
Lofters et al. 2018 Canada Retrospective chart review and Cross-sectional Survey Level 5 N=125	Population: 60 patients included in the chart review and 15 physicians in the survey from 6 interprofessional primary care practices in Ontario. Purpose: To determine the preventative care methods physicians use as well as determining physicians’ comfort level in dealing with patients with SCI. Treatment: No treatment. Outcome Measures: Survey measuring physicians’ comfort level dealing with SCI patients.	1. 27.3% of physicians were at least somewhat comfortable with managing autonomic dysreflexia, however 100% were comfortable managing blood pressure. 2. Physician comfort level was also low when dealing with SCI patients with spasticity and respiratory issues.
Liu et al. 2018 China Cross-sectional Survey Level 5 N=125	Population: 125 Chinese SCI physicians who attended annual workshops two years in a row. Purpose: To determine SCI physicians’ knowledge of the Spinal Cord Independence Measure (SCIM) and how it could be used for more applications. Treatment: No treatment. Outcome Measures:10-item survey determining a physician’s use and knowledge of SCIM.	1. 29.6% (n=37) physicians were aware of the SCIM. 2. 20.8% of physicians had used the SCIM. 3. 74.4% of physicians believe they needed formal training before they use the SCIM.
Lala et al. 2014 Canada Cross-sectional Survey Level 5 N=1137	Population: 1137 traumatic SCI patients >1 year post injury, 33.5% of patients had pressure ulcers. Purpose: To determine the effects of pressure ulcers on patients’ participation in everyday activities as well as health utilization patterns in those with a pressure ulcer. Treatment: No treatment. Outcome Measures: Survey determining the type and extent of participation in everyday activities and percentage of patients that have visited various health services.	1. The three most common health professionals seen among those with a pressure ulcer were, in descending order, GP (77.9%), occupational therapist (44.9%) and nurse (40%). 2. 77.9% of participants with no pressure ulcers visited a GP as compared with 83.9% of participants with 1 pressure ulcer; this difference was significant (P=.005). 3. No significant difference in GP visits between those individuals with 1 pressure ulcer and those with 2 or more.
Milligan et al. 2018 Canada Cross-sectional Survey Level 5 N=14	Population: Primary care practitioners completed the survey: 3 GPs, 6 specialists, 5 inter-disciplinary health professionals. Purpose: To determine how important various elements of care are for patients with SCI. Treatment: No treatment. Outcome Measures: Each element of care is scored on a scale of 1 (lowest level of importance) to 9 (highest level of importance).	1. The elements with the highest importance scores (mean ± SD) were autonomic dysreflexia (8.56 ± 0.10) and pain (8.33 ± 0.19). 2. The elements with the lowest importance scores (mean ± SD) were social issues (7.01 ± 1.19) and vital signs (6.90 ± 0.78).
Macdonald et al. 2015 Canada Cross-sectional Survey and Interviews Level 5 N=28	Population: Family physician residents at the University of Waterloo were invited to participate – 28 completed the surveys, and 10 completed the follow-up interviews. Purpose: To evaluate the Caring for Persons with Spinal Cord Injury eLearning resource and answer the following research question: How effective are eLearning modules for meeting learning outcomes of family medicine resident physicians treating spinal cord injury? Treatment: No treatment. Outcome Measures: The resources consisted of the following six modules – Autonomic Dysreflexia; Neurogenic Bladder; Neurogenic Bowel; Pressure Ulcers; Respiratory Complications; Health Promotion and Maintenance.	1. The most common theme that emerged was that residents said the resource addressed an important topic omitted in medical school and they expect they will access the resource in the future. 2. Overall, all participants were pleased with the modules, and they found them to be authentic, relevant, and interactive. Scores for all the constructs were extremely high, with most responses being either ‘agree’ or ‘strongly agree’. The constructs of service, media and content had the highest responses. 3. Twelve out of 28 participants disagreed that the modules provided opportunities for problem-solving experiences and 11 out of 28 disagreed that the module provided opportunities to apply material learned. 4. Eight out of 28 participants indicated in the open-ended question regarding structure that problem-solving or case studies would be a useful addition to make the modules more interactive.
Hamilton et al. 2017 USA Cross-sectional survey Level 5 N=142	Population: People with SCI more than 12-months post-injury. Treatment: No treatment. Purpose: Determine which types of health care providers patients have visited in the last 12 months, the accessibility of the health care providers, as well as the participants’ satisfaction with the health care providers. Outcome Measures: 34-item questionnaire, in-person or over the phone.	1. 66% of participants believe that their primary care physician is “knowledgeable of their SCI needs” and 100% of respondents reported their SCI physiatrist was knowledgeable. 2. 55% of participants believe that their primary care physician is an effective communicator.
Evans et al. 2011 USA Cross-sectional Survey Level 5 N=118	Population: 118 VA clinicians; 80 primary care physicians, 20 nurse practitioners, 18 physician assistants. Purpose: To assess provider knowledge of infection control in SCI. Treatment: No treatment. Outcome Measures: Internet-based survey of antimicrobial prescribing and infections resistant to antimicrobials.	1. 77.1% aware antibiotic prescribing increased drug resistant infection. 2. 61.0% agreed patient demand a major reason for over-prescribing antibiotics. 3. 17.8% admit they over-prescribe antibiotics. 4. 75% agree with active surveillance for antibiotic resistant organisms. 5. 67.8% believed that reducing the use of a particular drug could reduce antibiotic resistance.
Fann et al. 2011 USA Cross-sectional Survey Level 5 N=947	Population: 947 participants with SCI; mean age 43.8, YPI 11.0. Purpose: Survey of depression and co-morbid psychological conditions. Treatment: No Treatment. Outcome Measures: Patient Health Questionnaire-9 (PHQ-9), Depression Scale, psychiatric history questionnaire, Cornell Service Index, current medication use.	1. Prevalence of major depression endorsed by 23%; suicidal ideation endorsed by 15%; high lifetime prevalence of psychiatric disorders, especially anxiety (60% among currently depressed, 28% among non-depressed). 2. 22% of depressed participants currently receiving treatment. 3. Only 11% of depressed participants receiving guideline-level therapy.
Weaver et al. 2011 USA Observational study Level 5 N=1210	Population: 1210 SCI/D respondents (4% F), 61% incomplete injury; 37% tetraplegia; mean age: 60.3; mean years YPI: 20.7. Purpose: Survey of smoking behavior among SCI veterans. Treatment: No treatment. Outcome Measures: Survey, medical records, smoking behavior and attitudes, readiness to quit, key informant interviews.	1. 22% were current smokers, 51% were past smokers and 27% never smoked. 2. Current smokers significantly more likely to have obesity, alcohol problems, COPD, asthma, shortness of breath, chronic cough, chest wheeze, depression (p<0.01). 3. 70% of current smokers reported more pain than the past smokers (p<0.01). 4. Smoking cessation strategies need to be encouraged by health care providers.
Ashe et al. 2009 Canada Observational (Survey) Level 5 N=22	Population: 22 physiatrists treating SCI patients. Treatment: No treatment. Purpose: To assess opinions about bone health and treatments among physiatrists. Outcome Measures: A survey assessing opinions and practice patterns relating to assessment, management, and treatment of bone health after SCI.	1. 86% of physiatrists considered bone health after SCI an important issue. 2. Most physiatrists reported that pharmacological treatments were most beneficial, whereas rehabilitation modalities had lower support for effectiveness.
van Loo et al. 2009 Netherlands Observational (Survey) Level 5 N = 453	Population: 453 participants with SCI. Mean age = 47.7; Male = 65.1%; Complete tetraplegia = 19.9%, Incomplete tetraplegia = 14.4%, Complete paraplegia = 46.3%, Incomplete paraplegia = 19.4%. Treatment: No treatment. Purpose of the study: To determine the care received for secondary condition and extra care needs, and to determine if the secondary conditions were preventable. Outcome Measures: Questionnaire inquiring about frequency of SCI-related contacts with professional caregivers during previous 12 months, secondary conditions and which conditions were perceived as most important, what kind of care they received, and how the condition could have been prevented.	1. 58% of contacts with family physician were related to secondary complications, 34% of which were preventable. 2. On average, participants mentioned 8 secondary conditions, and 3.9 most important secondary conditions, including: bladder and bowel regulation; pain; spasms, and sexuality and pressure sores. 3. 50% of the pressure sores, 25% of the bladder, bowel and sexuality problems could have been prevented according to the participants. 4. 72% indicated need for additional care due to secondary conditions. 5. For most important secondary conditions, 47% received care, and extra care in 41.3%.
Donnelly et al. 2007 Canada, US, & UK Observational (Survey) Level 5 N=373	Population: 373 people with SCI (315 male, 56 female); 127 Canadian [aged 55.9 (±10.7) years; 32.1(±8.4) years of SCI]; 162 British [aged 62 (±7.7) years; 39.2 (±5.5) years of SCI]; 84 Americans [aged 56.7(±8.9) years; 35.3 (±6.5) years of SCI]. Treatment: No treatment. Purpose: 1) To describe utilization, accessibility, and satisfaction with primary and preventative health care services by individuals with long term SCI. 2) To compare results across Canada, US, and UK. Outcome Measures: 46-item measure [compilation of Health Care Questionnaire (HCQ) and Patient Satisfaction with Health Care Provider Scale (PSHCPS)] surveying utilization, access, and satisfaction with primary and preventative health care services.	1. Issues of sexual health, alcohol use, community functioning, and emotional health were not addressed by either FD or SIS for > 70% of participants. 2. The highest utilization of FD was for pain (86%, p<0.05) and fatigue (84%, p<0.05); The highest utilization of SIS was for routine rehab follow-up (91%, p<0.05).
Gontkovsky et al. 2007 USA Observational (Survey) Level 5 N=82	Population: Chronic SCI, community dwelling, 1-13 years post injury, mean age 42±14 years. Treatment: No treatment. Purpose: To examine the perceived information needs of individuals with chronic SCI and determine the factors that influence these needs. Outcome Measures: A questionnaire assessing issues of access to health and healthcare information needs (23 domains) since inpatient discharge.	1. Information needs most endorsed were: Aging (73%), SCI Research Information (66%) and SCI Educational Information (63%). 2. ≥16% of the sample reported information needs in all 23 domains. 3. Six domains were endorsed by at least half of the participants, and 15 domains were endorsed by at least one-third of the sample. 4. Ethnic minority participants endorsed significantly more information needs.
Collins et al. 2005 USA Observational (Survey) Level 5 N=853	Population: 853 veterans with SCI. Treatment: No treatment. Purpose: to assess patient satisfaction with the annual comprehensive preventative health evaluation (CPHE). Outcome Measures: 21 item questionnaire about the satisfaction with CPHE content, whether needs were met, what respondents valued about the examination and health concerns they would like to see addressed. Answers were dichotomized for analysis purposes.	1. 76% of survey respondents had completed the CPHE within the previous year. 2. Top two reasons for completing the CPHE was to get medication and supplies refilled and talking to doctors. 3. Topics discussed during the CPHE were muscle strength and weakness, bladder care, chronic pain, digestion and bowel care issues, and equipment problems. 4. Completion of CPHE was related to other health care utilization and having health needs met.
Aulagnier et al. 2005 France Observational (Survey) Level 5 N=600	Population: 600 GPs in southeastern France. Purpose: to study GP characteristics, attitudes, and opinions towards people with disabilities and their knowledge and practices in this field. Treatment: No treatment. Outcome Measures: Cross-sectional survey.	1. 21.3% of the GP reported discomfort in treating people with mental impairments and 8.2% people with physical impairments. Discomfort with either type of impairment was more frequent among GPs who perceived frequent communication problems with persons with disabilities (p<0.05) or who did not belong to a professional network (p<0.10). 2. GPs who reported less experience with the disabled patients (p<0.05), no medical training about disabilities (p= 0.04), a lack of assistance during consultations (p = 0.02), and inadequate consultation time (p= 0.09) expressed more discomfort in caring for patients with mental impairments. GPs’ discomfort was associated with their assessment of the patient’s level of disability among patients with physical impairments (p = 0.01).
Vaidyanathan et al. 2001 UK Observational (Survey) Level 5 N=128	Population: SCI patients attending a follow up clinic in a Regional Spinal Injuries Centre. Treatment: No treatment. Purpose: To collect information on desire to receive written information about changes in their condition and whether this information would cause needless anxiety to patients and or their relatives/careers. Outcome Measures: 28 item yes/no survey.	1. 106 (83%) patients wished to receive written information. 2. 115 (90%) preferred to receive a copy of their MRI with interpretation and felt it would be valuable to show their primary care provider. 3. 122 (95%) did not feel that written information would cause needless anxiety. 4. 109 (93%) wished to receive written information about changes in their medical condition after readmission to the spinal unit.
Oshima et al. 1998 USA Observational (Survey) Level 5 N=44	Population: 30 Internal Medicine (IM) students (2^nd(57%) and 3^rd (43%) year of residency training) and 14 Ob/Gyn students (2^nd(14%),3^rd(43%) and 4^th (43%) year). Treatment: No treatment. Purpose: To assess knowledge base and comfort level of potential physicians when treating women with SCI. Outcome Measures: A hypothetical case scenario of a pregnant woman with tetraplegia was presented. Students were asked how they would conduct an examination, deal with her spasticity and how they would assist her to the exam table. They were also asked to record their comfort level in managing the patient.	1. 75% of IM residents and 67% of Ob/Gyn indicated that they would conduct a pelvic examination. 2. 53% of IM and 64% of Ob/Gyn said they would use staff to lift her on the table. 40% of IM said they did not have resources/knowledge, 21% of Ob/Gyn reported access to an electric table. 3. 17% of IM and 14% of Ob/Gyn said they did not know how to manage spasticity. 4. 36% of Ob/Gyn students expressed concern about spasticity as a complication. 5. 30% of IM students said they would consult obstetrics and 36% of Ob/Gyn said they would refer her to ‘high risk’ obstetrics; 43% would also refer her to physiatry. 6. Most Ob/Gyn students reported their comfort level as neutral for this case while IM students reported as uncomfortable.
Glickman et al. 1996 England Observational (Survey) Level 5 N=139	Population: 139 General Practitioners (GPs) with SCI patients. Treatment: No treatment. Purpose: To examine the workload and common problems facing primary care teams in SCI management. Outcome Measures: Mailed survey inquiring about annual number of consultations with the patient regarding gastrointestinal, urological and dermatological problems, and the magnitude of pain and spasticity.	1. 78.5% of the patients had multiple problems; 11.5% had 0 problems, 10.1% had 1 problem. 2. 72% had urological problems; 49.6% had colonic issues; 41.7% had dermatological problems; 65.5% had spasticity; and 55.4% had pain. 3. 53.9% of the GPs offered services to change urethral catheters; 15.8% were able to change suprapubic catheters; and 29.5% offered psychological or social counselling.
Warms 1987 USA Observational (Survey) Level 5 N=59	Population: 59 adult (53 males; 5 females) patients with SCI, at least two years post-injury. Age range 21-60. 29 cervical injury; 24 thoracic injury; 6 lumbar or sacral injury. Treatment: No treatment. Purpose: To survey the source and content of health care received by individuals with spinal cord injury and to describe what healthcare services are desired. Outcome Measures: A self-reported survey assessing source of health care, content of care, and healthcare services desired, but not obtained.	1. 52.9% reported discussing bladder or kidney problems, 47.1% reported discussing pressure sore prevention, and 23% reported discussing spasticity, and 23% discussed bowel issues. 2. 80% of issues raised were disability-related. 3. Unmet needs for health promotion services, fitness, and diet counselling.
Norman et al. 2010 Canada Qualitative N=12	Population: 12 patients (58% F), mean age 52, mean YPI 16.9. Purpose: To explore information needs regarding chronic pain. Treatment: No treatment. Outcome Measures: Qualitative interviews; Brief Pain Inventory (BPI-SF), Short Form McGill Pain Questionnaire (MPQ-SF).	1. Majority of participants not satisfied with information received from family physician. 2. Two themes warrant further research: ‘nobody knows’ – physicians, nurses, family, friends don’t understand chronic pain experience; ‘desire to educate others’ about SCI-related chronic pain.
Schladen et al. 2011 USA Qualitative N=3	Population: 3 SCI participants with (1 F), 2 paraplegia, 1 tetraplegia. Treatment: No treatment. Outcome Measures: Semi-structured interviews on diet management, pressure relief, cardiometabolic disease screening and preventive care, consumer interest. Number of hits counted for SCI-focused media over YouTube.	1. During the 30-day period viewing period, the 10 videos on YouTube logged 6,136 views. 2. Need for timely transfer of knowledge and information among providers with a lack of understanding of special circumstances of people with SCI. 3. Need for up-to-date evidence-based knowledge to effectively manage health. 4. YouTube has the potential to be a useful tool for exploring the interests of the SCI consumer community.

Author Year; Country
Score
Research Design
Total Sample Size

Methods

Outcome

McDermott et al. 2005

USA

Case Control

Level 3

N=3636 (1552 with disability, 35 SCI)

Population: 35 SCI (8 female, 12 with paraplegia, 23 with tetraplegia).

Treatment: No treatment.

Purpose: Computerized medical records from rural and urban primary care settings from 1990 to 2003 and companion paper records were reviewed.

Outcome Measures: Determine the rate of depression among individuals with disabilities, comparing both within the disability group (e.g., different diagnosis) and to the control group.

1. Patients with disabilities have significantly higher rates of depression (p=0.019).

2. 28.6% of people with SCI were found to be depressed.

3. Patients with trauma (SCI and TBI) had significantly earlier onset of depression compared to controls (p=0.0007).

4. By age 50, 16-17% of patients with trauma had depression.

5. By age 60, 45% of patients with trauma had depression compared to 18% of controls.

Evans et al. 2010

USA

Retrospective Cohort

Level 3

N=1277

Population: 1277 veterans with SCI with acute respiratory infection (ARI); 57.1% paraplegia, 64.3% incomplete injury, mean age 59.1, mean YPI 20.3 yrs.

Purpose: follow-up survey of 2006 study of SCI outpatients.

Treatment: new antibiotic prescription within 3 days of ARI.

Outcome Measures: Survey on long term outcome of traumatic SCI, health-care utilization, subsequent outpatient visit or hospitalization.

1. 53.2% of patients with ARI were prescribed an antibiotic.

2. 47.0% had subsequent outpatient visit within 30 days.

3. No significant difference in health care utilization for those prescribed antibiotic.

4. Patients without chronic respiratory condition were fine without additional antibiotic prescription.

Patel et al. 2017

Canada

Retrospective Cohort

Level 3

N=19

Population: Patients with SCI presented in an interprofessional primary care mobility clinic.

Purpose: To determine how frequently different secondary health conditions SCI patients present with in a primary care clinic and the patients’ most common complaints.

Treatment: No treatment.

Outcome Measures: Frequency of patients who presented with a certain medical condition or had a certain complaint.

1. The most frequent secondary health conditions are depression/anxiety (37%), osteoporosis/osteopenia (26%) and hypertension (21%).

2. The most common referral for people with SCI present were pain (23%) or bowel/bladder issues (13%) or erectile dysfunction (10%).

McColl et al. 2015

Canada and Australia

Pre-post

Level 4

N=125

Population: 49 primary care physicians.

Purpose: To determine whether sending weekly ‘Actionable Nuggets’ (short messages related primary care for SCI patients) to physicians improve their knowledge of SCI treatment.

Treatment: No treatment.

Outcome Measures: Self-rated physician knowledge of SCI primary care, usefulness and acceptability of ‘Actionable Nuggets’.

1. Primary care physicians identified the top five most important issues associated with SCI to be: bladder care, skin care, office accessibility and bowel care.

2. Areas that they were most knowledgeable were the areas of depression, cardiac disease and pain. Areas they were least knowledgeable were autonomic dysreflexia, office accessibility, skin breakdown and sexual and reproductive health.

3. After 20 weeks of sending weekly SCI ‘Actionable Nuggets’, self-rated physician knowledge went from 58% to 75%.

4. 53% of physicians have stated that they have changed their practice after receiving ‘Actionable Nuggets’.

Smith et al. 2014

Canada

Pre-post

Level 4

N=49

Population: 49 family physicians.

Purpose: To determine physicians’ satisfaction with the ‘Actionable Nuggets’ (short messages related to primary care for SCI patients).

Treatments: No treatment.

Outcome Measures: Survey asking physicians on the effects of the ‘Actionable Nuggets’.

1. 15% of participants stated that their practice is or will be changed or improved because of the ‘Actionable Nuggets’.

2. 57% of participants stated that they learned something new because of the ‘Actionable Nuggets’.

3. Top 5 module topics that were completed included: epidemiology of SCI, screening for cardiovascular disease risk, autonomic dysreflexia, pharmacological management of neuropathic pain in SCI and management of musculoskeletal pain.

Goetz et al. 2005

USA

Pre-post

Level 4

N=4432

Population: 4432 participants (3% F); age: 47-69 yrs.

Treatment: Targeted dissemination & implementation of neurogenic bowel Clinical Practice Guideline.

Purpose: to determine whether adherence to clinical guidelines could be improved through a targeted implementation strategy.

Outcome Measures: Adherence to CPG before implementation (T1), after publication (T2) and after dissemination and implementation strategies (T3).

1. Overall adherence to recommendations did not change between T1 and T2.

2. Statistically significant increase in adherence for 3 of 6 recommendations from T2 to T3 (p<0.001).

3. Publication alone did not alter adherence, targeted implementation increased adherence for 3 of 6 recommendations.

Lofters et al. 2018

Canada

Retrospective chart review and Cross-sectional Survey

Level 5

N=125

Population: 60 patients included in the chart review and 15 physicians in the survey from 6 interprofessional primary care practices in Ontario.

Purpose: To determine the preventative care methods physicians use as well as determining physicians’ comfort level in dealing with patients with SCI.

Treatment: No treatment.

Outcome Measures: Survey measuring physicians’ comfort level dealing with SCI patients.

1. 27.3% of physicians were at least somewhat comfortable with managing autonomic dysreflexia, however 100% were comfortable managing blood pressure.

2. Physician comfort level was also low when dealing with SCI patients with spasticity and respiratory issues.

Liu et al. 2018

China

Cross-sectional Survey

Level 5

N=125

Population: 125 Chinese SCI physicians who attended annual workshops two years in a row.

Purpose: To determine SCI physicians’ knowledge of the Spinal Cord Independence Measure (SCIM) and how it could be used for more applications.

Treatment: No treatment.

Outcome Measures:10-item survey determining a physician’s use and knowledge of SCIM.

1. 29.6% (n=37) physicians were aware of the SCIM.

2. 20.8% of physicians had used the SCIM.

3. 74.4% of physicians believe they needed formal training before they use the SCIM.

Lala et al. 2014

Canada

Cross-sectional Survey

Level 5

N=1137

Population: 1137 traumatic SCI patients >1 year post injury, 33.5% of patients had pressure ulcers.

Purpose: To determine the effects of pressure ulcers on patients’ participation in everyday activities as well as health utilization patterns in those with a pressure ulcer.

Treatment: No treatment.

Outcome Measures: Survey determining the type and extent of participation in everyday activities and percentage of patients that have visited various health services.

1. The three most common health professionals seen among those with a pressure ulcer were, in descending order, GP (77.9%), occupational therapist (44.9%) and nurse (40%).

2. 77.9% of participants with no pressure ulcers visited a GP as compared with 83.9% of participants with 1 pressure ulcer; this difference was significant (P=.005).

3. No significant difference in GP visits between those individuals with 1 pressure ulcer and those with 2 or more.

Milligan et al. 2018

Canada

Cross-sectional Survey

Level 5

N=14

Population: Primary care practitioners completed the survey: 3 GPs, 6 specialists, 5 inter-disciplinary health professionals.

Purpose: To determine how important various elements of care are for patients with SCI.

Treatment: No treatment.

Outcome Measures: Each element of care is scored on a scale of 1 (lowest level of importance) to 9 (highest level of importance).

1. The elements with the highest importance scores (mean ± SD) were autonomic dysreflexia (8.56 ± 0.10) and pain (8.33 ± 0.19).

2. The elements with the lowest importance scores (mean ± SD) were social issues (7.01 ± 1.19) and vital signs (6.90 ± 0.78).

Macdonald et al. 2015

Canada

Cross-sectional Survey and Interviews

Level 5

N=28

Population: Family physician residents at the University of Waterloo were invited to participate – 28 completed the surveys, and 10 completed the follow-up interviews.

Purpose: To evaluate the Caring for Persons with Spinal Cord Injury eLearning resource and answer the following research question: How effective are eLearning modules for meeting learning outcomes of family medicine resident physicians treating spinal cord injury?

Treatment: No treatment.

Outcome Measures: The resources consisted of the following six modules – Autonomic Dysreflexia; Neurogenic Bladder; Neurogenic Bowel; Pressure Ulcers; Respiratory Complications; Health Promotion and Maintenance.

1. The most common theme that emerged was that residents said the resource addressed an important topic omitted in medical school and they expect they will access the resource in the future.

2. Overall, all participants were pleased with the modules, and they found them to be authentic, relevant, and interactive. Scores for all the constructs were extremely high, with most responses being either ‘agree’ or ‘strongly agree’. The constructs of service, media and content had the highest responses.

3. Twelve out of 28 participants disagreed that the modules provided opportunities for problem-solving experiences and 11 out of 28 disagreed that the module provided opportunities to apply material learned.

4. Eight out of 28 participants indicated in the open-ended question regarding structure that problem-solving or case studies would be a useful addition to make the modules more interactive.

Hamilton et al. 2017

USA

Cross-sectional survey

Level 5

N=142

Population: People with SCI more than 12-months post-injury.

Treatment: No treatment.

Purpose: Determine which types of health care providers patients have visited in the last 12 months, the accessibility of the health care providers, as well as the participants’ satisfaction with the health care providers.

Outcome Measures: 34-item questionnaire, in-person or over the phone.

1. 66% of participants believe that their primary care physician is “knowledgeable of their SCI needs” and 100% of respondents reported their SCI physiatrist was knowledgeable.

2. 55% of participants believe that their primary care physician is an effective communicator.

Evans et al. 2011

USA

Cross-sectional Survey

Level 5

N=118

Population: 118 VA clinicians; 80 primary care physicians, 20 nurse practitioners, 18 physician assistants.

Purpose: To assess provider knowledge of infection control in SCI.

Treatment: No treatment.

Outcome Measures: Internet-based survey of antimicrobial prescribing and infections resistant to antimicrobials.

1. 77.1% aware antibiotic prescribing increased drug resistant infection.

2. 61.0% agreed patient demand a major reason for over-prescribing antibiotics.

3. 17.8% admit they over-prescribe antibiotics.

4. 75% agree with active surveillance for antibiotic resistant organisms.

5. 67.8% believed that reducing the use of a particular drug could reduce antibiotic resistance.

Fann et al. 2011

USA

Cross-sectional Survey

Level 5

N=947

Population: 947 participants with SCI; mean age 43.8, YPI 11.0.

Purpose: Survey of depression and co-morbid psychological conditions.

Treatment: No Treatment.

Outcome Measures: Patient Health Questionnaire-9 (PHQ-9), Depression Scale, psychiatric history questionnaire, Cornell Service Index, current medication use.

1. Prevalence of major depression endorsed by 23%; suicidal ideation endorsed by 15%; high lifetime prevalence of psychiatric disorders, especially anxiety (60% among currently depressed, 28% among non-depressed).

2. 22% of depressed participants currently receiving treatment.

3. Only 11% of depressed participants receiving guideline-level therapy.

Weaver et al. 2011

USA

Observational study

Level 5

N=1210

Population: 1210 SCI/D respondents (4% F), 61% incomplete injury; 37% tetraplegia; mean age: 60.3; mean years YPI: 20.7.

Purpose: Survey of smoking behavior among SCI veterans.

Treatment: No treatment.

Outcome Measures: Survey, medical records, smoking behavior and attitudes, readiness to quit, key informant interviews.

1. 22% were current smokers, 51% were past smokers and 27% never smoked.

2. Current smokers significantly more likely to have obesity, alcohol problems, COPD, asthma, shortness of breath, chronic cough, chest wheeze, depression (p<0.01).

3. 70% of current smokers reported more pain than the past smokers (p<0.01).

4. Smoking cessation strategies need to be encouraged by health care providers.

Ashe et al. 2009

Canada

Observational (Survey)

Level 5

N=22

Population: 22 physiatrists treating SCI patients.

Treatment: No treatment.

Purpose: To assess opinions about bone health and treatments among physiatrists.

Outcome Measures: A survey assessing opinions and practice patterns relating to assessment, management, and treatment of bone health after SCI.

1. 86% of physiatrists considered bone health after SCI an important issue.

2. Most physiatrists reported that pharmacological treatments were most beneficial, whereas rehabilitation modalities had lower support for effectiveness.

van Loo et al. 2009

Netherlands

Observational (Survey)

Level 5

N = 453

Population: 453 participants with SCI. Mean age = 47.7; Male = 65.1%; Complete tetraplegia = 19.9%, Incomplete tetraplegia = 14.4%, Complete paraplegia = 46.3%, Incomplete paraplegia = 19.4%.

Treatment: No treatment.

Purpose of the study: To determine the care received for secondary condition and extra care needs, and to determine if the secondary conditions were preventable.

Outcome Measures: Questionnaire inquiring about frequency of SCI-related contacts with professional caregivers during previous 12 months, secondary conditions and which conditions were perceived as most important, what kind of care they received, and how the condition could have been prevented.

1. 58% of contacts with family physician were related to secondary complications, 34% of which were preventable.

2. On average, participants mentioned 8 secondary conditions, and 3.9 most important secondary conditions, including: bladder and bowel regulation; pain; spasms, and sexuality and pressure sores.

3. 50% of the pressure sores, 25% of the bladder, bowel and sexuality problems could have been prevented according to the participants.

4. 72% indicated need for additional care due to secondary conditions.

5. For most important secondary conditions, 47% received care, and extra care in 41.3%.

Donnelly et al. 2007

Canada, US, & UK

Observational (Survey)

Level 5

N=373

Population: 373 people with SCI (315 male, 56 female); 127 Canadian [aged 55.9 (±10.7) years; 32.1(±8.4) years of SCI]; 162 British [aged 62 (±7.7) years; 39.2 (±5.5) years of SCI]; 84 Americans [aged 56.7(±8.9) years; 35.3 (±6.5) years of SCI].

Treatment: No treatment.

Purpose: 1) To describe utilization, accessibility, and satisfaction with primary and preventative health care services by individuals with long term SCI.

2) To compare results across Canada, US, and UK.

Outcome Measures: 46-item measure [compilation of Health Care Questionnaire (HCQ) and Patient Satisfaction with Health Care Provider Scale (PSHCPS)] surveying utilization, access, and satisfaction with primary and preventative health care services.

1. Issues of sexual health, alcohol use, community functioning, and emotional health were not addressed by either FD or SIS for > 70% of participants.

2. The highest utilization of FD was for pain (86%, p<0.05) and fatigue (84%, p<0.05); The highest utilization of SIS was for routine rehab follow-up (91%, p<0.05).

Gontkovsky et al. 2007

USA

Observational (Survey)

Level 5

N=82

Population: Chronic SCI, community dwelling, 1-13 years post injury, mean age 42±14 years.

Treatment: No treatment.

Purpose: To examine the perceived information needs of individuals with chronic SCI and determine the factors that influence these needs.

Outcome Measures: A questionnaire assessing issues of access to health and healthcare information needs (23 domains) since inpatient discharge.

1. Information needs most endorsed were: Aging (73%), SCI Research Information (66%) and SCI Educational Information (63%).

2. ≥16% of the sample reported information needs in all 23 domains.

3. Six domains were endorsed by at least half of the participants, and 15 domains were endorsed by at least one-third of the sample.

4. Ethnic minority participants endorsed significantly more information needs.

Collins et al. 2005

USA

Observational (Survey)

Level 5

N=853

Population: 853 veterans with SCI.

Treatment: No treatment.

Purpose: to assess patient satisfaction with the annual comprehensive preventative health evaluation (CPHE).

Outcome Measures: 21 item questionnaire about the satisfaction with CPHE content, whether needs were met, what respondents valued about the examination and health concerns they would like to see addressed. Answers were dichotomized for analysis purposes.

1. 76% of survey respondents had completed the CPHE within the previous year.

2. Top two reasons for completing the CPHE was to get medication and supplies refilled and talking to doctors.

3. Topics discussed during the CPHE were muscle strength and weakness, bladder care, chronic pain, digestion and bowel care issues, and equipment problems.

4. Completion of CPHE was related to other health care utilization and having health needs met.

Aulagnier et al. 2005

France

Observational (Survey)

Level 5

N=600

Population: 600 GPs in southeastern France.

Purpose: to study GP characteristics, attitudes, and opinions towards people with disabilities and their knowledge and practices in this field.

Treatment: No treatment.

Outcome Measures: Cross-sectional survey.

1. 21.3% of the GP reported discomfort in treating people with mental impairments and 8.2% people with physical impairments. Discomfort with either type of impairment was more frequent among GPs who perceived frequent communication problems with persons with disabilities (p<0.05) or who did not belong to a professional network (p<0.10).

2. GPs who reported less experience with the disabled patients (p<0.05), no medical training about disabilities (p= 0.04), a lack of assistance during consultations (p = 0.02), and inadequate consultation time (p= 0.09) expressed more discomfort in caring for patients with mental impairments. GPs’ discomfort was associated with their assessment of the patient’s level of disability among patients with physical impairments (p = 0.01).

Vaidyanathan et al. 2001

Observational (Survey)

Level 5

N=128

Population: SCI patients attending a follow up clinic in a Regional Spinal Injuries Centre.

Treatment: No treatment.

Purpose: To collect information on desire to receive written information about changes in their condition and whether this information would cause needless anxiety to patients and or their relatives/careers.

Outcome Measures: 28 item yes/no survey.

1. 106 (83%) patients wished to receive written information.

2. 115 (90%) preferred to receive a copy of their MRI with interpretation and felt it would be valuable to show their primary care provider.

3. 122 (95%) did not feel that written information would cause needless anxiety.

4. 109 (93%) wished to receive written information about changes in their medical condition after readmission to the spinal unit.

Oshima et al. 1998

USA

Observational (Survey)

Level 5

N=44

Population: 30 Internal Medicine (IM) students (2^nd(57%) and 3^rd (43%) year of residency training) and 14 Ob/Gyn students (2^nd(14%),3^rd(43%) and 4^th (43%) year).

Treatment: No treatment.

Purpose: To assess knowledge base and comfort level of potential physicians when treating women with SCI.

Outcome Measures: A hypothetical case scenario of a pregnant woman with tetraplegia was presented. Students were asked how they would conduct an examination, deal with her spasticity and how they would assist her to the exam table. They were also asked to record their comfort level in managing the patient.

1. 75% of IM residents and 67% of Ob/Gyn indicated that they would conduct a pelvic examination.

2. 53% of IM and 64% of Ob/Gyn said they would use staff to lift her on the table. 40% of IM said they did not have resources/knowledge, 21% of Ob/Gyn reported access to an electric table.

3. 17% of IM and 14% of Ob/Gyn said they did not know how to manage spasticity.

4. 36% of Ob/Gyn students expressed concern about spasticity as a complication.

5. 30% of IM students said they would consult obstetrics and 36% of Ob/Gyn said they would refer her to ‘high risk’ obstetrics; 43% would also refer her to physiatry.

6. Most Ob/Gyn students reported their comfort level as neutral for this case while IM students reported as uncomfortable.

Glickman et al. 1996

England

Observational (Survey)

Level 5

N=139

Population: 139 General Practitioners (GPs) with SCI patients.

Treatment: No treatment.

Purpose: To examine the workload and common problems facing primary care teams in SCI management.

Outcome Measures: Mailed survey inquiring about annual number of consultations with the patient regarding gastrointestinal, urological and dermatological problems, and the magnitude of pain and spasticity.

1. 78.5% of the patients had multiple problems; 11.5% had 0 problems, 10.1% had 1 problem.

2. 72% had urological problems; 49.6% had colonic issues; 41.7% had dermatological problems; 65.5% had spasticity; and 55.4% had pain.

3. 53.9% of the GPs offered services to change urethral catheters; 15.8% were able to change suprapubic catheters; and 29.5% offered psychological or social counselling.

Warms 1987

USA

Observational (Survey)

Level 5

N=59

Population: 59 adult (53 males; 5 females) patients with SCI, at least two years post-injury. Age range 21-60. 29 cervical injury; 24 thoracic injury; 6 lumbar or sacral injury.

Treatment: No treatment.

Purpose: To survey the source and content of health care received by individuals with spinal cord injury and to describe what healthcare services are desired.

Outcome Measures: A self-reported survey assessing source of health care, content of care, and healthcare services desired, but not obtained.

1. 52.9% reported discussing bladder or kidney problems, 47.1% reported discussing pressure sore prevention, and 23% reported discussing spasticity, and 23% discussed bowel issues.

2. 80% of issues raised were disability-related.

3. Unmet needs for health promotion services, fitness, and diet counselling.

Norman et al. 2010

Canada

Qualitative

N=12

Population: 12 patients (58% F), mean age 52, mean YPI 16.9.

Purpose: To explore information needs regarding chronic pain.

Treatment: No treatment.

Outcome Measures: Qualitative interviews; Brief Pain Inventory (BPI-SF), Short Form McGill Pain Questionnaire (MPQ-SF).

1. Majority of participants not satisfied with information received from family physician.

2. Two themes warrant further research: ‘nobody knows’ – physicians, nurses, family, friends don’t understand chronic pain experience; ‘desire to educate others’ about SCI-related chronic pain.

Schladen et al. 2011

USA

Qualitative

N=3

Population: 3 SCI participants with (1 F), 2 paraplegia, 1 tetraplegia.

Treatment: No treatment.

Outcome Measures: Semi-structured interviews on diet management, pressure relief, cardiometabolic disease screening and preventive care, consumer interest. Number of hits counted for SCI-focused media over YouTube.

1. During the 30-day period viewing period, the 10 videos on YouTube logged 6,136 views.

2. Need for timely transfer of knowledge and information among providers with a lack of understanding of special circumstances of people with SCI.

3. Need for up-to-date evidence-based knowledge to effectively manage health.

4. YouTube has the potential to be a useful tool for exploring the interests of the SCI consumer community.

Discussion

There is consensus in the literature about the issues that are of most concern to people with spinal cord injuries when they seek primary care. Fifty-eight percent (58%) of contacts with the family physician were related to secondary complications (van Loo et al. 2009). Most consistently mentioned were bowel and bladder problems and pain (Donnelly et al. 2007; Collins et al. 2005; Glickman et al. 1996; Warms 1987; Williams 2005). Eighty percent (80%) of SCI patients in primary care bring multiple problems to their family physician (Glickman et al. 1996), and according to Warms (1987), 80% of the issues raised are disability-related.

Both Collins et al. (2005) and Beatty et al. (2003) refer to the need for adaptive equipment and prescription medications as concerns in primary care. Collins et al. (2005) notes that these are key reasons why individuals seek an annual check-up. Beatty et al. (2003) notes that 94% of patients with SCI have needs for prescription medications, and 69% for adaptive equipment. In both instances, the primary care physician is the coordinator for these needs. They also found that 93% of prescription medication needs and 69% of equipment needs were met.

Ashe et al. (2009) provide support for the importance of bone density, and the need for pharmacological treatment if indicated. Two articles highlighted the need for attention to skin care and spasticity. Glickman et al. (1996) claim that 42% of patients have dermatological issues and 65% need help with the management of spasticity. van Loo’s sample in the Netherlands (2009) demonstrated that 34% of all secondary complications were preventable, especially skin complications, which were judged to be 53% preventable.

Unfortunately, there are a number of issues where unmet needs have been observed in primary care. Donnelly et al. (2007) noted that issues of psychological health, sexual and reproductive health, lifestyle and community not be well covered by primary care, whether it came from a family physician or physiatrist. McDermott et al. (2005) noted that depression is significantly higher among people with disabilities, and that it has a significantly earlier onset when the disability is of a traumatic origin. Warms (1987) also found unmet needs for health promotion and lifestyle issues.

One frequently overlooked area of primary care for people with spinal cord injuries is the area of sexual and reproductive health. Oshima et al. (1998) note that physicians are typically not prepared for the special issues associated with the gynaecological or obstetric needs of women with spinal cord injuries, or of the procedures necessary to provide them with a reasonable standard of primary care.

Several studies referred to the information needs of people with spinal cord injuries in primary care. Vaidyanathan et al. (2001) found unequivocally that patients wanted clear information about their health, preferably in written form. They wanted information shared among health providers as well as with themselves. Gontkovsky et al. (2007) also identified information needs in a spinal cord injured population, especially information about aging, current research and other educational offerings. Ethnic minorities in particular had a difficult time having their information needs met.

Fann et al. (2011) substantiated previous findings about high prevalence of psychiatric conditions among people with SCI, and found that only a small percentage (11%) were given treatment consistent with clinical guidelines. The importance of treatment for psychiatric conditions is highlighted by Findley et al. (2011) who found that mental illness and substance abuse disorders are associated with excess mortality.

Information needs continued to be an issue for people with SCI. Norman et al. (2010) found that participants depended on family physicians as an important source of information on the management of chronic pain, and were frequently unsatisfied, and felt “alone with their pain”. Family physicians were an important source of health information post discharge according to a cohort of individuals followed by Thietje et al. (2011). Only 47% of this cohort, however, had good knowledge about skin and bladder care at discharge from rehabilitation, and the level of knowledge did not improve up to 2½ years post-discharge. Those particularly at risk due to poor information were those over 65 years of age, and those with lower education. Weaver et al. (2011) looked at smoking and found 22% of their sample were currently smokers. Smoking was shown to exacerbate a number of important health conditions among people with SCI, including chronic pain, respiratory conditions and depression. Family physicians were seen as an important source of information about health risks and smoking cessation strategies.

Two articles by the same group of authors examined prescription of antibiotics for acute respiratory infections among people with SCI. The first study (Evans et al. 2010) showed that in uncomplicated acute cases, antibiotic use did not change subsequent health service utilization (ED visits or hospital admissions) following a visit with an acute respiratory infection. The second study (Evans et al. 2011) offered the perspective of family physicians, the majority of whom recognized the risks of over-prescribing antibiotics and were in favour of surveillance strategies and efforts to reduce the use of antibiotics.

Conclusions

There is level 2 evidence that patient knowledge of two key health risks (skin and bladder management) is poor at the point of discharge from rehabilitation (Thietje et al. 2011).

There is level 3 evidence that depression rates are higher and onset is earlier among individuals with disabilities, especially traumatic-onset disabilities, such as SCI, compared to controls (McDermott et al. 2005).

There is level 4 evidence that antibiotic prescription does not significantly affect subsequent health service use among acute uncomplicated cases of respiratory infection (Evans et al. 2010).

There is Level 5 evidence that veterans with mental illness and substance abuse issues are at increased risk of mortality (Findley al. 2011).

There is level 5 evidence that relatively few confirmed cases of depression are receiving guideline-level treatment (Fann et al. 2011).

There is Level 5 evidence that physicians are aware that antibiotic prescription must be carefully monitored to avoid antibiotic resistance (Evans et al. 2011).

There is level 5 evidence that 80% of issues raised by patients with SCI in primary care are disability-related (Warms 1987).

There is level 5 evidence that 52% of contact with GPs was regarding secondary complications; 34% of secondary complications are believed to be preventable; 72% of people with SCI report an unmet need for health care related to secondary health conditions (van Loo et al. 2009).

There is level 5 evidence that physiatrists consider bone health after SCI as an important issue and that they favour pharmacological treatment (Ashe et al. 2009).

There is level 5 evidence that the majority of medical residents are not comfortable treating a woman with tetraplegia who has recently become pregnant (Oshima et al. 1998).

There is level 5 evidence that individuals with chronic SCI would like more information regarding SCI and health risks. Needs for lifestyle and emotional issues often go unmet (Donnelly et al. 2007).

There is level 5 evidence that health promotion and counselling needs, including smoking cessation, are typically unmet (Warms 1987; Weaver et al .2011).

There is level 5 evidence that information about chronic pain and pain management strategies is insufficient (Norman et al. 2010).

There is level 5 evidence that ethnic minorities had the greatest unmet needs for information (Gontkovsky et al. 2007).

There is level 5 evidence that individuals with chronic SCI would like more information regarding aging with SCI, SCI research, and SCI educational information; ethnic minorities had the greatest unmet needs for information (Gontkovsky et al . 2007).

There is level 5 evidence that 90% of individuals with SCI would like to receive written information about their condition following a medical checkup (Vaidyanathan et al. 2001).

Individuals with SCI consistently raise common health issues in primary care. The most commonly raised issues are bowel, bladder and pain. Also of significant concern are skin care, equipment, medication needs, depression and bone density.

The majority of issues raised in primary care are disability-related; specifically, they are secondary complications of the SCI.

Unmet needs in primary care pertain primarily to information needs, psychological issues, sexual and reproductive health, health promotion and lifestyle.