Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN: Retrospective, 3-year case series. OBJECTIVE: To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI). SETTING: Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI. METHOD: Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores. RESULTS: Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores. CONCLUSIONS: Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.     

Development and initial evaluation of the SCI-FI/AT

ObjectivesTo describe the domain structure and calibration of the Spinal Cord Injury Functional Index for samples using Assistive Technology (SCI-FI/AT) and report the initial psychometric properties of each domain.DesignCross sectional survey followed by computerized adaptive test (CAT) simulations.SettingInpatient and community settings.ParticipantsA sample of 460 adults with traumatic spinal cord injury (SCI) stratified by level of injury, completeness of injury, and time since injury.InterventionsNoneResultsConfirmatory factor analysis (CFA) and Item response theory (IRT) analyses identified 4 unidimensional SCI-FI/AT domains: Basic Mobility (41 items) Self-care (71 items), Fine Motor Function (35 items), and Ambulation (29 items). High correlations of full item banks with 10-item simulated CATs indicated high accuracy of each CAT in estimating a person''s function, and there was high measurement reliability for the simulated CAT scales compared with the full item bank. SCI-FI/AT item difficulties in the domains of Self-care, Fine Motor Function, and Ambulation were less difficult than the same items in the original SCI-FI item banks.ConclusionWith the development of the SCI-FI/AT, clinicians and investigators have available multidimensional assessment scales that evaluate function for users of AT to complement the scales available in the original SCI-FI.     

脊髓损伤患者62例前瞻性临床研究

目的:通过前瞻性研究设计,对影响脊髓损伤患者功能恢复的各种影响因素进行初步分析.方法:设计前瞻性队列研究方案,在不干涉临床治疗方案前提下,采集2006年12月至2007年12月收治的脊髓损伤患者资料,纳入标准定为:急性脊髓损伤(受伤时间在1周以内),男女不限,年龄限定在18～65岁,根据临床查体结合MRI或CT检查证实为美国脊髓损伤协会(ASIA)分级标准(2000年修订)的A级(完全性脊髓损伤,损伤平面下不存在任何运动和感觉功能)或者B级(不完全性脊髓损伤,损伤平面下不存在运动功能,但存在感觉功能).所有入选病例均获随访,并分别在受伤入院当时及第1次评估后1、3、6个月采用ASIA分级标准、功能独立性评测(FIM)评价脊髓损伤及恢复情况,分析影响脊髓损伤患者功能恢复的因素.结果:共入选62例患者,男性60例,女性2例;年龄18～41岁,平均24岁;A级损伤29例,B级损伤33例.A级损伤中,手术减压患者(手术组)和非手术减压患者(非手术组)的感觉、运动ASIA评分及FIM评分比值在术后各时间点上的差异无统计学意义(P>0.05),B级损伤中,手术组和非手术组在手术前后感觉、运动ASIA评分、FIM评分的比值在各个时间点上差异均具有统计学意义(P<0.05).在手术组患者中,减压手术在伤后8 h以内(≤8 h)进行者,术前和术后感觉、运动ASIA评分、FIM评分比值与在伤后8 h以外(>8 h)进行者相比差异具有统计学意义(P<0.05).结论:对于A级损伤,手术减压时间点的选择对损伤的脊髓功能恢复影响差别不大,考虑到护理的方便和维持脊柱稳定性的要求,可以选择减压内固定手术;对于B级损伤,应该尽早进行减压手术以最大程度地恢复损伤脊髓的功能.     

Psychosocial outcomes among youth with spinal cord injury by neurological impairment

Objective

Examine psychosocial outcomes of youth with spinal cord injury (SCI) as a function of neurological level (paraplegia/tetraplegia) and severity (American Spinal Injury Association (ASIA) Impairment Scale (AIS)).

Design

Survey research.

Setting

Three pediatric SCI specialty centers in the USA.

Participants

Youth with SCI ages 5–18 with neurological impairment classifications of: tetraplegia AIS ABC (tetraplegia ABC), paraplegia AIS ABC (paraplegia ABC), or AIS D.

Outcome Measures

Children''s Assessment of Participation and Enjoyment, Pediatric Quality of Life Inventory, Revised Children''s Manifest Anxiety Scale, and Children''s Depression Inventory.

Results

Three hundred and forty youth participated; 57% were male; 60% were Caucasian, 21% Hispanic, 7% African-American, 2% Native American, and 3% reported “other”. Their mean age was 8.15 years (standard deviation (SD) = 5.84) at injury and 13.18 years (SD = 3.87) at interview. Ninety-six youth (28%) had tetraplegia ABC injuries, 191 (56%) paraplegia ABC injuries, and 53 (16%) AIS D injuries. Neurological impairment was significantly related to participation and quality of life (QOL). Specifically, youth with paraplegia ABC and AIS D injuries participated in more activities than youth with tetraplegia ABC (P = 0.002; P = 0.018, respectively) and youth with paraplegia ABC participated more often than youth with tetraplegia ABC (P = 0.006). Youth with paraplegia ABC reported higher social QOL than youth with tetraplegia ABC (P = 0.001) and AIS D injuries (P = 0.002). Groups did not differ regarding mental health.

Conclusion

Interventions should target youth with tetraplegia ABC, as they may need support in terms of participation, and both youth with tetraplegia ABC and AIS D injuries in terms of social integration.     

年龄因素和性别因素对患者脊髓圆锥末端位置的影响

目的 探讨年龄因素和性别因素对患者脊髓圆锥末端(CMT)位置的影响.方法 选择行腰椎MRI检查的患者1339例,性别不限,年龄4～ 89岁.采用Visart 1.5 T型磁共振仪或MagnetomTrio 3.0T型磁共振仪观察T1相和T2相CMT位置.矢状位时肉眼所见脊髓圆锥的最远处为CMT.结果 入选患者男性594例,女性745例.男性CMT位于L2,3椎间盘的比例(0.5％)与女性(1.2％)比较差异无统计学意义(P＞0.05);女性CMT平均位置低于男性(P＜0.01).各年龄段CMT平均位置比较差异无统计学意义(P＞0.05).≤19岁的患者,年龄与CMT平均位置无相关性(P＞0.05);≥20岁的女性患者,年龄与CMT平均位置呈正相关(相关系数0.076,P＜0.05),≥20岁的男性患者,年龄与CMT平均位置无相关性(P＞0.05).结论 女性CMT平均位置低于男性,虽然男性和女性CMT位于L2,3椎间盘的几率较低,但仍存在穿刺风险;成年女性CMT位置随着年龄增长而降低,成年男性CMT位置与年龄无关.     

Prediction of the level of cognitive functional independence in acute care following traumatic brain injury

Primary objective: To determine a predictive model for cognitive functional outcome of patients with traumatic brain injury (TBI) at discharge from acute care.

Methods and procedure: Three hundred and thirty-five patients were included in this analysis. Variables considered were age, education, initial score on the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA), cerebral imaging results and the need for neurosurgical intervention.

Experimental interventions: Functional Independence Measure (FIM).

Main outcomes and results: Results of this analysis indicated better cognitive FIM at discharge from acute care settings for patients with TBI when PTA was less than 24 hours, when level of education was higher, when no parietal lesion was identified, when no neurosurgical intervention was required, for patients with TBI who were younger and who presented with a higher GCS score upon admission.

Conclusions: This model will help to plan resource allocation for treatment and discharge planning within the first weeks following TBI.     

Are the ACSCOT filters associated with outcome? Examining morbidity and mortality in a European setting

INTRODUCTION: Quality indicators are widely needed for external assessment and comparison of trauma care. It is common to extend the use of the American College of Surgeons Committee on Trauma (ACSCOT) audit filters to this scope. This mandates that their actual link with outcome be demonstrated. Several studies attempted to do so, but with inconsistent risk-adjustment, conflicting results and never using long-term disability as outcome measure, despite its recognised importance. We tried to overcome these limitations. METHODS: Risk-adjusted analysis of the association of filters 1, 3, 10 and 13 with 30-day mortality and 6-month disability measured with the EQ5D scale. Multivariate logistic and linear regression models were used respectively. The data came from a National Italian Trauma Registry comprising 838 patients with major trauma. RESULTS: Three (1, 3 and 10) of the filters analysed did not show any significant association with either outcome. Filter 13 was associated with decreased mortality and lower (worse) disability scores. CONCLUSIONS: Methodological difficulties, incomplete, obsolete or non-generalisable definitions of some filters can explain the generally poor correlation with outcomes. The conflicting association of filter 13 with the two types of outcomes raises some interesting questions about the targeted outcomes in trauma research. It is recommended that further studies develop better quality indicators and test their link with both survival and functional outcome in the same setting where they are applied for assessment and comparison of trauma care.     

Predicting health preference in chronic spinal cord injury

Context/Objective

Health preference values relate to a person''s state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). Health preference plays a key role in health economics and health policy, particularly in interpreting the results of cost-effectiveness studies, and supports the allocation of healthcare resources. The current study used elements of the International Classification of Functioning, Disability and Health (ICF) framework to predict health preference in persons with spinal cord injury (SCI).

Methods

Data were collected by telephone survey on (1) demographics, (2) impairment (etiology, neurological level of injury, and ASIA impairment scale), (3) secondary health conditions (SHCs) using the SCI-Secondary Conditions Scale-Modified, (4) functional abilities using the Spinal Cord Independence Measure (SCIM), and (5) health preference using the Health Utilities Index-Mark III (HUI-Mark III) among adults with chronic SCI. Variables were categorized according to ICF headings and hierarchical regression analyses were used to predict HUI-Mark III scores.

Results

Adults with chronic traumatic or non-traumatic SCI (N = 357) reported a mean health preference score of 0.27 (±0.27). In predicting health preference, our model accounted for 55.1% of the variance with “body functions and structure”, and “activity and participation”, significantly contributing to the model (P < 0.0001). In particular, older age, being employed, and having higher SCIM scores were positively associated with health preference. Conversely, a higher SHC impact score was associated with poorer health preference.

Conclusions

Variables representative of “activity and participation” largely influence health preference among persons with chronic SCI, which may be amenable to intervention. These findings could be applied to advocate for health promotion and employment support programs to maximize well-being in persons aging with chronic SCI in the community.     

Are pre-hospital time and emergency department disposition time useful process indicators for trauma care in Italy?

BACKGROUND: It is recommended that process indicators (PI) for trauma-care be validated in the setting where they are applied for quality assurance (QA) and quality improvement (QI). In a pilot attempt at trauma QA and QI, we evaluated pre-hospital time (PT) and emergency department disposition time (EDt) as possible PIs in three Italian trauma-referral hospitals. METHODS: We used registry data on all the 753 major (ISS>15) trauma cases admitted to the participating hospitals between the 1 July 2004 and the 31 June 2005. The distribution of PT and EDt in the hospitals was investigated together with the performances of the hospitals. The performances were evaluated in terms of patient outcome with multivariate regression models. Outcome measures were trauma death, Euroqol 5-D (EQ5D), and Glasgow Outcome Score (GOS). The possible PIs were then evaluated as independent predictors of outcome. RESULTS: In the hospital with the best outcome-measures (Hospital A) PT and EDt were also the shortest. The differences in PT and EDt were significant (p<0.05) versus Hospital B and Hospital C, respectively. However, at the patient level, longer PT and EDt were not independently associated with bad outcome. Neither a threshold could be found that indicated higher risks of bad outcome. EDt>120 min was paradoxically associated with lower mortality. CONCLUSION: Although PT and EDt were significantly shorter in the hospital with best outcome performances, we could not confirm at the patient level their expected independent association with outcome. More evidence is needed before these indicators can be validated as standard tools for system analysis in our setting.     

State-of-the-science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. An introduction

The Rehabilitation Research and Training Center on Measuring Rehabilitation Outcomes and Effectiveness, along with academic, professional, provider, accreditor, and other organizations, sponsored a 2-day State-of-the-Science of Postacute Rehabilitation Symposium in February 2007. The aim of this symposium was to serve as a catalyst for expanded research on postacute care (PAC) rehabilitation so that health policy is founded on a solid evidence base. The goals were to (a) describe the state of our knowledge regarding utilization, organization, and outcomes of postacute rehabilitation settings, (b) identify methodologic and measurement challenges to conducting research, (c) foster the exchange of ideas among researchers, policy makers, industry representatives, funding agency staff, consumers, and advocacy groups, and (d) identify critical questions related to setting, delivery, payment, and effectiveness of rehabilitation services. Plenary presentation and state-of-the-science summaries were organized around 4 themes: (a) the need for improved measurement of key rehabilitation variables and methods to collect and analyze this information, (b) factors that influence access to postacute rehabilitation care, (c) similarities and differences in quality and quantity of services across PAC settings, and (d) effectiveness of postacute rehabilitation services. The full set of symposium articles, including recommendations for future research, appear in Archives of Physical Medicine and Rehabilitation.