Race, employment, and spinal cord injury

OBJECTIVES: To examine issues of employment and race for persons with spinal cord injury (SCI), by assessing the type of work that was being done before and after injury and by placing this in the context of patterns for the general population. DESIGN: Retrospective, cross-sectional analysis. SETTING: Centers funded as part of the federally sponsored Model Spinal Cord Injury Systems (MSCIS) Project. PARTICIPANTS: Two samples: 5925 African Americans and whites with SCI who are part of the MSCIS and a subset of 577 people with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic information, occupational status, employment rate, job census codes, Craig Hospital Assessment and Reporting Technique-Short Form, and Satisfaction With Life Scale. RESULTS: Racial disparities were found in employment rates before injury and at 1, 5, 10, 15, and 20 years after SCI. Differences were also found in the types of jobs that were held before SCI with patterns for participants similar to those of African Americans and whites in the general population. No differences were found in the types of jobs held by African Americans and whites with SCI at 1 year after injury. After injury, African Americans had lower economic self-sufficiency scores, regardless of employment status, and lower social integration scores among those who were not employed. CONCLUSIONS: Racial disparities found in employment patterns among persons with SCI mirrored patterns among the general population.     

Gender-related differences in acute rehabilitation lengths of stay, charges, and functional outcomes for a matched sample with spinal cord injury: a multicenter investigation

OBJECTIVE: To examine the effects of gender on length of stay (LOS), treatment costs, and outcomes by using a matched sample of patients with spinal cord injury (SCI). DESIGN: A 2 x (15 x 3) mixed, block design was used retrospectively to analyze the impact of gender on subjects matched for age, American Spinal Injury Association (ASIA) motor impairment classification, and level of neurologic injury. SETTING: Twenty medical centers in the federally sponsored Spinal Cord Injury Model Systems project. PARTICIPANTS: One thousand seventy-four adult patients with SCI admitted between 1988 and 1998 were assessed at acute-care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: ASIA motor index and FIM instrument admission, discharge, and efficiency scores; rehabilitation LOS and medical care charges; and discharge disposition. RESULTS: Analysis revealed no gender-related differences in FIM motor scores on admission and discharge. No differences in FIM motor efficiencies or daily change were observed. No significant differences were found for ASIA motor scores on acute-care admission and rehabilitation discharge. No differences in acute rehabilitation LOS and charges were observed. No gender-related differences were seen in the likelihood of discharge to an institutional setting. CONCLUSION: Gender was not a significant factor in functional outcome of SCI patients after acute rehabilitation.     

Outcomes after spinal cord injury: comparisons as a function of gender and race and ethnicity

OBJECTIVE: To identify gender and racial and ethnic differences in subjective well-being (SWB), participation, and general health ratings in participants with spinal cord injury (SCI). DESIGN: A multisite, cross-sectional study that used stratified sampling to identify and maximize participation among groups of people traditionally underrepresented in SCI research. SETTING: Four Model Spinal Cord Injury Systems participated in the data collection. The primary site was a large southeastern specialty hospital; the other 3 were in the western and mountain regions of the United States. PARTICIPANTS: A total of 512 participants, 475 of whom were included in the analysis. This group included relatively equal portions of whites, African Americans, American Indians, and Hispanics. Approximately 40% of the sample was women. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The primary outcome measures included 2 measures of SWB (Life Situation Questionnaire-Revised, Older Adult Health and Mood Questionnaire), 1 measure of participation (Craig Handicap Assessment and Reporting Technique), and several items from the Behavioral Risk Factor Surveillance System. RESULTS: The majority of racial and ethnic differences in SWB related to specific life areas (eg, economics, employment), rather than more global outcomes (eg, engagement, health), with whites generally reporting the best outcomes, followed by African Americans. American Indians, and whites generally reported the highest participation scores, whereas limited differences were noted between the racial and ethnic groups on health indicators. Women reported lower satisfaction with health, more poor mental health days, and lower SWB related to home life, but higher SWB related to interpersonal relations. CONCLUSIONS: There are racial and ethnic differences in outcomes after SCI focused primarily on subjective outcomes in areas in which racial and ethnic minorities have traditionally been disadvantaged. The results of this study direct rehabilitation professionals to the outcomes that need to be targeted for intervention to eliminate inequities in outcomes for all persons with SCI.     

Race: predictor versus proxy variable? Outcomes after spinal cord injury

OBJECTIVE: To examine the impact of race on acute, rehabilitation, and long-term outcomes after spinal cord injury (SCI). DESIGN: Two case control studies (study 1: acute and rehabilitation outcomes, study 2: long-term outcomes) in which white and nonwhite individuals were matched case for case on multiple demographic, medical, and geographic characteristics with the rationale being that a case-control methodology would increase the internal validity of the design, thereby increasing confidence in the assertion that any between-group differences observed may be specifically attributed to race. SETTING: Data drawn from the Spinal Cord Injury Model Systems. Institutional practice and general community. PARTICIPANTS: Study 1: 187 pairs of individuals, study 2: 158 pairs of matched individuals. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcome measures assessed included economic (eg, cost of care), treatment-related (eg, length of hospital stay), functional (eg, FIM instrument), and medical (eg, number of medical complications) variables, as well as self-reported life satisfaction, level of handicap, and mental and physical health. RESULTS: In study 1, none of the outcome measures differed significantly across racial groups. Similarly, study 2 failed to indicate significant differences in any of the outcome variables across racial groups, with the exception that nonwhites were at increased risk of greater self-reported handicap in the area of mobility. Power analyses indicated these finding were not merely the result of inadequate power. CONCLUSION: For the outcomes assessed in studies 1 and 2, race appeared to act primarily as a proxy for other variables (eg, injury severity, age, educational achievement), which in turn may be associated with poor outcome after SCI. Theoretical implications and recommendations are discussed.     

A multicenter investigation of age-related differences in lengths of stay, hospitalization charges, and outcomes for a matched tetraplegia sample.

OBJECTIVE: To examine the effects of age at injury on lengths of stay, treatment costs, and outcomes using a matched sample of tetraplegic spinal cord injury (SCI) patients. DESIGN: Differences were examined by separating the sample into three age categories (18 to 34, 35 to 64, and 65+ years old) matched for American Spinal Injury Association (ASIA) Motor Impairment Classification and level of neurologic preservation bilaterally. Analysis of variance was used to examine age group differences for lengths of stay, medical expenses, and functional outcome. SETTING: Sixteen medical centers in the federally sponsored Spinal Cord Injury Model Systems Project. PARTICIPANTS: Three hundred seventy-five adult patients with tetraplegic SCI admitted between 1988 and 1996 were assessed at acute care admission, inpatient rehabilitation admission, and inpatient rehabilitation discharge. MAIN OUTCOME MEASURES: ASIA Motor Index and Functional Independence Measure (FIM) admission, discharge, and efficiency scores; acute care and rehabilitation lengths of stay and medical care charges; and discharge disposition. RESULTS: Analyses revealed equivalent lengths of stay and charges for all age groups. There were no age-related differences in ASIA and FIM Motor scores at acute care and inpatient rehabilitation admission. Younger patients' scores on the FIM Motor subscale improved significantly more than did middle and older patients'. The two younger groups of patients had a more significant improvement than did older patients, as indicated by ASIA Motor Index scores. When taking lengths of stay into account, the FIM motor scores of the youngest group of patients improved more quickly than those of the two older groups. Furthermore, the younger and middle age groups demonstrated greater treatment efficiency than the older patient group based on ASIA Motor Index score ratios. Younger patients were least likely to be discharged to institutional settings. CONCLUSIONS: Along with neurologic and functional status, age should be considered when formulating treatment plans and prognostic statements. For older patients, alternative rehabilitation settings with lower-intensity treatment and lower charges may prove to be a more efficacious use of resources.     

Longitudinal Analysis of Hospitalization After Spinal Cord Injury: Variation Based on Race and Ethnicity

Objective

To examine the longitudinal effects of race/ethnicity on hospitalization among adults with spinal cord injury (SCI) in the 10-year period after initial injury.

Design

Retrospective analysis of postinjury hospitalizations among non-Hispanic white, non-Hispanic African American, and Hispanic adults with SCI.

Setting

Community. Data were extracted from the 2011 National Spinal Cord Injury Model Systems database.

Participants

Patients with traumatic SCI (N= 5146; white, 3175; African American, 1396; Hispanic, 575) who received rehabilitation at one of the relevant SCI Model Systems.

Interventions

Not applicable.

Main Outcome Measures

Hospitalization, including rate of hospitalization, number of hospitalizations, and number of days hospitalized during the 12 months before the first-, fifth-, and tenth-year follow-up interviews for the SCI Model Systems.

Results

Significant differences were found in rates of hospitalization at 1 and 5 years postinjury, with participants from Hispanic backgrounds reporting lower rates than either whites or African Americans. At 10 years postinjury, no differences were noted in the rate of hospitalization between racial/ethnic groups; however, compared with whites (P=.011) and Hispanics (P=.051), African Americans with SCI had 13 and 16 more days of hospitalization, respectively. Compared with the first year postinjury, the rate of hospitalization declined over time among whites, African Americans, and Hispanics; however, for African Americans, the number of days hospitalized increased by 12 days (P=.036) at 10 years versus 5 years postinjury.

Conclusions

Racial/ethnic variation appears to exist in postinjury hospitalization for individuals with SCI, with Hispanics showing the lowest rates of hospitalization at 1 and 5 years postinjury and African Americans having a significantly higher number of days hospitalized at 10 years postinjury. Potential explanations for these variations are discussed, and recommendations are made for potential changes to policy and clinical care.     

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation.

OBJECTIVE: To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation. DESIGN: A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. SETTING: Tertiary university medical centers. PATIENTS: Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria. MAIN OUTCOME MEASURES: Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home. RESULTS: Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges. CONCLUSIONS: Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.     

Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study

OBJECTIVE: To examine what effect the injury-to-rehabilitation interval has on the outcome of spinal cord injury (SCI) rehabilitation. DESIGN: Retrospective study. SETTING: Spinal unit of a large rehabilitation hospital. PARTICIPANTS: Consecutive admissions were divided into groups according to age, sex, and American Spinal Injury Association impairment grade and neurologic level of injury. The patients were matched for these variables and divided into groups according to the interval from injury to admission into acute rehabilitation. This approach resulted in 150 patients with SCI grouped into 50 comparison subgroupings. Interventions Three comparison groups-short (<30 d), medium (31-60 d), and long (>60 d) time to admission (TTA)-were evaluated for rehabilitation outcomes. MAIN OUTCOME MEASURES: Barthel Index, Rivermead Mobility Index, Walking Index for Spinal Cord Injury, and motor scores at admission and discharge were examined. The changes and efficiencies were evaluated. RESULTS: The 3 groups were comparable for all medical and demographic characteristics as well as neurologic recovery. The 3 subgroups differed significantly in activity of daily living outcomes, with the short TTA group exhibiting higher Barthel Index raw discharge scores, score increases, and score efficiencies. CONCLUSIONS: Early rehabilitation seems to be a relevant prognostic factor of functional outcome. Rehabilitation intervention in patients with SCI should begin as soon as possible, in a specialized setting, because delay may adversely affect functional recovery.     

Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury

OBJECTIVE: To compare neurologic, medical, and functional outcomes of patients with acute spinal cord injury (SCI) undergoing early (<24 h and 24-72 h) and late (>72 h) surgical spine intervention versus those treated nonsurgically. DESIGN: Retrospective case series comparing outcomes by surgical and nonsurgical groups during acute care, rehabilitation, and at 1-year follow-up. SETTING: Multicenter National Spinal Cord Injury Database. PARTICIPANTS: Consecutive patients with acute, nonpenetrating, traumatic SCI from 1995 to 2000, admitted in the first 24 hours after injury. Surgical spinal intervention was likely secondary to nature of injury and the need for spinal stabilization. Interventions Not applicable. MAIN OUTCOME MEASURES: Changes in neurologic outcomes (motor and sensory levels, motor index score, American Spinal Injury Association [ASIA] Impairment Scale [AIS]), medical complications (pneumonia and atelectasis, deep vein thrombosis and pulmonary embolism, pressure ulcers, autonomic dysreflexia, rehospitalization), and functional outcomes (acute and rehabilitation length of stay [LOS], hospital charges, FIM instrument score, FIM motor efficiency scores). RESULTS: Subjects in the early surgery group were more likely ( P <.05) to be women, have paraplegia, and have SCI caused by motor vehicle collisions. The nonsurgical group was more likely ( P <.05) to have an older mean age and more incomplete injuries. ASIA motor index improvements (from admission to 1-y follow-up) were more likely ( P <.05) in the nonsurgical groups, as compared with the surgical groups. Those with late surgery had significantly ( P <.05) increased acute care and total LOS and hospital charges along with higher incidence of pneumonia and atelectasis. No differences between groups were found for changes in neurologic levels, AIS grade, or FIM motor efficiency. CONCLUSIONS: ASIA motor index improvements were noted in the nonsurgery group, though likely related to increased incompleteness of injuries within this group. Early versus late spinal surgery was associated with shorter LOS and reduced pulmonary complications, however, no differences in neurologic or functional improvements were noted between early or late surgical groups.     

Predicting "charge outliers" after spinal cord injury: a multicenter analysis of demographics, injury characteristics, outcomes, and rehabilitation charges

OBJECTIVE: To describe the distribution of charges, to distinguish between "charge outliers" and nonoutliers, and to identify a model that uses demographics and injury characteristics to predict charge outlier status in individuals with spinal cord injury (SCI). DESIGN: Retrospective data analysis of patients admitted to 24 acute inpatient rehabilitation national Spinal Cord Injury Model Systems centers. Statistical analysis, including proportions, means, and standard deviations (SDs), were compiled for the following variables: demographic and injury information, rehabilitation charges, medical complications, associated injuries, and surgical procedures. SETTING: Tertiary, university medical centers participating in the National Institute on Disability and Rehabilitation Research's SCI Model Systems project. PARTICIPANTS: A total of 13,392 patients who were admitted to 24 acute, intensive, interdisciplinary rehabilitation settings after traumatic SCI between November 1972 and August 1996. MAIN OUTCOME MEASURES: Statistical data analysis was used to determine significance between charge outliers and nonoutliers on the basis of demographic, injury characteristics, and clinical factors. Outliers, under the current diagnostic-related group system, are defined as cases in which lengths of stay exceed the mean by the lesser of 20 days or 1.94 SDs. RESULTS: Statistically significant differences were found between SCI charge outliers and nonoutliers based on ethnicity, education, employment, level of injury, American Spinal Injury Association impairment classification, and sponsor of hospitalization. On average, outliers were 4 years older than nonoutliers, and tended to have more associated injuries, pressure ulcers, surgical procedures, and medical complications. A forward-conditional stepwise multiple logistic regression analysis was used to confirm univariate analysis and to predict the presence or absence of outliers based on the predictor variables. A model for the prediction of SCI charge outlier status was defined. CONCLUSIONS: SCI charge outliers are most likely to be retired, insured, have high cervical level injuries, and be educated beyond high school. Improved treatment efficiency serves as a means of cost reduction and is a reason to identify outlier characteristics.     

Nontraumatic vs. traumatic spinal cord injury: a rehabilitation outcome comparison

OBJECTIVE: Nontraumatic spinal cord injury (SCI) represents a significant proportion of individuals admitted for SCI rehabilitation; however, there is limited literature regarding their outcomes. As our society continues to age and nontraumatic injuries present with greater frequency, further studies in this area will become increasingly relevant. The objective of this study was to compare outcomes of patients with nontraumatic SCI with those with traumatic SCI after inpatient rehabilitation. DESIGN: A longitudinal study with matched block design was used comparing 86 patients with nontraumatic SCI admitted to a SCI rehabilitation unit and 86 patients with traumatic SCI admitted to regional model SCI centers, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. Main outcome measures included acute and rehabilitation hospital length of stay, FIM scores, FIM change, FIM efficiency, rehabilitation charges, and discharge-to-home rates. RESULTS: Results indicate that when compared with traumatic SCI, patients with nontraumatic SCI had a significantly (P < 0.01) shorter rehabilitation length of stay (22.38 vs. 41.35 days) and lower discharge FIM scores (57.3 vs. 65.6), FIM change (18.6 vs. 31.0), and rehabilitation charges ($25,050 vs. $64,570). No statistical differences were found in acute care length of stay, admission FIM scores, FIM efficiency, and community discharge rates. CONCLUSIONS: The findings indicate that patients with nontraumatic SCI can achieve rates of functional gains and community discharge comparable with traumatic SCI. Whereas patients with traumatic SCI achieved greater overall functional improvement, patients with nontraumatic SCI had shorter rehabilitation length of stay and lower rehabilitation charges. These findings have important implications for the interdisciplinary rehabilitation process in the overall management and outcome of individuals with nontraumatic SCI.     

Quality of life after spinal cord injury caused by gunshot.

OBJECTIVE: To determine what effect gunshot-caused spinal cord injury (SCI) has on self-reported quality of life (QOL) and on the frequency of pain sufficient to interfere with day-to-day activities. DESIGN: Follow-up, case-control design. SETTING: Analysis of data obtained from the (US) National Spinal Cord Injury Statistical Center from 18 funded Spinal Cord Injury Model Systems. PARTICIPANTS: Individuals with traumatic onset SCI (n = 1901). From these, 111 persons with gunshot-caused SCI were matched to persons with nongunshot SCI. MAIN OUTCOME MEASURES: Satisfaction with Life Scale (SWLS), the Craig Handicap Assessment and Reporting Technique (CHART), Medical Outcomes Study Short-Form Health Survey (SF-12), and an individual pain item from the SF-12. RESULTS: No between-group differences were found on any of the QOL outcome measures. In contrast, those with SCI caused by gunshot reported that pain more frequently interfered with day-to-day activities than the matched comparison group. CONCLUSIONS: SCI caused by gunshot appears largely unrelated to QOL, after controlling for demographic and medical characteristics associated with this group. Gunshot as a mechanism of SCI may place individuals at an increased risk of subsequent development of pain that interferes with activities of daily living.     

Emergency, acute, and surgical management of spine trauma

OBJECTIVES: To assess trends in emergency, acute, and surgical management of spinal cord injury (SCI), and evaluate the relations between surgery and the occurrence of specific complications. SETTING: Model SCI Care Systems. DESIGN: Case series. PARTICIPANTS: Consecutive samples of 3,756 acute spinal injuries admitted to the Midwest Regional Spinal Cord Injury Care System between 1990 and 1999, 2,204 individuals admitted to a Model SCI System within 24 hours of injury before 1995, and 941 individuals who were injured between December 1995 and August 1998 and were admitted to a Model System within 24 hours of injury. MAIN OUTCOME MEASURES: Frequencies of injury types, nonoperative treatment and types of spine surgeries, and time sequence associated complications including postoperative wound infections, pressure ulcers, deep vein thrombophlebitis, pulmonary embolism, and pneumonia or atelectasis. RESULTS: Eighty-eight percent of cases entering a Model System through acute care were admitted within 72 hours of injury, 85% were admitted within 24 hours. Comparing 1990 with 1998, the number of persons admitted to Model Systems within 72 hours of injury declined 11%. Operative treatment within the Model Systems increased 5% (p < .01), with increases due to decompression surgeries. Complication rates of nonoperative and surgical cases were not different. CONCLUSIONS: The reduction in 72-hour admissions suggests an increasing percentage of admissions are directly to rehabilitation at a Model System after receiving acute care elsewhere. The increase in the use of surgical procedures involving surgical decompression of the spine is probably due to advances in surgical technology and increased experience and confidence in spine surgery. Surgery does not influence complication development beyond the usual expectations for those who sustain SCI.     

Recent demographic and injury trends in people served by the Model Spinal Cord Injury Care Systems

OBJECTIVE: To identify trends in the demographic and injury data of persons with spinal cord injury (SCI). DESIGN: Consecutive case series. SETTINGS: Model Spinal Cord Injury Care Systems throughout the United States. PATIENTS: A total of 25,054 persons admitted to a Model Spinal Cord Injury Care System within 365 days of injury between 1973 and 1998. RESULTS: Many trends and changes have been noted in the clinical features of patients who have been admitted to the Model SCI Care Systems. Average age at time of injury is rising; persons older than 60 comprise 11.5% of all persons enrolled in the National Database during the 1994-1998 period. Although the overall male-to-female ratio is greater than 4:1, the proportion of males has decreased significantly in recent years. Violence-related injuries have increased dramatically from 13.9% in 1973-1977 to 21.8% in 1994-1998. Since 1973, the proportions of injuries resulting from vehicular crashes and sports declined while injuries from falls increased. Injury continues to occur most commonly in the summer. When age, race, and gender are considered, violence is a more common cause of injury among individuals who are younger, male, or African American. Complete injuries were more common among younger individuals and among men than among older adults and women. CONCLUSION: Trends in the national database provide valuable data for tracking groups at risk for traumatic SCI.     

Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis

OBJECTIVES: To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence. DESIGN: Survey design with analysis of cross-sectional data. SETTING: Model Spinal Cord Injury Systems (MSCIS) centers. PARTICIPANTS: Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups. RESULTS: The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports. CONCLUSIONS: Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.     

Mothers with spinal cord injuries: impact on marital, family, and children's adjustment.

OBJECTIVE: To evaluate how mothers with spinal cord injury (SCI) adjust to parenting, their marriages, and their families, and how their children adjust to their mothers' disability. DESIGN: Randomized control study of mothers with SCI and their children, matched to able-bodied mothers and their children on key demographic variables. SETTING: Subjects were selected from 7 regional Spinal Cord Injury Model Systems from across the United States. PARTICIPANTS: A total of 310 volunteers (experimental: 88 mothers with SCI, 46 partners, 31 children; matched controls: 84 able-bodied mothers, 33 partners, 28 children). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Children's adjustment, gender role identity; self-esteem; children's attitude toward mother and father; dyadic and family adjustment; parenting stress; and satisfaction. RESULTS: No significant differences were found between mothers with SCI and able-bodied mothers. Moreover, there were no significant differences between children raised in families with mothers with SCI and children raised in families with able-bodied mothers. Also, no significant differences were found in dyadic or family functioning with mothers with SCI or able-bodied mothers. CONCLUSIONS: SCI in mothers does not appear to affect their children adversely in terms of individual adjustment, attitudes toward their parents, self-esteem, gender roles, and family functioning. Our results may challenge health care providers, social policy-makers, and the general public to end negative stereotyping of children, couples, and families with a disabled mother and wife.     

Effects of gender on neurologic and functional recovery after spinal cord injury

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.     

Sex-related differences of rehabilitation outcomes of spinal cord lesion patients

OBJECTIVES: To evaluate sex-related differences of spinal cord lesion patients. PATIENTS: Two hundred and eighty-one patients were included with evaluation of: lesion to admission time, aetiology, lesion level, associated injury, medical complications and surgical intervention, length of stay, American Spinal Injury Association (ASIA) impairment and motor scores. MAIN OUTCOME MEASURES: ASIA impairment grade and ASIA motor scores; Barthel Index, Rivermead Mobility Index and Walking Index for Spinal Cord Injury. RESULTS: In the entire group female patients had a lower frequency of traumatic lesions, a lower frequency of complications at admission and a higher frequency of incomplete lesions (ASIA impairment C). In the matching cohorts comparison female patients showed the same neurological and functional recovery as male patients. CONCLUSION: Gender does not seems to influence spinal cord rehabilitation outcomes despite the fact that men and women showed significant epidemiological differences. Further studies are needed to evaluate some aspects such as long-term bladder management and complications.     

Aging with spinal cord injury: changes in selected health indices and life satisfaction

OBJECTIVES: To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes. DESIGN: Retrospective cross-sectional and longitudinal examination of people with SCI. SETTING: Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System. PARTICIPANTS: People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year. RESULTS: The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome. CONCLUSIONS: Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.     

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury--1990-1997

OBJECTIVES: To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes. DESIGN: Longitudinal, exploratory study of patients with SCI. SETTING: Eighteen Model Spinal Cord Injury Centers across the United States. SAMPLE: A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury. MAIN OUTCOME MEASURES: Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence. RESULTS: Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger. DISCUSSION: High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving one's residence.