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 3 summarizes the health issues and information needs of individuals with SCI when they seek primary care.

Table 3: Health issues of key importance

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 2005; Glickman 1996; Warms 1987; Williams 2005).  Eighty percent (80%) of SCI patients in primary care bring multiple problems to their family physician (Glickman 1996), and according to Warms (1987), 80% of the issues raised in the typical family medicine encounter are disability-related.

Both Collins (2005) and Beatty (2003) refer to the need for adaptive equipment and prescription medications as concerns in primary care.  Collins (2005) notes that these are key reasons why individuals seek an annual check-up.  Beatty (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 and associates (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 and associates (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 and colleagues (2007) noted that there are issues that appear not be well covered by primary care, whether it came from a family physician or physiatrist – specifically issues of psychological health, sexual and reproductive health, lifestyle and community functioning.  McDermott and colleagues (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 and colleagues (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. 

Finally, several studies referred to the information needs of people with spinal cord injuries in primary care.  Vaidyanathan and colleagues (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 and colleagues (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. 

Conclusions

• 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 5 evidence that 52% of contact with GP’s was regarding secondary complications; 34% of secondary complications are believed to be preventable; 72% report an unmet need for health care, particularly rehabilitation services (van Loo et al. 2009)
• There is level 5 evidence that physiatrists consider bone health after SCI is an important issue, and favour treatment pharmacologically over rehabilitation (Ashe et al. 2009).
• 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).
• There is level 5 evidence that 80% of issues raised by patients with SCI in primary care are disability-related; health promotion and counseling needs typically unmet (Warms 1987).
• There is level 5 evidence that needs for lifestyle and emotional issues often go unmet (Donnelly et al. 2007).
• There is level 5 evidence that the majority medical residents are not comfortable treating a women with tetraplegia who has recently become pregnant. (Oshima et al. 1998)

• There is a high level of consistency in identifying the most common issues raised by people with spinal cord injuries in primary care.
• The majority of the issues raised in primary care are disability-related — specifically, they are secondary complications of the spinal cord injury.
• The most commonly raised issues are bowel, bladder and pain.  Also of significant concern are skin care, equipment and medication needs, depression and bone density.
• Unmet needs in primary care pertain primarily to psychological issues, sexual and reproductive health, health promotion and lifestyle, and information needs.