Indmedica Home | About Indmedica | Medical Jobs | Advertise On Indmedica
Search Indmedica Web
Indmedica - India's premier medical portal

Indian Journal of Physiotherapy and Occupational Therapy

Demographic Characteristics of Individuals with Paraplegia in India- A survey

Author(s): Nalina Gupta, John Solomon M, Kavitha Raja

Vol. 2, No. 3 (2008-07 - 2008-09)

Nalina Gupta1, John Solomon M2, Kavitha Raja3

1Department of Physiotherapy, Sardar Bhagwan Singh Post- graduate Institute of Biomedical Sciences and Research, Dehradun;
2,3 Department of Physiotherapy, Manipal College of Allied Health Sciences (MCOAHS), Manipal, Karnataka, India.

Abstract

Study Design: A postal survey from August 2004 to May 2006.
Objective: To ascertain the demographic characteristics of individuals with paraplegia in India.
Settings: India
Methods: The questionnaire was mailed to the identified individuals (n=600) whose addresses were obtained from the medical records section of our hospital and by contacting non-government organizations (NGOs), working for individuals with paraplegia in various cities. The demographic characteristics studied were age, gender, education, etiology, level of lesion, duration since injury and employment after injury.
Results: The return rate was 46% (276/600). Falls from height was the leading cause (25%), followed by road traffic accidents (17.4%). Fifty-three subjects (19.2% each) were in the age group of 18-<25 and 40-<50 years age group. Majority of the subjects were men (233/276), had secondary educational level (148/276) and had the lesion at the lumbar level (60.1%).
Conclusions: Fall from a height is still the leading cause for spinal cord insult in India. Traumatic lesions are common in men and non-traumatic in women. Lumbar level is the commonest level of lesion in these individuals. Survival rate and the employment after injury are still towards the lower side.
Sponsorship: This study was funded in part by “Indian Association of Physiotherapists”.
Key words: Demographics, etiology, age at injury, gender, level of lesion, spinal cord injury.

Introduction

In India, approximately fifteen lac people live with spinal cord injury. Every year, ten thousand new cases add to this group of individuals. Majority of them (82%) are males in the age group of 16-30 years. However, this is only an estimate as there is no reliable national database.1

Chacko, Joseph, Mohanty and Jacob in 1986 evaluated the problems encountered in a general hospital situated in rural India. They found that male to female ratio was 13.5:1, 60.5% of cases with neurological deficits were in the 3rd and 4th decade of life and the causes for spinal injury were falling from trees (55.2%), road traffic accidents (12.8%), weights falling on patients (18.4%) and other causes (13.6%). The infrequent occurrence of road traffic accidents was most likely due to the rural bias of the patients.2

An epidemiologic study done in Harayana, by Roop Singh, have reported male to female ratio of 2.96:1 and the average age at injury of 35.4 years. Fall from height was the most common cause of trauma (44.5%), followed by motor vehicle accidents (34.7%). Most common level of injury was first lumbar vertebra among individuals with paraplegia.3 A hospital based study done by Agrawal P, Upadhaya P and Raja K have also reported ratio of men to women who sustained spinal injuries being 3.6:1.The maximum number of patients was in the age range of 20- 39 years . Mechanisms of injury recorded were fall from height (58.9%), fall of weight (7.2%), Motor Vehicle Accident (21.3%) and non-traumatic causes (12.6%).4

From casual observation, it appears that the demographic trend that Chacko etal had seen in their study is still the same even after 20 years. The author had highlighted the necessity for appropriate preventive measures and also had re-emphasized the shortcomings of treatment in general hospitals.2 So, it is intuitive to assume that the rescue and retrieval systems for these patients are still inadequate in India and the knowledge regarding precautions to be taken when transporting the patient is also lacking. Globally, the etiology responsible for the maximum number of SCI is road traffic accidents (RTA).

There is a lack of team approach to these individuals in various centers all over India. There are some Non- Government Organizations (NGO’s), workings for these individuals. But there is still a lack of team approach to the community from the various hospitals to give awareness programme regarding spinal cord injury, its prevention and treatment. There is also a lack of regular follow-ups.5

But all these aspects cannot be generalized. Although there are studies going on in different parts of India, they are either regional or hospital based. There are no reported statistics covering the whole country.

Thus, this study was an attempt to ascertain the demographic characteristics of individuals with paraplegia in the entire country, which may pave the way for better primary care all over India. The demographic characteristics studied were age, gender, education, etiology, level of injury, duration since injury and employment after injury.

Method

Study design
Postal survey.

Subjects

Individuals with paraplegia of any cause, either gender with evidence of complete cord lesion who were 18 years or older were selected. Subjects included were community dwelling as well as institutionalized individuals.

Study period

1 August 2004 to 31 May 2006.

Procedure

Part I: Development of questionnaire and validation We developed a questionnaire in English, which was constructed at the language level of third-grade education. The questionnaire was evaluated for face validity by five physiotherapists. Each of the physiotherapists had a minimum of 5 years working experience with SCI including community-based work with this population. The suggestions put forth by the evaluators were incorporated and the revised questionnaire was pilottested on 10 SCI individuals for comprehensibility. Changes suggested were incorporated and this version was again pilot-tested on five patients who had not participated in the first pilot testing. The final version was translated into Indian languages by means of parallel back translation ensuring that the language level was maintained at the third grade level in all languages. The final versions of the questionnaire consisted of three sections. The first section included demographic and disease characteristics,namely age, gender, education, occupation, level of lesion, duration since injury and ambulation status. The expected responses to this section were open ended except ambulation status, which was dichotomous (walking/not walking). The second section consisted of questions regarding occurrence of morbidities, namely respiratory dysfunction, continuous use of catheter, pressure sores, postural hypotension, pain, spasticity, and fractures. The third section consisted of details of employment following the SCI. The responses to this section were open-ended.

Part II: Administration of questionnaire Owing to the absence of a national database on SCI, addresses of potential subjects were collected from hospitals, organizations and associations dedicated to the SCI population.

Addresses of individuals living in 20 of 28 states in India were collected. The questionnaire in English and the relevant regional language was mailed to the identified individuals (n=600). The mail packet included a covering letter in English and the regional language, clearly outlining the purpose of the questionnaire, the subject’s option to participate or not, and the expected return date; the questionnaire itself with instructions for completion and a reply paid self-addressed envelope. One reminder was sent a week after the expected date of reply had passed. Those subjects who did not respond to the reminder were not contacted again.

Data analysis

Demographic data even those that were ordinal in nature were pooled into categories for ease of analysis.However, owing to the lack of substantial number of subjects, all groups were not of equal intervals. The demographic data were analysed using descriptive statistics. Associations of demographic characteristics was carried out using lambda coefficient of association for categorical data.

Results

Return rate
Of the 600 individuals, 276 responded to the mailed questionnaire, with a return rate of 46%.

Demographics
Demographic details are mentioned in table 1. Age: Of the 276 participants, 53 (19.2%) were in the age group of 18-<25 years, 53 (19.2%) in 40-<50 years, 49 (17.8%) in 25-<30 years, 41 (14.9%) in 35-<40 years, 38 (13.8%) in 30-<35 years, 30 (10.9%) in 50-<60 years and one each (0.4%) in 70-<80 and more than 80 years. Gender: 233 subjects were men and 43 were women.

Education: 148 subjects (53.6%) belonged to secondary education category, 40 (14.5%) subjects had higher secondary education, 23 (8.3%) subjects were illiterate, 22 (8%) subjects were graduates, 19 (6.9%) subjects were professionals, 19 subjects (6.9%) had primary education and 5 (1.8%) subjects were post-graduates. Relationship between age, gender and education is as shown in table 2. Level of lesion: 166 subjects (60.1%) had the lesion at the lumbar level, 39 subjects (14.1%) at the upper thoracic level, 31 subjects (11.2%) at the lower thoracic level and 40 subjects (14.5%) did not mention about the level.

Etiology: Falls from height was the leading cause for spinal cord insult (25%), followed by road traffic accidents (17.4%), non-traumatic insult (8.3%), fall of an object (6.5%), gun shot injuries (4.3%) and sports related cause of an insult (0.7%). Thirty-eight percent individuals did not mention the cause for injury. The etiology is shown in figure I. We found an association of etiology with age at injury and gender, which is as shown in figures 2 and 3.

Duration since injury: The duration since injury was arbitrarily divided into 11 categories, ranging from 1-<6 months to more than 25 years. Of the 276 participants, most of the subjects (57, 20.7%) were 1-<6 months post injury and the least (6, 2.2%) were in 15-<20 years post injury period.

Employment: 162 subjects (59%) were non-employed and 114 subjects (41%) were employed.

Discussion

For the sake of clarity, we will discuss each of the demographic characteristics separately.

Age
Majority of the SCI victims in the present study were in the age group of 18-<25 years and 40-<50 years. We found an association of age at injury with etiology, as depicted in figure 2. Fall from a height was the commonest cause for the spinal cord insult in all the age groups, especially till 40-<50 years. Road traffic accident was the leading cause in 18-<25 years age group. This is in contradiction to western data where motor vehicle accidents are the commonest cause for injury and falls were the leading cause of injury after the age 45.6 In the present study, falls were the leading cause even before the age 45. This can be explained, as the majority of the patients in the study were manual workers and compared to western countries, in India, falls from heights still rank first under the etiology category. These findings have a notable part to play in increasing awareness. The population most at risk is also that which is contributing the most to the society. Hence, the social impact of these preventable causes of SCI is a cause for concern.

Gender

The most common cause for the insult to spinal cord injury in males was traumatic and in females, it was non-traumatic. This finding is in agreement with those of McKinley, Seel and Hardman, in their five years prospective study in 1999. They had reported that the individuals with non-traumatic spinal cord injury were significantly females.7 Fall of object on the head was another common cause in both the genders. This can be attributed to unsafe working conditions in construction, head load working etc. These causes are modifiable with increase in awareness and safety guards.

Education

Majority of the SCI victims had secondary education followed by subjects with higher secondary education. The group of patients with lower education is often blue-collar workers and is most likely to be engaged in the high-risk occupations.

Level of lesion

The most common level of lesion in individuals with paraplegia is lumbar (60.1%). This is similar to the findings of Roop Singh, where he found the first lumbar vertebra being the most common level of lesion.3

Etiology

As shown in figure 1, falls from height were the leading cause of spinal cord insult followed by road traffic accidents. Our findings are similar to those shown by Chacko, Joseph, Mohanty and Jacob in 19862 , by Roop Singh in 20053 and by Agrawal Petal in 20064, where fall from trees was the commonest cause for spinal cord injury in India followed by road traffic accidents. Thus, we can say that the appropriate preventive measures which Chacko et al had stressed upon in 1986 are still lacking in our country. This necessitates the need to create an awareness regarding the causes for spinal cord insult in the community and to impart knowledge regarding transportation of SCI victim. We assume that attention towards these individuals in the in community is still inadequate. Thirty eight percent subjects did not mention the etiology, this could be due to the noncomprehensibility of the question or the insult was nontraumatic in nature.

Table 1: Demographic characteristics (n=276)

Demographic characteristics

Fig. 1: Etiology of spinal cord insult

Etiology of spinal cord insult

Gender

The most common cause for the insult to spinal cord injury in males was traumatic and in females, it was non-traumatic. This finding is in agreement with those of McKinley, Seel and Hardman, in their five years prospective study in 1999. They had reported that the individuals with non-traumatic spinal cord injury were significantly females.7 Fall of object on the head was another common cause in both the genders. This can be attributed to unsafe working conditions

Table 2: Description of frequencies of age, gender and education (n=276)

S.No. Age groups (in years) Gender Education
Men Women 0 1 2 3 4 5 6
1. 18-<25 45 08 04 00 22 16 07 00 04
2. 25-<30 41 08 03 01 25 09 08 00 03
3. 30-<35 32 06 01 03 23 04 03 01 03
4. 35-<40 34 07 01 05 25 05 02 01 02
5. 40-<50 45 08 05 06 34 04 02 00 02
6. 50-<60 24 06 07 00 16 02 00 01 04
7. 60-<70 10 00 02 03 03 00 00 02 00
8. 70-<80 01 00 00 00 00 00 00 00 01
9. >80 01 00 00 01 00 00 00 00 00

Note: Education categories: 0- no education, 1- primary education, 2- secondary education, 3- higher secondary education, 4- graduation, 5- post graduation and 6- professional

Duration since injury

The least group in our study was the one in 15-<20 years post injury period. We had some individuals in 20-<25 years and more than 25 years post injury period. But the majority was in 1-<6 months. It might be due to the fact that in India, the survival rate is still low. Decreased survival rate could be due to lack of acute and rehabilitation services, lack of pre-discharge home visits, development of secondary morbidities at home, lack of regular follow-ups, sociocultural variations, unfavorable family atmosphere and psychological impact of the injury.

Employment

In the present study, one hundred and fourteen subjects were employed. Majority of these subjects were either getting pensions or were working in sheltered workshops. Individuals living in the community were either having telephone booths, fruit shops or were taking care of their family business. Some of the individuals were professionals too. But one hundred and sixty eight patients were unemployed. Unemployment can be due to their level of lesion, as individuals with lesion at upper thoracic level were more likely to be unemployed. Lack of specialized centers and NGOs in most of the areas, lack of knowledge regarding the job opportunities and lack of initiative on the part of medical or paramedical personnel, can be some of the reasons for their unemployment. Another factor may be reluctance on the part of family to allow the disabled individual to seek employment.

Conclusion

Fall from height is still the leading cause for spinal cord insult in India. Road traffic accident is the commonest cause in the younger age group i.e. 18-<25 years. Traumatic lesions are common in men and non-traumatic lesions are common in women. Lumbar level is the commonest level of lesion in individuals with paraplegia. Though there is an advent of new technologies and rehabilitation facilities, survival rate and the employment after injury are still low.

Fig. 2: Association of age with etiology

Association of age with etiology

Note: Age at injury categories (in years): 1-18-<25, 2-25-<30, 3-30-<40, 4- 40-<50, 5-50-<60, 6-60-<70 and 7-70-<80.

Fig. 3: Association of etiology with gender

Association of etiology with gender

Limitations of the study

The comprehensibility of the questionnaire is one of the limitations as many subjects did not mention about the etiology and level of lesion. The return rate of the questionnaire was not uniform from different parts of the country. Hence the sample may not be representative of the country.

Implications

The results of this study suggest the following:

  • It is essential to increase the awareness regarding the usage of safe-guards at construction-sites and other high risk jobs.
  • It is essential to create an awareness regarding safe transportation of SCI victim.
  • Emphasis is to be given for better rehabilitation all over India.
  • Emphasis is to be for formation of multidisciplinary community rehabilitation teams.
  • It is essential to have regular life long follow-ups for these patients.
  • Vocational rehabilitation should be given importance

References

  1. Awareness and Prevention. [http://www.isiconline.org/aware.htm.]
  2. Chacko V, Joseph B, Mohanty S.P, Jacob T. Management of spinal cord injury in a general hospital in rural India. Paraplegia 1986; 330-335.
  3. Singh R, Sharma SC, Mittal R, Sharma A. Traumatic SCI in Haryana: An epidemiologic study. Indian Journal of Community Medicine 2005; vol.XXVIII, No.4.
  4. Agrawal P, Upadhaya P, Raja K. A Demographic Profile of Traumatic and Non-Traumatic Spinal Injury Cases: A hospital based study from India. Spinal cord 2007; 597-602.
  5. Chhabra HS. Life after SCI in India- Results of a survey of 53 centres. [http://www.iscos.org.uk/ abstract13.html.]
  6. Spinal cord injury information network. [http://www.spinalcord.org.]
  7. Mckinley WO, Seel RT, Hardman JT. Non-traumatic spinal cord injury: incidence, epidemiology and functional outcome. Arch Phys Med Rehabil 1999; 80: 619-623

Corresponding Author:
Nalina Gupta,
Lecturer
Department of Physiotherapy, Sardar Bhagwan Singh Post- graduate Institute of Biomedical Sciences and Research, Dehradun
Tel no. +91 9719832566, +91 9719018650, +91 9719217737
Email: nals235(at)yahoo.co.in

Access free medical resources from Wiley-Blackwell now!

About Indmedica - Conditions of Usage - Advertise On Indmedica - Contact Us

Copyright © 2005 Indmedica