Tracking Spinal Cord Injury Functional Outcomes Across the Lifespan: Validation of Linking Coefficients

ObjectiveValidation of linking coefficients to transform Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI/AM) scores to adult Spinal Cord Injury-Functional Index (SCI-FI) scores.DesignThis cross-sectional study administered PEDI-SCI/AM and SCI-FI computerized adaptive tests (CATs) and short forms (SFs) to children with SCI and parents or caregivers.SettingHospitals, university, and rehabilitation institute.ParticipantsAbout 107 children with SCI and 96 parent or caregivers.InterventionsNot applicable.Main Outcome MeasuresLinking coefficients estimated SCI-FI (est-SCI-FI) scores from PEDI-SCI/AM scores for matched domains. Correlations between est-SCI-FI and actual SCI-FI scores were calculated. If correlations exceeded the criterion linking (0.866), the following analyses to compare est-SCI-FI and actual SCI-FI scores were conducted: paired t tests, intraclass correlation coefficients (ICCs 3, 1), percent of cases with absolute score differences at different thresholds.ResultsTwo matched domains, PEDI-SCI/AM Daily Routine/SCI-FI Self-Care and PEDI-SCI/AM General Mobility/SCI-FI Basic Mobility, met the linking criterion for both respondent-types (parent and child) and administration modes (CAT and SF). PEDI-SCI/AM Daily Routine and SCI-FI Fine Motor Function did not meet linking criterion for respondent type or mode. The linking criterion was met for wheelchair domains (child SF and CAT) and ambulation domains (child SF only). Significant differences between est-SCI-FI and actual SCI-FI scores were noted for all matched domains except Daily Routine/Self-Care (child SF only; parent SF and CAT). ICC values showed excellent agreement (range=0.75-0.89). Absolute differences between est-SCI-FI and actual SCI-FI scores were less than 1 standard deviation (except wheelchair CAT child).ConclusionsLinking coefficients applied to PEDI-SCI/AM scores can provide valid SCI-FI estimates that vary by domain, mode, and respondent type.     

Validation of the Spinal Cord Injury–Functional Index for Use in Community-Dwelling Individuals With SCI

ObjectiveTo evaluate the psychometric properties of the Spinal Cord Injury–Functional Index (SCI-FI) instruments in a community-dwelling sample.DesignCross-sectional study.SettingCommunity setting.ParticipantsIndividuals (N=269) recruited from 6 SCI Model Systems sites.InterventionsNot applicable.Main Outcome MeasuresParticipants completed computer adaptive test and short form versions of 4 SCI-FI/Capacity (C) banks (ie, Ambulation, Basic Mobility, Fine Motor, Self-Care) and 1 SCI-FI/Assistive Technology (AT) bank (Wheelchair Mobility) at baseline and after 2 weeks. The Self-Report Functional Measure (SRFM) and the clinician-rated motor FIM were used to evaluate evidence of convergent validity.ResultsPearson correlations, intraclass correlation coefficients, minimal detectable change, and Bland-Altman plots supported the test-retest reliability of the SCI-FI instruments. Correlations were large with the SRFM (.69-.89) and moderate-to-large for the FIM instrument (.44-.64), supporting convergent validity. Known-groups validity was demonstrated by a significant main effect of injury level on all instruments and a main effect of injury completeness on the SCI-FI/C instruments. A ceiling effect was detected for individuals with incomplete paraplegia on the Fine Motor/C and Self-Care/C Short Forms.ConclusionFindings support the test-retest reliability, convergent validity, and known-groups validity of the SCI-FI/C instruments and the SCI-FI/AT Wheelchair Mobility instruments for use by community-dwelling individuals.     

Applying a Bookmarking Approach to Setting Clinically Relevant Interpretive Standards for the Spinal Cord Injury–Functional Index/Capacity Basic Mobility and Self-Care Item Bank Scores

ObjectivesTo develop clinically relevant interpretive standards for the Spinal Cord Injury–Functional Index/Capacity (SCI-FI/C) Basic Mobility and Self-Care item bank scores.DesignModified “bookmarking” standard-setting methodology, including 2 stakeholder consensus meetings with individuals with spinal cord injury (SCI) and SCI clinicians, respectively, and a final, combined (consumers and clinicians) “convergence” meeting.SettingTwo SCI Model System centers in the United States.ParticipantsFourteen adults who work with individuals with traumatic SCI and 14 clinicians who work with individuals with SCI.Main Outcome MeasuresPlacement of bookmarks between vignettes based on SCI-FI Basic Mobility and Self-Care T scores. Bookmarks were placed between vignettes representing “No Problems,” “Mild Problems,” “Moderate Problems,” and “Severe Problems” for each item bank.ResultsEach consensus group resulted in a single set of scoring cut points for the SCI-FI/C Basic Mobility and Self-Care item banks. The cut points were similar but not identical between the consumer and clinician groups, necessitating a final convergence meeting. For SCI-FI/C Basic Mobility, the convergence group agreed on cut scores of 61.25 (no problems/mild problems), 51.25 (mild problems/moderate problems), and 41.25 (moderate problems/severe problems). For SCI-FI/C Self-Care, the convergence group agreed on cut scores of 56.25 (no/mild), 51.25 (mild/moderate), and 38.75 (moderate/severe).ConclusionsThe results of this study provide straightforward interpretive guidelines for SCI researchers and clinicians using the SCI-FI/C Basic Mobility and Self-Care instruments. These results are appropriate for the full bank, computer adaptive test, and short-form versions of the SCI-FI/C Basic Mobility and Self-Care item banks.     

Racial and Ethnic Disparities in Functioning at Discharge and Follow-Up Among Patients With Motor Complete Spinal Cord Injury

Objective

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

Design

Retrospective cohort study.

Setting

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

Participants

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

Interventions

Not applicable.

Main Outcome Measures

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

Results

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

Conclusions

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.     

Development and initial evaluation of the spinal cord injury-functional index

Jette AM, Tulsky DS, Ni P, Kisala PA, Slavin MD, Dijkers MP, Heinemann AW, Tate DG, Whiteneck G, Charlifue S, Houlihan B, Williams S, Kirshblum S, Dyson-Hudson T, Zanca J, Fyffe D. Development and initial evaluation of the Spinal Cord Injury-Functional Index.ObjectivesTo describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain.DesignCross-sectional survey followed by calibration data simulations.SettingInpatient and community settings.ParticipantsA sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury.InterventionsNone.Main Outcome MeasureSCI-FI instrument.ResultsItem response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks.ConclusionsInitial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI.     

Tracking Functional Status Across the Spinal Cord Injury Lifespan: Linking Pediatric and Adult Patient-Reported Outcome Scores

Objective

To use item response theory (IRT) methods to link scores from 2 recently developed contemporary functional outcome measures, the adult Spinal Cord Injury–Functional Index (SCI-FI) and the Pedi SCI (both the parent version and the child version).

Design

Secondary data analysis of the physical functioning items of the adult SCI-FI and the Pedi SCI instruments. We used a nonequivalent group design with items common to both instruments and the Stocking-Lord method for the linking. Linking was conducted so that the adult SCI-FI and Pedi SCI scaled scores could be compared.

Setting

Community.

Participants

This study included a total sample of 1558 participants. Pedi SCI items were administered to a sample of children (n=381) with SCI aged 8 to 21 years, and of parents/caregivers (n=322) of children with SCI aged 4 to 21 years. Adult SCI-FI items were administered to a sample of adults (n=855) with SCI aged 18 to 92 years.

Interventions

Not applicable.

Main Outcome Measures

Five scales common to both instruments were included in the analysis: Wheelchair, Daily Routine/Self-care, Daily Routine/Fine Motor, Ambulation, and General Mobility functioning.

Results

Confirmatory factor analysis and exploratory factor analysis results indicated that the 5 scales are unidimensional. A graded response model was used to calibrate the items. Misfitting items were identified and removed from the item banks. Items that function differently between the adult and child samples (ie, exhibit differential item functioning) were identified and removed from the common items used for linking. Domain scores from the Pedi SCI instruments were transformed onto the adult SCI-FI metric.

Conclusions

This IRT linking allowed estimation of adult SCI-FI scale scores based on Pedi SCI scale scores and vice versa; therefore, it provides clinicians with a means of tracking long-term functional data for children with an SCI across their entire lifespan.     

Linking the Spinal Cord Injury–Functional Index (SCI-FI) to the PROMIS Physical Functioning Item Bank

ObjectiveTo link 3 Spinal Cord Injury–Functional Index (SCI-FI) item banks (Basic Mobility, Fine Motor Function, Self-Care) to the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) metric.DesignObservational studySettingSix SCI Model Systems rehabilitation hospitals in the United States.ParticipantsAdults with SCI (n=855) and healthy individuals (n=730) (N=1585).InterventionsNot applicable.Main Outcome MeasuresThree SCI-FI item banks (Basic Mobility, Fine Motor Function, Self-Care), PROMIS PF v1.0 item bank.ResultsSCI-FI item banks (including 30 items from the PROMIS PF item bank) were administered to 855 adults with SCI as part of the original SCI-FI development study. The data were used to attempt to link 3 SCI-FI banks to the PROMIS PF metric via 2 item-response theory methods: fixed-parameter calibration and separate calibration. Sixteen items common to SCI-FI and PROMIS and verified as free of differential item functioning were used as anchor items to implement the methods. Of the 3 banks, only SCI-FI Basic Mobility could be linked with sufficient precision to PROMIS PF. Comparisons of actual vs linked PROMIS PF scores and test characteristic curves suggested the fixed-parameter method provided slightly more precision than the separate calibration method.ConclusionsThe linkage between PROMIS PF and SCI-FI Basic Mobility was considered satisfactory for group-level usage. Score equivalents computed from SCI-FI Basic Mobility will be useful for researchers comparing functional levels in SCI to those observed in other clinical and nonclinical groups (eg, in comparative effectiveness research).     

Physical Function Recovery Trajectories After Spinal Cord Injury

ObjectiveTo explore trajectories of functional recovery that occur during the first 2 years after spinal cord injury (SCI).DesignObservational cohort study.SettingEight SCI Model System sites.ParticipantsA total of 479 adults with SCI completed 4 Spinal Cord Injury–Functional Index (SCI-FI) item banks within 4 months of injury and again at 2 weeks, 3, 6, 12, and 24 months after baseline assessment (N=479).InterventionNone.Main Outcome MeasuresSCI-FI Basic Mobility/Capacity (C), Fine Motor Function/C, Self-care/C, and Wheelchair Mobility/Assistive Technology (AT) item banks.ResultsGrowth mixture modeling was used to identify groups with similar trajectory patterns. For the Basic Mobility/C and Wheelchair Mobility/AT domains, models specifying 2 trajectory groups were selected. For both domains, a majority class exhibited average functional levels and gradual improvement, primarily in the first 6 months. A smaller group of individuals made gradual improvements but had greater initial functional limitations. The Self Care/C domain exhibited a similar pattern; however, a third, small class emerged that exhibited substantial improvement in the first 6 months. Finally, for individuals with tetraplegia, trajectories of Fine Motor Function/C scores followed 2 patterns, with individuals reporting generally low initial scores and then making either modest or large improvements. In individual growth curve models, injury/demographic factors predicted initial functional levels but less so regarding rates of recovery.ConclusionsTrajectories of functional recovery followed a small number of change patterns, although variation around these patterns emerged. During the first 2 years after initial hospitalization, SCI-FI scores showed modest improvements; however, substantial improvements were noted for a small number of individuals with severe limitations in fine motor and self-care function. Future studies should further explore the personal, medical, and environmental characteristics that influence functional trajectories during these first 2 years and beyond.     

A computer adaptive testing simulation applied to the FIM instrument motor component

OBJECTIVE: To determine whether computer adaptive testing (CAT) can be used to decrease the number of FIM trade mark instrument motor component items administered in assessing persons with spinal cord injury (SCI). DESIGN: For a CAT simulation, a 3-step algorithm was used to select 6 FIM items for each individual; items were selected according to the subject's motor ability as estimated by 2 initial items. Separate estimates of motor ability for admission, discharge, and follow-up data (plus combined time points) derived from 6 items were compared statistically with estimates derived from 14 items (walking and wheelchair mobility were split). SETTING: Records from the Spinal Cord Injury Model Systems (SCIMS). PARTICIPANTS: Patients served by the SCIMS, for whom complete motor FIM information was available for rehabilitation admission (N=5,969), discharge (N=5,964), or follow-up at a first or later anniversary (N=5,176). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Similarity of mean, standard deviation, skewness, kurtosis, and Rasch reliability and separation of persons and items based on 6 and 13 items; intraclass correlation coefficient (ICC) for parallel estimates. RESULTS: Calibrations for FIM items and FIM steps differed for the 3 time points, but showed sufficient agreement (ICC, >.90) that combined calibration was feasible. Means and other distribution characteristics differed minimally between the 6- and 13-item estimates. The person and item separations and reliabilities were somewhat lower and the mean measurement errors somewhat higher for the 6-item estimates, but only marginally so. ICCs between 6- and 13-item estimates were .95 or higher. CONCLUSION: CAT can be used to reduce data collection time; the level of precision of estimates is minimally less than that provided by traditional assessment approaches.     

Characterizing Natural Recovery of People With Initial Motor Complete Tetraplegia

ObjectiveTo determine the differences in neurologic recovery in persons with initial cervical American Spinal Cord Injury Association Impairment Scale (AIS) grades A and B over time.DesignRetrospective analysis of data from people with traumatic cervical spinal cord injury (SCI) enrolled in the National Spinal Cord Injury Model Systems (SCIMS) database from 2011-2019.SettingSCIMS centers.ParticipantsIndividuals (N=187) with traumatic cervical (C1-C7 motor level) SCI admitted with initial AIS grade A and B injuries within 30 days of injury, age 16 years or older, upper extremity motor score (UEMS) ≤20 on both sides, and complete neurologic data at admission and follow-up between 6 months and 2 years.InterventionsNot applicable.Main Outcome MeasuresConversion in AIS grades, UEMS and lower extremity motor scores (LEMS), and sensory scores.ResultsMean time to initial and follow-up examinations were 16.1±7.3 days and 377.5±93.4 days, respectively. Conversion from an initial cervical AIS grades A and B to motor incomplete status was 13.4% and 50.0%, respectively. The mean UEMS change for people with initial AIS grades A and B did not differ (7.8±6.5 and 8.8±6.1; P=.307), but people with AIS grade B experienced significantly higher means of LEMS change (2.3±7.4 and 8.8±13.9 (P≤.001). The increased rate of conversion to motor incomplete status from initial AIS grade B appears to be the primary driving factor of increased overall motor recovery. Individuals with initial AIS grade B had greater improvement in sensory scores.ConclusionsWhile UEMS recovery is similar in persons with initial AIS grades A and B, the rate of conversion to motor incomplete status, LEMS, and sensory recovery are significantly different. This information is important for clinical as well as research considerations.     

Spinal Cord Injury–Functional Index/Capacity: Responsiveness to Change Over Time

ObjectiveTo establish responsiveness of 3 Spinal Cord Injury–Functional Index/Capacity (SCI-FI/C) item banks in the first year after spinal cord injury (SCI).DesignLongitudinal patient-reported outcomes assessment replicated through secondary analysis of an independent data set.SettingA total of 8 SCI Model Systems rehabilitation hospitals in the United States.ParticipantsStudy 1 participants included 184 adults with recent (≤4 months) traumatic SCI and 221 community-dwelling adults (>1 year post injury) (N=405). Study 2 participants were 418 individuals with recent SCI (≤4 months) (N=418).InterventionsIn study 1, SCI-FI/C computer adaptive tests were presented in a standardized interview format either in person or by phone call at baseline and 6-month follow-up. Responsiveness was examined by comparing 6-month changes in SCI-FI scores within and across samples (recently injured vs community-dwelling) because only the recent injury sample was expected to exhibit change over time. Effect sizes were also computed. In study 2, the study 1 results were cross-validated in a second sample with recent SCI 1 year after baseline measurement. Study 2 also compared the SCI-FI/C measures’ responsiveness to that of the Self-reported Functional Measure (SRFM) and stratified results by injury diagnosis and completeness.Main Outcome MeasuresThe SCI-FI Basic Mobility/C, Self-care/C and Fine Motor/C item banks (study 1 and study 2); Self-reported Functional Measure SRFM (study 2 only).ResultsIn study 1, changes in SCI-FI/C scores between baseline and 6-month follow-up were statistically significant (P<.01) for recently injured individuals. SCI-FI Basic Mobility/C, Self-care/C, and Fine Motor/C item banks demonstrated small to medium effect sizes in the recently injured sample. In the community-dwelling sample, all SCI-FI/C effects were negligible (ie, effect size<0.08). Study 2 results were similar to study 1. As expected, SCI-FI Basic Mobility/C and Self-care/C were responsive to change for all individuals in study 2, whereas the SCI-FI Fine Motor/C was responsive only for individuals with tetraplegia and incomplete paraplegia. The SRFM demonstrated a medium effect size for responsiveness (effect size=0.65).ConclusionsThe SCI-FI Basic Mobility/C and Self-care/C banks demonstrate adequate sensitivity to change at 6 months and 1 year for all individuals with SCI, while the SCI-FI/C Fine Motor item bank is sensitive to change in individuals with tetraplegia or incomplete paraplegia. All SCI-FI/C banks demonstrate stability in a sample not expected to change. Results provide support for the use of these measures for research or clinical use.     

Trauma Indicators in Spinal Cord Injury Rehabilitation Outcomes: A Retrospective Cohort Analysis of the National Trauma Data Bank and National Spinal Cord Injury Database

ObjectiveTo investigate whether initial emergency department physiological measures and metrics of trauma severity predict functional outcomes and neurologic recovery in traumatic spinal cord injury.DesignRetrospective analysis of a clinical database.SettingMerged multicenter data from the Spinal Cord Injury Model Systems (SCIMS) database and National Trauma Data Bank from 6 academic medical centers across the United States.ParticipantsPatients (N=319) admitted to SCIMS rehabilitation centers within 1 year of injury. The majority of patients were men (76.2%), with a mean age of 44 years (SD, 19y). At rehabilitation admission, the most common neurologic level of injury was low cervical (C5-C8, 39.5%) and ASIA impairment scale (AIS) was A (34.4%).Main Outcome MeasuresPrimary outcomes were FIM motor score at discharge from inpatient rehabilitation and change in FIM motor score between inpatient rehabilitation admission and discharge. We hypothesized that derangements in emergency department physiological measures, such as decreased blood pressure and oxygen saturation, as well as increased severity of trauma burden, would predict poorer functional outcomes.ResultsLinear regression analysis showed that neurologic level of injury and AIS predicted discharge FIM motor score. Systolic blood pressure, heart rate, oxygen saturation, need for assisted respiration, and presence of penetrating injury did not predict discharge motor FIM or FIM motor score improvement.ConclusionsInitial emergency department physiological parameters did not prognosticate functional outcomes in this cohort.     

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.     

Testosterone replacement therapy and motor function in men with spinal cord injury: a retrospective analysis

OBJECTIVE: To evaluate motor function in men with spinal cord injury (SCI) given testosterone replacement therapy (TRT). DESIGN: American Spinal Injury Association (ASIA) rehabilitation discharge motor index scores were compared between men with SCI given TRT (testosterone cypionate, 200 mg, monthly; n = 50) and a comparison group (n = 480) in a retrospective study. Covariates included admission motor and FIM scores, level of injury (paraplegia/tetraplegia), days since injury, and age. RESULTS: ASIA discharge motor scores for ASIA impairment scale grades C and D were significantly different (P < 0.05) in men with incomplete SCI given TRT, relative to the comparison group. The covariate-adjusted mean discharge score for the TRT group was higher than for the comparison group. There were no significant differences in discharge FIM scores (P = 0.34) for men with incomplete injuries and no differences in the adjusted discharge ASIA motor scores (P = 0.92) or adjusted discharge FIM scores (P = 0.16) for men with complete injuries. CONCLUSION: The data support a relationship between TRT and strength gains in men with residual motor function after SCI. Prospective studies are necessary to validate these findings.     

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.     

Determining Pressure Injury Risk on Admission to Inpatient Spinal Cord Injury Rehabilitation: A Comparison of the FIM,Spinal Cord Injury Pressure Ulcer Scale,and Braden Scale

ObjectiveAssess the utility of the admission Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), Braden Scale, and the FIM for identifying individuals at risk for developing pressure injury during inpatient spinal cord injury (SCI) rehabilitation.DesignRetrospective cohort.SettingTwo tertiary rehabilitation centers.ParticipantsIndividuals (N=754) participating in inpatient SCI rehabilitation.InterventionsNot applicable.Main Outcome MeasuresLogistic regression analysis was performed to determine the utility of the SCIPUS, Braden Scale, and FIM for identifying individuals at risk for developing pressure injury (PI) during inpatient SCI rehabilitation. Sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, odds ratio, likelihood ratio, and area under the curve (AUC) are reported.ResultsThe SCIPUS total score and its individual items did not demonstrate acceptable accuracy (AUC≥0.7) whereas the Braden Scale (0.73) and the FIM score (0.74) did. Once items were dichotomized into high and low risk categories, 1 Braden item (friction and shear), 5 FIM items (bathing, toileting, bed/chair transfer, tub/shower transfer, toilet transfer), the FIM transfers subscale, FIM Motor subscale, and the FIM instrument as a whole, maintained AUCs ≥0.7 and negative predictive values ≥0.95. The FIM bed/chair transfer score demonstrated the highest likelihood ratio (2.62) and overall was the most promising measure for determining PI risk.ConclusionStudy findings suggest that a simple measure of mobility, admission FIM bed/chair transfer score of 1 (total assist), can identify at-risk individuals with greater accuracy than both an SCI specific instrument (SCIPUS) and a PI specific instrument (Braden). The FIM bed/chair transfer score can be readily determined at rehabilitation admission with minimal administrative and clinical burden.     

Metric properties of the ASIA motor score: subscales improve correlation with functional activities

OBJECTIVE: To apply item response theory (IRT) methods to neurologic and functional scales to determine the value of using American Spinal Injury Association (ASIA) motor subscores and ability estimates, rather than total ASIA motor scores, to predict motor FIM instrument scores. DESIGN: Secondary analysis of prospectively collected data. SETTING: Model Spinal Cord Injury Systems centers. PARTICIPANTS: People with traumatic spinal cord injury (SCI) (N=4338) discharged from inpatient rehabilitation between January 1, 1994, and March 31, 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total discharge motor FIM scores, FIM subscale scores, and IRT-derived ability estimates of motor FIM scores. RESULTS: Use of separate ASIA upper-extremity and lower-extremity motor scores improved prediction of motor FIM scores over that of total ASIA motor score (R(2) for motor FIM score, .71 vs .59). Use of IRT-based ability estimates derived by applying a 2-parameter graded response model to the raw scores, however, did not improve prediction of motor FIM scores above that of the ASIA motor subscale scores. CONCLUSIONS: Consistent with the metric properties of the ASIA motor score, and with recent models of disablement, impairment in SCI is more accurately characterized by using separate ASIA upper- and lower-extremity motor scores than by using a single motor score. Use of subscores for impairment should improve prediction of functional abilities and enhance more complex models of disability.     

Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries

Zariffa J, Curt A, for the EMSCI Study Group, Steeves JD. Functional motor preservation below the level of injury in subjects with American Spinal Injury Association Impairment Scale grade A spinal cord injuries.ObjectiveTo assess how frequently subjects with spinal cord injuries (SCIs) classified as American Spinal Injury Association Impairment Scale (AIS) grade A have substantial preserved motor function below the neurologic level of injury, despite having no preserved sensory or motor function at the S4-5 spinal cord segment.DesignAnalysis of the European Multicenter Study about Spinal Cord Injury database to determine how frequently subjects assessed as AIS A would have been AIS D based on motor scores alone (ie, had scores of ≥3 in at least half of the International Standards for Neurological Classification of Spinal Cord Injury [ISNCSCI] key muscles below the neurologic level of injury, despite having no sacral sparing).SettingEighteen European centers.ParticipantsIndividuals with traumatic SCI at any level (total of 2557 assessments).InterventionsNot applicable.Main Outcome MeasureISNCSCI assessments.ResultsOver the first year after SCI (with assessments at approximately 1, 4, 12, 24, and 48wk) and for all rostrocaudal levels of injury, only 3.2% of AIS A assessments were found to meet the AIS D motor score criteria. The percentage was highest for lumbar (16.3%) and lower thoracic (4.4%) SCI. No trends were observed across time points.ConclusionsThese results suggest that the low frequency of individuals with an AIS A classification and high levels of motor function are not a significant concern in subject recruitment for clinical trials, unless the level of SCI is within the lumbar cord.