Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: The SCIRehab Project

Background/objective

To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury.

Methods

Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R² using 75% of the dataset to the R² for the same outcome using a validation subsample.

Results

Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly.

Conclusion

Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study.

Note

This is the first of nine articles in the SCIRehab series.     

Development and psychometric characteristics of the SCI-QOL Ability to Participate and Satisfaction with Social Roles and Activities item banks and short forms

ObjectiveTo develop a spinal cord injury (SCI)-focused version of PROMIS and Neuro-QOL social domain item banks; evaluate the psychometric properties of items developed for adults with SCI; and report information to facilitate clinical and research use.DesignWe used a mixed-methods design to develop and evaluate Ability to Participate in Social Roles and Activities and Satisfaction with Social Roles and Activities items. Focus groups helped define the constructs; cognitive interviews helped revise items; and confirmatory factor analysis and item response theory methods helped calibrate item banks and evaluate differential item functioning related to demographic and injury characteristics.SettingFive SCI Model System sites and one Veterans Administration medical center.ParticipantsThe calibration sample consisted of 641 individuals; a reliability sample consisted of 245 individuals residing in the community.ResultsA subset of 27 Ability to Participate and 35 Satisfaction items demonstrated good measurement properties and negligible differential item functioning related to demographic and injury characteristics. The SCI-specific measures correlate strongly with the PROMIS and Neuro-QOL versions. Ten item short forms correlate >0.96 with the full banks. Variable-length CATs with a minimum of 4 items, variable-length CATs with a minimum of 8 items, fixed-length CATs of 10 items, and the 10-item short forms demonstrate construct coverage and measurement error that is comparable to the full item bank.ConclusionThe Ability to Participate and Satisfaction with Social Roles and Activities CATs and short forms demonstrate excellent psychometric properties and are suitable for clinical and research applications.     

The Natural-Fit Handrim: Factors Related to Improvement in Symptoms and Function in Wheelchair Users

Background/Objective:     

Intrathecal baclofen: Its effect on symptoms and activities of daily living in severe spasticity due to spinal cord injuries: A pilot study

Background:

Spasticity is a major problem related to spinal cord injuries. Use of intrathecal baclofen with an implanted pump seems a very useful mode of therapy in patients in whom oral antispasmodic agents are either not effective or produce intolerable side-effects.

Materials and Methods:

Twenty-four patients with mean age 50 years (range 32-72 years) had intrathecal baclofen pump implanted for the severe spasticity of spinal origin. One patient died following implantation of pump due to natural causes and was not included in the study. The patients were followed up for mean 22 months (range, one to five years).

Results:

All 24 patients showed improvement in their spasm following the procedure. Improvement was noted in pain (12), sleep disturbance (20) and sphincter control (14). Patients had improvement in activities of daily living such as feeding ability (10), self care (10), indoor and outdoor mobility (19), and driving (4). One patient had catheter leakage immediately after the surgery and required change of catheter. The radio telemetry allows very good adjustment of the dose according the individual patients needs.

Conclusion:

Intrathecal baclofen pump improves the symptoms of spasm and also the quality of life. It helps the patient to live more independently. It is not an irreversible surgery for the patient and hence it is very useful in the changing the dynamics in this group of patients.     

Examining the effectiveness of intrathecal baclofen on spasticity in individuals with chronic spinal cord injury: A systematic review

Objective

To review the available evidence on the effectiveness of intrathecal baclofen in the treatment of spasticity in individuals with spinal cord injuries (SCIs) at least 6 months post-injury or diagnosis.

Data sources

A literature search of multiple databases (Pub Med, CINAHL, EMBASE) was conducted to identify articles published in the English language.

Study selection

Studies were included for review if: (1) more than 50% of the sample size had suffered a traumatic or non-traumatic SCI; (2) there were more than three subjects; (3) subjects received continuous intrathecal baclofen via an implantable pump aimed at improving spasticity; and (4) all subjects were ≥6 months post-SCI, at the time of the intervention.

Data extraction

Data extracted from the studies included patient and treatment characteristics, study design, method of assessment, and outcomes of the intervention.

Data synthesis

Methodological quality was assessed using the PEDro for randomized-controlled trials (RCTs) and the Downs and Black (D&B) tool for non-RCTs. A level of evidence was assigned to each intervention using a modified Sackett scale.

Conclusion

The literature search resulted in 677 articles. No RCTs and eight non-RCTs (D&B scores 13–24) met criteria for inclusion, providing a pooled sample size of 162 individuals. There was substantial level 4 evidence that intrathecal baclofen is effective in reducing spasticity. Mean Ashworth scores reduced from 3.1–4.5 at baseline to 1.0–2.0 (P < 0.005) at follow-up (range 2–41 months). Average dosing increased from 57–187 µg/day at baseline to 218.7–535.9 µg/day at follow-up. Several complications from the use of intrathecal baclofen or pump and catheter malfunction were reported.     

Development of valid and reliable measures of postural stability

BACKGROUND/OBJECTIVE: The development of simple postural stability tests that relate to performance of activities of daily living (ADL) and can be quickly performed in a clinical setting may assist clinicians in determining appropriate wheelchair configurations and postural supports in an efficient manner. The study's purpose was to validate 3 clinical measures of reach-functional reach (FR), reach area (RA), and bilateral reach (BR)-against the performance of ADL tasks. METHODS: Two groups of 20 subjects differing by time since spinal cord injury were tested. Three measures of reach-FR, RA, and BR-were recorded with and without permitting compensatory strategies. Subjects also attempted a series of ADL tasks. Group 2 subjects participated in test-retest reliability of the reach measures and to measure reach while using compensatory strategies. Correlation, ANOVA, and linear regression were used for analysis. RESULTS: Regression analysis showed that injury level was a significant predictor of success in performing ADL tasks (%ADL). Significant but not strong correlations were found between %ADL and all uncompensated reach measures. Within Group 2 subjects, compensated FR (r = 0.663) and RA (r = 0.647) were more related to the %ADL score than the uncompensated FR (r = 0.348) and RA (r = 0.305) measurements. BR had the strongest relationship with %ADL scores (P = 0.031) and was the only significant uncompensated reach measurement within the regression analyses. DISCUSSION AND CONCLUSION: While working with clients on seated stability and functional movement, clinicians should be encouraged to incorporate BR tasks because it has the strongest relationship to ADL performance. Researchers interested in studying postural control and stability during functional tasks should consider using uncompensated reach measures.     

Scapular Stabilization in Patients With Spinal Cord Injury

Background:

Severe scapular instability can be a considerable problem for people with high-level cervical spinal cord injury. Scapular instability reduces the effectiveness of the already weakened shoulder flexors and abductors, thereby limiting hand-to-mouth and hand-to-head activities. The winged scapula may cause inferior pole skin breakdown, as well as neck and shoulder pain.

Objective:

To report the efficacy of a fusionless scapular stabilization procedure as a means to enhance function in a consecutive group of patients with high-level cervical spinal cord injury.

Methods:

Four people with spinal cord injury at C4–C5 (2 male, 2 female; mean age  =  17.3 years, range  =  14–20 years) underwent scapular stabilization via scapulothoracic fusion (N  =  2) or by tethering the scapula to the rib cage with Mersilene tape as a fusionless stabilization (N  =  2). One patient died of unrelated causes 18 months after surgery, and the remaining 3 were followed for 26, 39, and 41 months, respectively. Data collection included radiographic analysis, active range of motion measures, and functional assessment.

Results:

Active shoulder flexion and abduction remained unchanged in 2 patients, but functional scores improved with regard to feeding and grooming capability. All patients reported satisfaction with postoperative appearance, and 3 patients reported considerable reduction in shoulder pain after surgery. Radiographs demonstrated maintenance of stable scapular alignment in all patients at final follow up. Wound breakdown, requiring removal of instrumentation, occurred in 2 patients.

Conclusion:

Scapular stabilization with or without fusion is a viable option to improve appearance, pain, and upper extremity function in people with high-level tetraplegia and scapular instability.     

Impact of Demographic and Medical Factors on Satisfaction with Life After Spinal Cord Injury: A Normative Study

Abstract

Objective: The aim of this study was (1) to examine demographic and medical predictors of the Satisfaction With Life Scale (SWLS) among individuals with spinal cord injury (SCI) and (2) to provide a normative table for the SWLS that includes appropriate adjustments for the most important predictors of life satisfaction.

Study Design: We examined predictors of the SWLS including age, education, sex, race, injury duration, number of rehospitalizations, marital status, employment status, SCI etiology, and level of neurological impairment.

Participants: Individuals in the National Spinal Cord Injury Statistical Center database [from 18 SCI model systems (1995-1999)] undergoing follow-up assessment were included for study.

Outcome Measure: Satisfaction With Life Scale.

Results: Univariate analyses indicated that marital and employment status, race, sex, education, and injury duration were significant factors associated with scores on the SWLS. In general, individuals who were female, white, married, and currently employed and had a higher education and longer injury duration reported significantly higher scores on the SWLS (P <.01). Effect-size estimates for these factors ranged from 0.16 to 0.41. Regression analyses showed that education, employment status, and injury duration were the strongest unique predictors of satisfaction with life but accounted for only 10% of the variance.

Conclusion: The SWLS is a global measure of life satisfaction and is relatively unre ated to demographic and medical characteristics. Normative tables are provided for epidemiologic comparison.     

The SCIRehab project: treatment time spent in SCI rehabilitation. Occupational therapy treatment time during inpatient spinal cord injury rehabilitation

Background

Occupational therapy (OT) is a critical component of the rehabilitation process after spinal cord injury (SCI), the constitution of which has not been studied or documented in full detail previously.

Objective

To describe the type and distribution of SCI rehabilitation OT activities, including the amount of time spent on evaluation and treatment, and to discuss predictors (patient and injury characteristics) of the amount of time dedicated to OT treatment activities.

Methods

Six inpatient rehabilitation centers enrolled 600 patients with traumatic SCI in the first year of the SCIRehab. Occupational therapists documented 32 512 therapy sessions including time spent and specifics of each therapeutic activity. Analysis of variance and contingency tables/chi-square tests were used to test differences across neurologic injury groups for continuous and categorical variables.

Results

SCIRehab patients received a mean total of 52 hours of OT over the course of their rehabilitation stay. Statistically significant differences among four neurologic injury groups were seen in time spent on each OT activity. The activities that consumed the most OT time (individual and group sessions combined) were strengthening/endurance exercises, activities of daily living (ADLs), range of motion (ROM)/stretching, education, and a grouping of ‘therapeutic activities’ that included tenodesis training, fine motor activities, manual therapy, vestibular training, edema management, breathing exercise, cognitive retraining, visual/perceptual training desensitization, and don/doff adaptive equipment. Seventy-seven percent of OT work occurred in individual treatment sessions, with the most frequent OT activity involving ADLs. The variation in time (mean minutes per week) spent on OT ROM/stretching, ADLs, transfer training, assessment, and therapeutic activities can be explained in part by patient and injury characteristics, such as admission Functional Independence Measure (FIM) score, neurologic injury group, and the medical severity of illness score.

Conclusion

OT treatment patterns for patients with traumatic SCI show much variation in activity selection and time spent on activities, within and among neurologic level of injury groups. Some of the variation can be explained by patient and injury characteristics. Almost all patients with SCI participated in strengthening/endurance and ROM/stretching exercises during OT treatment and these two activities are where the most time was spent when therapy provided in individual and group settings was combined. ADL work consumed the most time in individual therapy sessions.     

The association between bladder-emptying methods and health-related quality of life among Iranian individuals with spinal cord injury

Objectives: In this study, we compared the health-related quality of life (HRQoL) among patients with spinal cord injury (SCI) using different bladder emptying methods including normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization.

Design: Cross-sectional.

Setting: Tertiary rehabilitation center.

Participants: Patients referred to Brain and Spinal Cord Injury Research Center between 2012 and 2014.

Outcome measures: HRQoL was assessed by Short Form Health Survey (SF-36). Hierarchical regression analysis with adjustment for probable confounders (demographic and injury-related variables) was performed to assess the relationship between bladder-emptying method and total SF-36 score.

Results: Patients with injury at cervical sections had significantly lower scores in domain of physical functioning (PF), physical component summary (PCS) and total score (P: 0.001, <0.0001 and 0.027, respectively). Longer time since injury was associated with better scores of PCS, Mental component summary (MCS) and total score (P: 0.002, <0.0001 and 0.003, respectively). Regression analysis showed that the effect of bladder-emptying method on total score of SF-36 was significant (P < 0.0001) and this relationship remained significant after adjustment for probable confounders in the second step of hierarchical regression analysis (R: 0.923, R²: 0.852, Adjusted R²: 0.847, P?<?0.0001). Patients with NSM had the highest scores in SF-36 instrument and individuals with indwelling catheterization had the poorest HRQoL in all domains.

Conclusion: This study shows that the type of bladder management method affects HRQoL significantly in patients with SCI. Intermittent catheterization are recommended to be administered instead of indwelling catheterization to improve HRQoL.