The comparison of recovery patterns between ischemic spinal cord injury and traumatic spinal cord injury from acute to chronic phase

Objective: To investigate the neurological and functional recovery patterns of ischemic spinal cord injury (ISCI) compared with traumatic spinal cord injury (TSCI) in the acute to chronic phase.Design: Retrospective cohort study.Settings: Department of Neurology, Neurosurgery, Rehabilitation Medicine at a tertiary hospital.Participants: Fifty-four patients with ISCI and 86 patients with TSCI.Interventions: Not applicable.Outcome measures: MRI findings, American Spinal Injury Association Impairment Scale (AIS), modified Rankin Scale (mRS), Korean Spinal Cord Independence Measure (KSCIM), ambulatory status, and bladder status were reviewed. The functional outcomes were measured at admission, discharge, and >6 months after discharge.Results: AIS classification did not significantly change after 6 months in both ISCI and TSCI groups. Between admission and discharge, the proportion of patients needing a wheelchair or assistive device to ambulate decreased more in the ISCI group compared with the TSCI group [odds ratio (OR) 0.40, P = 0.04]. In addition, the proportion of catheterized voiding in the ISCI group was significantly higher than in the TSCI group at all time points (OR 5.12, P < 0.001). Lastly, both groups showed that functional improvement was the greatest between admission and discharge. In addition, the proportion of catheterized voiding decreased (Diff = −0.12, P = 0.019) and mRS score decreased (Diff=−0.48, P < 0.001) significantly in the ISCI group at >6 months post discharge.Conclusion: The ISCI group showed better recovery of mobility during inpatient rehabilitation period and worse recovery of bladder function as demonstrated by higher number of patients requiring bladder catheterization at all time points when compared with the TSCI group.     

Antispasmodic medications may be associated with reduced recovery during inpatient rehabilitation after traumatic spinal cord injury

Objective: To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI).

Design/Methods: Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not.

Outcome measures: Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level.

Results: Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4–24.2). Total motor score averaged 39.2 (95% CI 37.8–40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P?=?0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics.

Conclusions: Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.     

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

Abstract

Objective

To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).

Design

A retrospective cohort design was employed, using data retrieved from administrative databases.

Setting

Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.

Participants

Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.

Outcome measures

Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics.

Results

There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).

Conclusion

Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.     

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

ObjectiveTo compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).DesignA retrospective cohort design was employed, using data retrieved from administrative databases.SettingRehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.ParticipantsPatients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.ResultsThere was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).ConclusionDespite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.     

Peer-led,transformative learning approaches increase classroom engagement in care self-management classes during inpatient rehabilitation of individuals with spinal cord injury

Objective: Evaluate effects of revised education classes on classroom engagement during inpatient rehabilitation for individuals with spinal cord injury/disease (SCI/D).

Design: Multiple-baseline, quasi-experimental design with video recorded engagement observations during conventional and revised education classes; visual and statistical analysis of difference in positive engagement responses observed in classes using each approach.

Participants/Setting: 81 patients (72% male, 73% white, mean age 36 SD 15.6) admitted for SCI/D inpatient rehabilitation in a non-profit rehabilitation hospital, who attended one or more of 33 care self-management education classes that were video recorded. All study activities were approved by the host facility institutional review board.

Intervention: Conventional nurse-led self-management classes were replaced with revised peer-led classes incorporating approaches to promote transformative learning. Revised classes were introduced across three subject areas in a step-wise fashion over 15 weeks.

Outcome Measure: Positive engagement responses (asking questions, participating in discussion, gesturing, raising hand, or otherwise noting approval) were documented from video recordings of 14 conventional and 19 revised education classes.

Results: Significantly higher average (per patient per class) positive engagement responses were observed in the revised compared to conventional classes (p=0.008).

Conclusion: Redesigning SCI inpatient rehabilitation care self-management classes to promote transformative learning increased patient engagement. Additional research is needed to examine longer term outcomes and replicability in other settings.     

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

Background

Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams.

Objective

To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI.

Methods

Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models.

Results

Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent.

Conclusions

Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.     

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: The SCIRehab Project

Context/objective

Rehabilitation teams generally are described as consisting of a single representative of 6–8 disciplines, but research suggests that the number of individuals involved may be much larger. This study aimed to determine the size of teams in spinal cord injury (SCI) rehabilitation, and the effect of team size on patients'' active participation in their treatment sessions.

Design

Prospective observational study.

Setting

Six SCI rehabilitation centers.

Participants

A total of 1376 patients with traumatic SCI admitted for first rehabilitation.

Interventions

Not applicable.

Outcome measures

Number of treatment sessions, by discipline and overall clinician rating of active participation of the patient; Treatment Concentration Index (TCI) calculated as Σp_k² (where p refers to the proportion of treatment sessions delivered by team member k).

Results

The average patient was treated by 39.3 different clinicians. The numbers were especially high for physical therapy (mean: 8.8), occupational therapy (7.2), and nursing (16.1). TCI was 0.08 overall; it varied by discipline. TCI was negatively correlated with length of stay, except for psychology. Participation ratings were minimally affected by the number of sessions the patient and the therapist had worked together.

Conclusions

In SCI rehabilitation, teams are at least as large as suggested by previous research. However, this may not mean lack of familiarity of patient and therapist with one another, or alternatively, the possibly weak therapeutic alliance does not affect the patients'' active participation in their sessions. Further research is needed to determine whether there are negative effects on rehabilitation outcomes.     

Outcomes of social work and case management services during inpatient spinal cord injury rehabilitation: The SCIRehab project

Objective

To investigate associations of social work/case management (SW/CM) services during inpatient rehabilitation following spinal cord injury (SCI) and patient characteristics with outcomes.

Design

Prospective observational cohort of individuals with SCI receiving inpatient rehabilitation.

Setting

Six inpatient rehabilitation centers.

Participants

1032 individuals with traumatic SCI.

Interventions

Not applicable.

Main outcome measure(s)

Type of residence at the time of rehabilitation discharge. Employment/school status, presence of a pressure ulcer, Patient History Questionnaire, Satisfaction with Life Scale, Craig Handicap Assessment and Reporting Technique (CHART) subscales, and rehospitalization at 1-year post-injury.

Results

The intensity of specific SW/CM services is associated with multiple outcomes examined. More sessions dedicated to discharge planning for a home discharge and financial planning were associated positively with more discharge to home, while more sessions focused on planning for discharge to a location other than home, e.g. nursing home or long-term acute care facilities, have negative associations with societal participation outcomes (CHART Social Integration, Occupation, and Mobility scores) as well as with residing at home at the time of the 1-year injury anniversary.

Conclusion(s)

The intensity and type of SW/CM services are associated with outcomes at rehabilitation discharge and at 1-year post-injury. Discharge to home may require assistance from SW/CM in the area of discharge planning and financial planning, while discharge to non-home residence demands directed SW/CM services for such placement.

Note

This is the eighth of nine articles of this SCIRehab series.     

Relationship of nursing education and care management inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Objective

To investigate associations of nursing bedside education and care management activities during inpatient rehabilitation with functional, participation, and quality-of-life outcomes for patients with traumatic spinal cord injury (SCI).

Methods

In a prospective observational study, data were obtained by means of systematic recording of nursing activities by registered nurses (RNs), chart review and patient interview.

Results

Greater patient participation in nursing activities is associated with better outcomes. More time spent by RNs in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) is associated with patient report of higher life satisfaction and higher CHART mobility at the one-year injury anniversary; more time providing psychosocial support is associated with higher CHART mobility and occupation scores and with greater likelihood of working or being in school at the anniversary. More time spent providing education about specific care needs is associated with several outcomes but not as consistently as might be expected.

Conclusion(s)

Higher levels of patient participation in nursing care activities is associated with multiple better outcomes, and hence, nurses should promote active patient participation during all aspects of care and interactions between themselves and patients with SCI. Time spent providing psychosocial support of patients and their families should be evaluated to ensure that other necessary education or care management interventions are not minimized.

Note

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

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

Background/objective

To describe the nature and distribution of activities during physical therapy (PT) delivered in inpatient spinal cord injury (SCI) rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities.

Methods

Six hundred patients from six inpatient SCI centers were enrolled in the SCIRehab study. Physical therapists documented details, including time spent, of treatment provided during 37 306 PT sessions that occurred during inpatient SCI rehabilitation. Ordinary least squares regression models associated patient and injury characteristics with time spent in specific PT activities.

Results

SCIRehab patients received a mean total of 55.3 hours of PT over the course of their rehabilitation stay. Significant differences among four neurologic groups were seen in the amount of time spent on most activities, including the most common PT activities of strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training. Most PT work (77%) was provided in individual therapy sessions; the remaining 23% was done in group settings. Patient and injury characteristics explained only some of the variations seen in time spent on wheelchair mobility, transfer and bed mobility training, and range of motion/stretching.

Conclusion

Analysis yielded both expected and unexpected trends in SCI rehabilitation. Significant variation was seen in time spent on PT activities within and among injury groups. Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings. Details about services provided, including time spent, will serve as a starting point in detailing the optimal treatment delivery for maximal outcomes.     

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

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

The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program

Objectives

To implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks.

Design

Quality improvement.

Setting

SCI Rehabilitation Center.

Participants

Inpatients admitted January 2012 to July 2013.

Interventions

Implementation of two PU best practices were targeted: (1) completing a comprehensive PU risk assessment and individualized interprofessional PU prevention plan (PUPP); and (2) providing patient education for PU prevention; as part of the pan-Canadian SCI Knowledge Mobilization Network. At our center, the SCI Pressure Ulcer Scale replaced the Braden risk assessment scale and an interprofessional PUPP form was implemented. Comprehensive educational programing existed, so efforts focused on improving documentation. Implementation science frameworks provided structure for a systematic approach to best practice implementation (BPI): (1) site implementation team, (2) implementation drivers, (3) stages of implementation, and (4) improvement cycles. Strategies were developed to address key implementation drivers (staff competency, organizational supports, and leadership) through the four stages of implementation: exploration, installation, initial implementation, and full implementation. Improvement cycles were used to address BPI challenges.

Outcome Measures

Implementation processes (e.g. staff training) and BPI outcomes (completion rates).

Results

Following BPI, risk assessment completion rates improved from 29 to 82%. The PUPP completion rate was 89%. PU education was documented for 45% of patients (vs. 21% pre-implementation).

Conclusion

Implementation science provided a framework and effective tools for successful pressure ulcer BPI in SCI rehabilitation. Ongoing improvement cycles will target timeliness of tool completion and documentation of patient education.     

Measuring pain phenomena after spinal cord injury: Development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools

Objective: To develop modern patient-reported outcome measures that assess pain interference and pain behavior after spinal cord injury (SCI).

Design: Grounded-theory based qualitative item development; large-scale item calibration field-testing; confirmatory factor analyses; graded response model item response theory analyses; statistical linking techniques to transform scores to the Patient Reported Outcome Measurement Information System (PROMIS) metric.

Setting: Five SCI Model Systems centers and one Department of Veterans Affairs medical center in the United States.

Participants: Adults with traumatic SCI.

Interventions: N/A.

Outcome Measures: Spinal Cord Injury - Quality of Life (SCI-QOL) Pain Interference item bank, SCI-QOL Pain Interference short form, and SCI-QOL Pain Behavior scale.

Results: Seven hundred fifty-seven individuals with traumatic SCI completed 58 items addressing various aspects of pain. Items were then separated by whether they assessed pain interference or pain behavior, and poorly functioning items were removed. Confirmatory factor analyses confirmed that each set of items was unidimensional, and item response theory analyses were used to estimate slopes and thresholds for the items. Ultimately, 7 items (4 from PROMIS) comprised the Pain Behavior scale and 25 items (18 from PROMIS) comprised the Pain Interference item bank. Ten of these 25 items were selected to form the Pain Interference short form.

Conclusions: The SCI-QOL Pain Interference item bank and the SCI-QOL Pain Behavior scale demonstrated robust psychometric properties. The Pain Interference item bank is available as a computer adaptive test or short form for research and clinical applications, and scores are transformed to the PROMIS metric.     

Participation following traumatic spinal cord injury: an evidence-based review for research

BACKGROUND/OBJECTIVE: To report an evidence-based review of participation instruments that have been used in spinal cord injury (SCI) clinical practice and research. METHODS: Rehabilitation literature was searched for instruments used by at least 2 independent SCI researchers since 2000. Each instrument was reviewed by 2 committee members. One person reviewed the scale and documented the level of use and psychometric properties. The second committee member verified the values and made suggestions for changes. RESULTS: Three instruments met the review criteria: Craig Handicap Assessment and Reporting Technique (CHART), Assessment of Life Habits (LIFE-H), and the Impact on Participation and Autonomy (IPA). Each instrument incorporates different perspectives in the measurement of participation. The LIFE-H uses a qualitative approach, whereas the CHART adopts a quantitative approach; both are based on societal norms of participation. In contrast, the IPA integrates individual choice and control in defining participation. CHART is the most widely used instrument, although its development predates the development of the ICF. The IPA is a relatively new instrument, and its psychometric properties have only recently published. CONCLUSIONS: Continuing research is needed to develop conceptually and psychometric valid measures of participation for use with people with SCI. Priorities include understanding the relationship between objective and subjective indicators of participation, describing the dimensions of participation, and identifying appropriate measurement models and psychometric approaches to evaluate the nonhierarchical character of participation. Researchers and clinicians should be aware of the strengths and limitations of existing measures to make informed decisions about appropriate instruments.     

Measurement properties of a modified measure of participation for persons with spinal cord injury

Objective: The primary aim of this study was to examine and refine a modified measure of participation for adults with spinal cord injury (SCI) based on a conceptual model of participation.

Method: This study involved secondary analysis of data from a larger study designed to identify a standard measure of participation for use in SCI research. The larger study recruited 634 community-dwelling adults with SCI from seven collaborating SCI Model Systems Centers, of whom 520 subjects (average age 45.1 ± 13.6 years, 76% were male) completed the survey that is the focus of the present analysis. Content review, confirmatory factor analysis (CFA), Rasch analysis, and precision analysis were employed to select the items for the modified participation measure.

Results: Three participation domains were supported: Productivity, Social, and Community, that displayed good model-fit (CFI=0.984, TLI=0.982, RMSEA=0.043) in CFA and good item-fit (infit= 0.6 to 1.4) in Rasch analysis. Differential Item Functioning (DIF) was found in one item, however its magnitude was small. The precision of each scale was better for participants in the middle range of participation and was lower for participants with extremely low or high participation.

Conclusion: The study results support the proposed three-dimensional construct of participation by demonstrating good model-fit and item-fit. Ongoing efforts are needed to expand the domain coverage and increase the precision of the instrument.     

Relationship of therapeutic recreation inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Objective

To investigate associations of therapeutic recreation (TR) interventions during inpatient rehabilitation for patients with traumatic spinal cord injury (SCI) with functional, participation, and quality of life outcomes.

Methods

In this prospective observational study, data were obtained from systematic recording of TR services by certified TR specialists, chart review, and patient interview.

Results

TR interventions, including exposure to community settings and leisure activities, add to the variance explained (in addition to the strong predictors of injury classification, admission motor Functional Independence Measure (FIM), and other patient characteristics) in outcomes at the time of rehabilitation discharge (FIM, discharge to home) and at the 1-year injury anniversary (FIM, working or being in school, residing at home, and societal participation as measured by the Craig Handicap Assessment and Reporting Technique (CHART)). They also are associated with less rehospitalization and less pressure development after discharge. In addition, more time spent in specific TR activities during rehabilitation is associated with more participation in the same type of activities at the 1-year injury anniversary.

Conclusion(s)

Greater participation in TR-led leisure skill and community activities during rehabilitation is a positive predictor of multiple outcomes at rehabilitation discharge and the 1-year injury anniversary demonstrating that TR activities are associated with a return to a productive and healthy life after SCI. Further research should focus on the impact of TR on longer-term outcomes to determine whether relationships continue or change as persons continue to adapt to their life after SCI.

Note

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

Peer mentoring reduces unplanned readmissions and improves self-efficacy following inpatient rehabilitation for individuals with spinal cord injury

ObjectiveEvaluate effectiveness of peer interventions on self-efficacy, unplanned hospital readmissions, and quality of life for patients with spinal cord injury (SCI) undergoing inpatient rehabilitation.DesignInterrupted time-series analysis (ITSA) examined effects of peer interventions on unplanned readmissions. Intervention variables added to ITSA regression examined relationships with exposure to peer interventions. Heterogeneity of treatment effects (HTE) analysis examined differences in intervention effectiveness for patients with quadriplegia and paraplegia.SettingRehabilitation hospital specializing in SCI and brain injury.ParticipantsSCI inpatients (n = 1117) admitted for rehabilitation whose discharge location was home (77% male, 71% Caucasian, mean age 38.2 (SD 16.8)). A subsample of 799 patients participated in secondary analyses examining relationship between peer interventions, readmissions, changes in patient-reported outcomes, and HTE.InterventionsOne-to-one mentoring and participation in peer-led self-management classes.Main outcome measuresUnplanned readmissions, general self-efficacy (GSE), and depressive symptoms 30, 90, and 180 days post discharge; satisfaction with life at 180 days.ResultsAfter implementing the peer interventions, we observed a significant decrease in both level and slope of number of patients readmitted, and level only of unplanned hospital days 30-days post-discharge. Reduction in the number of patients and unplanned hospital days was associated with number of peer visits but not peer-led education classes attended. Higher self-efficacy (GSE) was associated with greater exposure to peer mentoring, and a significant relationship between improvement in GSE and reduced hospital readmissions was observed.ConclusionsOne-to-one peer mentoring improves self-efficacy and reduces unplanned hospital readmissions following inpatient rehabilitation for persons with SCI.