Validity and Reliability of Assessment Tools for Measuring Unsupported Sitting in People With a Spinal Cord Injury

Boswell-Ruys CL, Sturnieks DL, Harvey LA, Sherrington C, Middleton JW, Lord SR. Validity and reliability of assessment tools for measuring unsupported sitting in people with a spinal cord injury.

Objectives

To develop simple tests to assess the abilities of people with spinal cord injury (SCI) to sit unsupported and to assess the construct validity and test-retest reliability of these tests.

Design

Cross-sectional comparisons, convenience sample.

Setting

Biomechanical laboratory.

Participants

People (N=30) with SCI between the C6 and the L2 level of 2 months to 37 years duration before assessment. The sample was stratified by impairment level (at T8) and time since injury (1y postinjury).

Interventions

Not applicable.

Main Outcome Measures

On 2 separate occasions, participants performed tests that measured the distance of upper-body sway and maximal torso leaning, errors made during a coordinated stability task, timed dressing/undressing of the upper body and alternating arm reaching, and percentage change in seated upper body/arm reaching.

Results

All tests showed good construct validity in that they distinguished between participants with higher (C6-T7) and lower (T8-L2) level impairments (P<.05) and between participants with acute (≤1y) and chronic (>1y) lesions (P<.05). The tests also showed good to excellent test-retest reliability (intraclass correlation coeffiecient_3,1 range, .51-.91).

Conclusions

These simple and quick-to-administer tests have both construct validity and test-retest reliability. They would be appropriate for research and clinical purposes to quantify the abilities of people with SCI to sit unsupported.     

Impact of Blood Pressure Dysregulation on Health-Related Quality of Life in Persons With Spinal Cord Injury: Development of a Conceptual Model

Objectives

To identify medically relevant aspects of blood pressure dysregulation (BPD) related to quality of life in individuals with spinal cord injury (SCI), and to propose an integrated conceptual framework based on input from both individuals with SCI and their clinical providers. This framework will serve as a guide for the development of a patient-reported outcome (PRO) measure specifically related to BPD.

Design

Three focus groups with individuals with SCI and 3 groups with SCI providers were analyzed using grounded-theory based qualitative analysis to ascertain how blood pressure impacts health-related quality of life (HRQOL) in individuals with SCI.

Setting

Focus groups were conducted at 2 Veterans Affairs medical centers and a research center.

Participants

Individuals with SCI (n=27) in 3 focus groups and clinical providers (n=25) in 3 focus groups.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Qualitative analysis indicated that all focus groups spent the highest percentage of time discussing symptoms of BPD (39%), followed by precipitators/causes of BPD (16%), preventative actions (15%), corrective actions (12%), and the impact that BPD has on social or emotional functioning (8%). While patient/consumer focus groups and provider focus groups raised similar issues, providers spent more time discussing precipitators/causes of BPD and preventative actions (38%) than patient/consumer groups (24%).

Conclusions

These results suggest that BPD uniquely and adversely impacts HRQOL in persons with SCI. While both individuals with SCI and their providers highlighted the relevant symptoms of BPD, the SCI providers offered additional detailed information regarding the precipitators/causes and what can be done to prevent/treat BPD. Further, the results suggest that persons with SCI are aware of how BPD impacts their HRQOL and are able to distinguish between subtle signs and symptoms. These findings exemplify the need for a validated and sensitive clinical measurement tool that can assess the extent to which BPD impacts HRQOL in patients 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.     

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.     

Self-Scoring Templates for Motor and Cognitive Subscales of the FIM Instrument for Persons With Spinal Cord Injury

Objective

To provide self-scoring templates for the FIM instrument's motor and cognitive scales that enable clinicians to monitor progress during rehabilitation using equal-interval Rasch-calibrated measures instead of ordinal raw scores.

Design

Secondary analysis of a prospective, observational cohort study.

Setting

Six geographically dispersed hospital-based rehabilitation centers in the United States.

Participants

Subset of consecutively enrolled individuals with new traumatic spinal cord injuries discharged from participating rehabilitation centers (N=1146).

Intervention

Not applicable.

Main Outcome Measures

Subscores of the FIM instrument, including a 13-item motor scale, a 5-item cognitive scale, an 11-item (without sphincter control items) motor scale, a 3-item transfer scale, a 6-item self-care scale, a 3-item self-care upper extremity scale, and a 3-item self-care lower extremity scale.

Results

KeyForms for the FIM instrument scales allow clinicians and investigators to estimate patients' functional status and monitor progress. In cases with no missing data, the look-up tables provide more accurate estimates of patients' functional status.

Conclusion

Clinicians can use KeyForms and look-up tables for FIM instrument subscales to monitor patients' progress and communicate improvement in equal-interval units.     

Measurement Properties of the Spinal Cord Injury-Functional Index (SCI-FI) Short Forms

Objective

To evaluate the psychometric properties of the Spinal Cord Injury-Functional Index (SCI-FI) short forms (basic mobility, self-care, fine motor, ambulation, manual wheelchair, and power wheelchair) based on internal consistency; correlations between short forms banks, full item bank forms, and a 10-item computer adaptive test version; magnitude of ceiling and floor effects; and test information functions.

Design

Cross-sectional cohort study.

Setting

Six rehabilitation hospitals in the United States.

Participants

Individuals with traumatic spinal cord injury (N=855) recruited from 6 national Spinal Cord Injury Model Systems facilities.

Interventions

Not applicable.

Main Outcome Measures

SCI-FI full item bank, 10-item computer adaptive test, and parallel short form scores.

Results

The SCI-FI short forms (with separate versions for individuals with paraplegia and tetraplegia) demonstrate very good internal consistency, group-level reliability, excellent correlations between short forms and scores based on the total item bank, and minimal ceiling and floor effects (except ceiling effects for persons with paraplegia on self-care, fine motor, and power wheelchair ability and floor effects for persons with tetraplegia on self-care, fine motor, and manual wheelchair ability). The test information functions are acceptable across the range of scores where most persons in the sample performed.

Conclusions

Clinicians and researchers should consider the SCI-FI short forms when computer adaptive testing is not feasible.     

Longitudinal Description of the Glasgow Outcome Scale-Extended for Individuals in the Traumatic Brain Injury Model Systems National Database: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

Objective

To comprehensively describe the temporal patterns of global outcome after traumatic brain injury (TBI) in the Traumatic Brain Injury Model Systems National Database (TBIMS NDB).

Design

Longitudinal prospective cohort study.

Setting

TBI Model Systems centers.

Participants

Patients (N=3870) ≥16 years of age with moderate or severe TBI enrolled in the TBIMS NDB.

Interventions

None.

Main Outcome Measure

Glasgow Outcome Scale-Extended (GOS-E).

Results

The trajectory of the GOS-E scores is best described with a model of quadratic change, in which scores initially increase and peak approximately 10 years after the first GOS-E assessment, and then decrease. Change occurs most rapidly in the initial and final years of the timeline. There was significant variability in each growth parameter (P<.05). A reduced multilevel model was built, including all covariates (age at first GOS-E assessment, FIM, race, sex, rehabilitation length of stay) that related significantly to the growth parameters. An interactive tool was created to generate individual level trajectories based on various combinations of covariate values. Results provide an individual level account of the chronological progression of TBI outcomes, as measured by the GOS-E.

Conclusions

Individual growth curve analysis is a statistically rigorous approach to describe temporal change with respect to the GOS-E at the individual level for participants within the TBIMS NDB. Results indicated that, for individuals in the TBIMS NDB as a group, functional status as measured by the GOS-E initially improves, plateaus, and then begins to decline. Factors such as age at first GOS-E assessment, race, FIM score at rehabilitation admission, and rehabilitation length of stay were found to influence baseline GOS-E scores, as well as the rate and extent of both improvement and decline over time. Additional research may be required to determine the generalizability of these findings and the usefulness of this tool for clinical applications.     

Increased Participation in Activities of Daily Living Is Associated With Lower Cholesterol Levels in People With Spinal Cord Injury

Hetz SP, Latimer AE, Martin Ginis KA, Buchholz AC, and the SHAPE-SCI Research Group. Increased participation in activities of daily living is associated with lower cholesterol levels in people with spinal cord injury.

Objective

To evaluate the relationships between activities of daily living (ADLs) participation and coronary heart disease (CHD) risk factors in people with spinal cord injury.

Design

Cross-sectional.

Setting

Community, university, hospital.

Participants

Participants (N=75) from the Study of Health and Activity in People With Spinal Cord Injury study (61 men, 14 women).

Interventions

Not applicable.

Main Outcome Measures

Physical Activity Recall Assessment for People With Spinal Cord Injury and CHD risk factor assessment including waist circumference, total cholesterol, low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol, and triglycerides.

Results

Using generalized linear models, and controlling for leisure time physical activity and covariates, increased Mobility ADLs (transferring and wheeling) were associated with lower plasma total cholesterol and LDL. No other significant relationships emerged.

Conclusions

Mobility ADLs were associated with lower total cholesterol and LDL. However, neither Total ADLs nor Domestic ADLs were associated with CHD risk. Further investigation is needed to determine causality between Mobility ADLs and CHD risk.     

Symptoms of Depression Over Time in Adults With Pediatric-Onset Spinal Cord Injury

Objective

To investigate the prevalence of depressive symptoms in adults with pediatric-onset spinal cord injury (SCI) and explore potential risk factors that may be associated with elevated symptoms.

Design

Longitudinal, cohort survey over a period of 2 to 9 years. Follow-up occurred approximately every year, a total of 868 interviews were conducted, and most participants contributed to at least 3 waves of data (72%; range, 2–8; mean, 4.34±2.16).

Setting

Community.

Participants

Adults (N=214; 133 men; mean age at first interview, 29.52±5.21y; range, 24–42y) who sustained an SCI prior to age 19 (mean age at injury, 13.93±4.37y; range, 0–18y). Participants tended to have complete injuries (71%) and tetraplegia (58%).

Interventions

Not applicable.

Main Outcome Measures

Participants completed measures assessing psychosocial functioning, physical independence, participation, and depression at each time point. Multilevel growth modeling analyses were used to explore depression symptoms across time.

Results

Depression symptoms at initial status were typically minimal (3.07±.24; 95% confidence interval, 2.6–3.54) but fluctuated significantly over time (P<.01). Several factors emerged as significant predictors of depressive symptoms in the final model, including less community participation (P<.01), incomplete injury (P=.02), hazardous drinking (P=.02), bladder incontinence (P=.01), and pain (P=.03). Within individuals, as bowel accidents (P<.01) and pain increased (P<.01), depression scores increased; however, marriage resulted in decreases in depression scores for individuals (P=.02).

Conclusions

These findings suggest that most patients with pediatric-onset SCI are psychologically resilient, but strategies to minimize secondary health complications and foster community participation and engagement should be considered.     

Reproducibility of Transcutaneous Oxygen Pressure Measurements in Persons With Spinal Cord Injury

Gélis A, Fattal C, Dupeyron A, Pérez-Martin A, Colin D, Pelissier J. Reproducibility of transcutaneous oxygen pressure measurements in persons with spinal cord injury.

Objectives

To assess the reproducibility and the effects of the subjects' characteristics on the reproducibility of transcutaneous oxygen pressure (TcPO₂) measurements in the sacral area in persons with spinal cord injury during loading in the supine position.

Design

Test-retest study.

Setting

Physical medicine and rehabilitation center.

Participants

Thirty spinal cord-injured American Spinal Injury Association grade A subjects.

Main Outcome Measures

Two TcPO₂ monitoring sessions in the sacral area during loading in the supine position were performed at 24-hour intervals, including the measurement of absolute resting sacral and chest TcPO₂ values and the calculation of regional perfusion index (RPI) and delta from rest oxygen pressure, taking into account systemic TcPO₂ changes.

Results

The intraclass coefficient of the sacral TcPO₂ absolute resting value, RPI, and delta from rest oxygen pressure was .787 and .798, .704 and .635, .760 and .465, respectively, at 20 and 40 minutes. The only characteristic with an influence on RPI reproducibility was the subject's smoking status, whereas age, weight, time since injury, lesion level, and presence of pressure ulcer showed no influence.

Conclusions

TcPO₂ measurement is a reproducible method for assessing cutaneous microcirculation during loading over 20-minute monitoring sessions, with RPI exhibiting better reproducibility than delta from rest oxygen pressure at 40 minutes.     

Development and Assessment of a Community Follow-Up Questionnaire for the Rick Hansen Spinal Cord Injury Registry

Objective

To develop a comprehensive community follow-up questionnaire for participants enrolled in the Rick Hansen Spinal Cord Injury Registry (RHSCIR).

Design

Development and preliminary assessment of measurement properties (reliability and validity) of instruments used during a community follow-up and aligned with the International Classification of Functioning, Disability and Health (ICF).

Setting

General community setting.

Participants

People with spinal cord injury (N=50) living in the community.

Intervention

Not applicable.

Main Outcome Measures

A comprehensive follow-up questionnaire, referred to as the RHSCIR Community Follow-up Questionnaire Version 2.0 (CFQ-V2.0), includes 8 instruments. Four new instruments were developed, 2 existing instruments were modified, and 2 previously published instruments were included.

Results

Intra- and interrater reliability statistics (Gwet's AC1) support the measurement properties of the new and modified instruments. Correlations between new and existing instruments and between groups based on the severity of injury support the construct validity of the secondary complications and person-perceived participation instruments.

Conclusions

The RHSCIR CFQ-V2.0 is a comprehensive community follow-up questionnaire that aligns to the ICF. Initial study results suggest that it covers all relevant aspects of community living, and the measurement properties are promising.     

Scale Refinement and Initial Evaluation of a Behavioral Health Function Measurement Tool for Work Disability Evaluation

Objective

To use item response theory (IRT) data simulations to construct and perform initial psychometric testing of a newly developed instrument, the Social Security Administration Behavioral Health Function (SSA-BH) instrument, that aims to assess behavioral health functioning relevant to the context of work.

Design

Cross-sectional survey followed by IRT calibration data simulations.

Setting

Community.

Participants

Sample of individuals applying for Social Security Administration disability benefits: claimants (n=1015) and a normative comparative sample of U.S. adults (n=1000).

Interventions

None.

Main Outcome Measure

SSA-BH measurement instrument.

Results

IRT analyses supported the unidimensionality of 4 SSA-BH scales: mood and emotions (35 items), self-efficacy (23 items), social interactions (6 items), and behavioral control (15 items). All SSA-BH scales demonstrated strong psychometric properties including reliability, accuracy, and breadth of coverage. High correlations of the simulated 5- or 10-item computer adaptive tests with the full item bank indicated robust ability of the computer adaptive testing approach to comprehensively characterize behavioral health function along 4 distinct dimensions.

Conclusions

Initial testing and evaluation of the SSA-BH instrument demonstrated good accuracy, reliability, and content coverage along all 4 scales. Behavioral function profiles of Social Security Administration claimants were generated and compared with age- and sex-matched norms along 4 scales: mood and emotions, behavioral control, social interactions, and self-efficacy. Using the computer adaptive test-based approach offers the ability to collect standardized, comprehensive functional information about claimants in an efficient way, which may prove useful in the context of the Social Security Administration's work disability programs.     

Changes in Pulmonary Function During the Early Years After Inpatient Rehabilitation in Persons With Spinal Cord Injury: A Prospective Cohort Study

Objective

To describe changes in pulmonary function (PF) during the 5 years after inpatient rehabilitation in persons with spinal cord injury (SCI) and to study potential determinants of change.

Design

Prospective cohort study.

Setting

Eight rehabilitation centers with specialized SCI units.

Participants

Persons with SCI (N=180).

Interventions

Not applicable.

Main Outcome Measures

PF was determined by forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV₁) as a percentage of the predicted value, at the start of rehabilitation, at discharge, and 1 and 5 years after discharge from inpatient rehabilitation. The population was divided into 3 subgroups on the basis of whether their PF declined, stabilized, or improved.

Results

FVC improved on average 5.1% over the whole period between discharge of inpatient rehabilitation and 5 years thereafter, but changes differed largely between persons. FVC declined in 14.9% of the population during the first year after discharge. During this year, body mass index, inspiratory muscle strength, change in peak power output, and change in peak oxygen uptake differed significantly between subgroups. FVC declined in 28.3% of the population during the following 4 years, but no differences were found between the subgroups for this period. Subgroups based on changes in FEV₁ differed only with respect to change in peak oxygen uptake the first year after discharge.

Conclusions

In our study, many persons with SCI showed a decline in PF, larger than the normal age-related decline, during the 5 years after inpatient rehabilitation. Results suggest that a decline in PF during the first year after inpatient rehabilitation is associated with higher body mass index, lower inspiratory muscle strength, and declined physical fitness.     

Functional and Clinical Outcomes of Telemedicine in Patients With Spinal Cord Injury

Dallolio L, Menarini M, China S, Ventura M, Stainthorpe A, Soopramanien A, Rucci P, Fantini MP, on behalf of the THRIVE Project. Functional and clinical outcomes of telemedicine in patients with spinal cord injury.

Objective

To compare the 6-month outcomes of telerehabilitation intervention with those of standard care for spinal cord injury (SCI).

Design

Multicenter randomized controlled trial.

Setting

Home, nursing, or unspecialized hospital care provided after discharge from a spinal cord unit.

Participants

Adult patients with nonprogressive, complete, or incomplete SCI discharged for the first time from the spinal cord unit to their homes (Belgium and Italy) or to their homes or another facility (England).

Interventions

All patients received the standard care they would have normally received after discharge from the spinal cord unit. In addition, patients in the telemedicine group received 8 telemedicine weekly sessions in the first 2 months, followed by biweekly telemedicine sessions for 4 months.

Main Outcome Measures

Functional status at 6 months, clinical complications during the postdischarge period, and patient satisfaction.

Results

No significant differences in the occurrence of clinical complications were found between the study groups. A higher improvement of functional scores in the telemedicine group was found only at the Italian site: FIM total score 3.38±4.43 (controls) versus 7.69±6.88 (telemedicine group), FIM motor score 3.24±4.38 (controls) versus 7.55±7.00 (telemedicine group; P<.05). Items contributing to this difference were grooming, dressing upper body, dressing lower body, and bed/chair/wheelchair transfer. Higher satisfaction with care was reported by patients in the telemedicine group across all sites.

Conclusions

Our study provides some of the first quantitative evidence, based on results from 1 site, that telerehabilitation may offer benefits to patients discharged from a spinal cord unit compared with standard care in terms of functional improvement. Further research is warranted to confirm or disprove this finding.