Research from the Model Spinal Cord Injury Systems: findings from the current 5-year grant cycle

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.     

Medical procedures, complications, and outcomes for patients with spinal cord injury: A multicenter investigation comparing African Americans and whites

OBJECTIVE: To examine the role of race on rehabilitation outcomes for a matched sample of patients with spinal cord injury (SCI). DESIGN: African Americans and whites with SCI were matched based on age group, level and completeness of injury, and sponsor of care to retrospectively analyze the impact of race. SETTING: Eighteen medical centers in the federally sponsored Model Spinal Cord Injury Systems project. PARTICIPANTS: A total of 628 adults with SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medical procedures and complications; American Spinal Injury Association motor index, and FIMT instrument scores at admission and discharge; and discharge dispositions. RESULTS: Analysis revealed race-related differences in spinal surgeries, laparotomies, traction during acute care, and method of bladder management at discharge. In most cases, these were explained by cause of injury rather than direct affects of race. No differences were found with regard to medical complications functional outcomes, or discharge disposition. CONCLUSIONS: Although differences exist in the medical procedures given to African Americans and whites with SCI, they are generally accounted for by cause of injury rather than the direct affects of race.     

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.     

History, implementation, and current status of the National Spinal Cord Injury Database

OBJECTIVE: To summarize a 25-year history of the Model Spinal Cord Injury Program and the coexistent National Spinal Cord Injury Database and provide the status of the Database with a discussion of the strengths and weaknesses. DESIGN: Inception cohort. SETTING: Model spinal cord injury systems throughout the United States. RESULTS: As of September 1998, the National Spinal Cord Injury Database included abbreviated registry records on 6,085 new patients, more complete initial injury and hospitalization records on 18,969 new patients, and 78,627 annual follow up records on those persons. Although stability and continuity of the Database has been a priority since it was started, some changes were needed to meet the changes in health care, health care policy, and new technology. CONCLUSION: This large database can now provide a wealth of information about short- and long-term outcomes, provide data on which future health care policies can be evaluated, and act as a source for answers to future research questions.     

Environmental factors and their role in participation and life satisfaction after spinal cord injury

OBJECTIVES: To investigate environmental barriers reported by people with spinal cord injury (SCI), and to determine the relative impact of environmental barriers compared with demographic and injury characteristics and activity limitations in predicting variation in participation and life satisfaction. DESIGN: Cross-sectional, follow-up survey. SETTING: Individuals rehabilitated at 16 federally designated Model Spinal Cord Injury Systems of care, now living in the community. PARTICIPANTS: People with SCI (N=2726) who completed routine follow-up research interviews between 2000 and 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF), the Craig Handicap Assessment and Reporting Technique-Short Form, and the Satisfaction With Life Scale. RESULTS: The top 5 environmental barriers reported by subjects with SCI, in descending order of importance, were the natural environment, transportation, need for help in the home, availability of health care, and governmental policies. The CHIEF-SF subscales accounted for only 4% or less of the variation in participation; they accounted for 10% of the variation in life satisfaction. CONCLUSIONS: The inclusion of environmental factors in models of disability was supported, but were found to be more strongly related to life satisfaction than to societal participation.     

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.     

Predictors of personal care assistance for people with spinal cord injury

OBJECTIVE: To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI). DESIGN: Cross-sectional. SETTING: Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center. PARTICIPANTS: A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Daily hours of paid, unpaid, and occasional PCA services. RESULTS: Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance. CONCLUSION: Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI.     

Trends in spinal cord injury demographics and treatment outcomes between 1973 and 1986.

A study of the National Spinal Cord Injury Statistical Center database on 6,563 persons treated at Spinal Cord Injury Care Systems was conducted to detect demographic and treatment outcome trends over time. Data from the initial hospitalization and first two years postinjury were divided into four time periods based on injury year (1973 to 1977, 1978 to 1980, 1981 to 1983, 1984 to 1986). Between 1973 and 1986, mean age at injury increased, as did the percentage of nonwhites and the percentage of persons with quadriplegia, while the percentage of neurologically complete lesions decreased. There was an increase in long-term use of intermittent catheterization. Ventilator use during hospitalization also increased. Mean lengths of stay for acute care and rehabilitation decreased, although mean inflation-adjusted hospital charges increased. The percentage of persons rehospitalized during the second postinjury year decreased substantially. From 1973 to 1986, for persons admitted to the model system within 24 hours of injury, there was a 66% decrease in the risk of dying within the first two years postinjury. Overall, these data document changing demographics and treatment practices as well as an improved prognosis for persons with spinal cord injuries.     

Spinal cord injury

Purpose : This article is an overview of the newer therapeutic interventions employed in the care of the spinal cord injured individual and the theoretical rationale supporting them. Issue : Spinal Cord Injury (SCI) care was, until recently, a maintenance type treatment, addressing systems mostly affected by complications of the original injury (e.g. bladder, skin, spasiticity). Conclusion : With the recent advances in the neuroscience field, more aggressive interventions geared at secondary injury prevention, neuronal regeneration and functional restoration are emerging.     

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.     

Health status, community integration, and economic risk factors for mortality after spinal cord injury

OBJECTIVE: To examine the association of health, community integration, and economic status with subsequent mortality and life expectancy among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model Spinal Cord Injury Systems (MSCIS) hospitals. PARTICIPANTS: A total of 5947 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and who were still alive and received an annual evaluation from November 1995 through March 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Mortality was determined by routine follow-up supplemented by information from the Social Security Death Index. A logistic regression model based on the full set of predictor variables was developed to estimate the chance of dying in any given year. RESULTS: After adjusting for demographic characteristics and injury severity, health status indicators, measures of community integration, and economic status indicators all had relatively small but statistically significant effects (20%-70% increases) on the likelihood of dying during the next year. Inclusion of these factors may result in higher life expectancy estimates under highly favorable conditions. CONCLUSIONS: Whereas previous reports of the MSCIS data have identified the life expectancies associated with a particular set of demographic (eg, age, gender) and injury-related characteristics (level and completeness of injury; ventilator dependence), the current analysis suggests that consideration of health, economic, and psychosocial factors may make computations of life expectancy more accurate.     

国际脊髓损伤脊柱损伤基础数据集

收集脊柱损伤的信息对于脊髓损伤患者的诊断和治疗非常重要,设立脊髓损伤患者脊柱损伤基础数据集是为了规范脊柱损伤相关信息的收集方式和报告内容,学习并使用国际脊髓损伤脊柱损伤基础数据集,有助于规范和统一我国脊髓损伤患者脊柱损伤信息的收集,为相关治疗提供依据。本文将介绍国际脊髓损伤脊柱损伤基础数据集的研发过程,数据元素的内容以及数据编码的应用实例。     

From ICU to rehabilitation: a checklist to ease the transition for the spinal cord injured

Spinal cord injuries are devastating. The injured person faces many unknowns including surgical procedures, hospitalization and rehabilitation. Frequently, the transition from acute care to rehabilitation is frightening. In the intensive care unit (ICU), the patient receives one-to-one nursing care and develops trust, but then may feel abandoned when faced with rehabilitation. In order to facilitate readiness for rehabilitation, coordinators of the Southeastern Michigan Spinal Cord Injury System proposed a checklist of activities designed to meet individual patient and family needs. Coordinators assess the patient within 24 hours of admission to the spinal ICU. The physiatrist is notified of the admission and recommends initial therapies as appropriate. The patient is followed through the acute phase and preparations are made for rehabilitation. A checklist format has been developed to coordinate the transfer. This article describes the checklist and its use at our institution.     

Spinal cord injury

Purpose : This article is an overview of the newer therapeutic interventions employed in the care of the spinal cord injured individual and the theoretical rationale supporting them.

Issue : Spinal Cord Injury (SCI) care was, until recently, a maintenance type treatment, addressing systems mostly affected by complications of the original injury (e.g. bladder, skin, spasiticity).

Conclusion : With the recent advances in the neuroscience field, more aggressive interventions geared at secondary injury prevention, neuronal regeneration and functional restoration are emerging.     

Economics of managed care in spinal cord injury

OBJECTIVE: To determine and describe trends in economic variables related to the care of individuals with spinal cord injury (SCI) and significant changes in these trends coincident with major developments in medical care cost control. DATA SOURCES: Data from the National Spinal Cord Injury Statistical Center (NSCISC) database were used to review the economic trends in SCI management from 1973 to 1998 and their relation to managed care and other health care cost-containment measures. A panel of SCI health care specialists was interviewed to determine the appropriate data variables to be reviewed. The Shepherd Center Care Health Management Program, Atlanta, GA, is presented as an example of a fiscally successful managed care program for patients with SCI. DATA EXTRACTION: Data from the NSCISC database for the years studied were extracted and converted to a form suitable for analysis by means of the statistical software SAS. DATA SYNTHESIS: Statistical techniques included multiple regression analysis, logistic regression analysis, and model selection methods. CONCLUSIONS: Trends in economic variables, in the care of individuals with SCI show changes coincident with the introduction of Diagnostic Related Groups (DRGs) and managed care as models for provider reimbursement. Significant changes occurred in acute care charges, rehabilitation charges, length of stay, rehospitalization 1 year postinjury, time from injury to admission to a Model System, and discharges to a nursing home.     

Trends in life expectancy after spinal cord injury

OBJECTIVE: To investigate whether there have been improvements in survival after spinal cord injury (SCI) over time, both in the critical first 2 years after injury and in the longer term. DESIGN: Pooled repeated observations analysis of person-years. For each person-year, the outcome variable is survival and mortality, and the explanatory variables include age, level and grade of injury, and calendar year (the main focus of the analyses). The method can be viewed as a generalization of proportional hazards regression. SETTING: Model spinal cord injury systems and hospital SCI units across the United States. PARTICIPANTS: Persons (N=30,822) admitted to a Spinal Cord Injury Model Systems facility a minimum of 1 day after injury. Only persons over 10 years of age and known not to be ventilator dependent were included. These persons contributed 323,618 person-years of data, with 4980 deaths, over the 1973 to 2004 study period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Survival. RESULTS: Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post-2-year period is small and not statistically significant. CONCLUSIONS: The absence of a substantial decline in mortality after the first 2 years postinjury is contrary to widely held impressions. Nevertheless, the finding is based on a large database and sensitive analytic methods and is consistent with previous research. Improvements in critical care medicine after spinal cord injury may explain the marked decline in short-term mortality. In contrast, although there have no doubt been improvements in long-term rehabilitative care, their effect in enhancing the life span of persons with SCI appears to have been overstated.     

Recent trends in mortality and causes of death among persons with spinal cord injury

OBJECTIVE: To identify and quantify trends in mortality and causes of death among persons with spinal cord injury. DESIGN: Cohort study. SETTING: Model spinal cord injury care systems and Shriner's Hospitals spinal cord injury units throughout the United States. PATIENTS: A total of 28,239 consecutive persons admitted to the model system or to a Shriner's Hospital within 1 year of injury. MAIN OUTCOME MEASURE: Length of survival and cause of death. RESULTS: Among persons who were admitted to the model system within 1 day of injury, the odds of dying during the first postinjury year were reduced by 67% for persons injured between 1993 and 1998 relative to persons injured between 1973 and 1977 after adjusting for trends in age, gender, race, neurologic level of injury, Frankel grade, ventilator status, etiology of injury, sponsor of care, and model system where treatment occurred. However, mortality rates after the first anniversary of injury, which had also been declining from 1973 to 1992, increased 33% for persons injured between 1993 and 1998 relative to persons injured between 1988 and 1992. Respiratory disease was the only cause of death after the first anniversary of injury for which the relative odds increased meaningfully during the latest time period (76% increase over 1988-1992 compared to all other causes). CONCLUSION: While great improvements in life expectancy have been achieved since the Model SCI Systems program began, current data support the need for renewed efforts to improve the prevention and treatment of the complications of spinal cord injury.