Benefits of rehabilitation for traumatic spinal cord injury. Multivariate analysis in 711 patients

International Spinal Cord Injury Physical Therapy-Occupational Therapy Basic Data Set (Version 1.2)

STUDY DESIGN

Expert workgroup consensus, focused literature review, and vetting via feedback from international presentations and spinal cord professional membership groups.

OBJECTIVES

Develop and refine a basic dataset to enable standardized documentation of physical therapy (PT) and occupational therapy (OT) interventions delivered in a controlled clinical trial intended to improve voluntary motor function.

SETTING

International Expert Working Group.

METHODS

An international working group with expertise in spinal cord injury, PT, OT, and measurement developed a draft of the International Spinal Cord Injury (ISCI) Physical Therapy-Occupational Therapy (PT-OT) Basic Data Set (BDS). Emphasis was placed on efficiency and practicality of use. The BDS was iteratively refined based on applicable literature, and feedback collected from presentations at the 2017 and 2019 International Spinal Cord Society meetings.

RESULTS

The ISCI PT-OT BDS contains seven broad categories of interventions: bed/seated mobility, standing activities, walking/stairs, gross motor upper extremity, fine motor upper extremity, strength training, and endurance training. The first five categories are classified as activity-directed and the last two as impairment-directed interventions. Time spent on interventions per category is recorded in 15-min intervals.

CONCLUSIONS

The ISCI PT-OT BDS enables standardized documentation of PT-OT activity-directed or impairment-directed interventions. The ISCI PT-OT BDS is a documentation tool to facilitate evaluation of the influence of rehabilitation therapies on motor function in clinical trials of biologic or pharmacologic agents or rehabilitation technologies that are delivered in the clinical setting.

Effect of Family Caregiving on Depression in the First 3 Months After Spinal Cord Injury

Objective

To investigate the effect of family caregiving on depression in the first 3 months after spinal cord injury (SCI).

Methods

A retrospective study was carried out on 76 patients diagnosed with an SCI from January 2013 to December 2016 at the Department of Physical Medicine and Rehabilitation of Kyungpook National University Hospital, Korea. Clinical characteristics including age, gender, level of injury, completeness of the injury, time since injury, caregiver information, etiology, and functional data were collected through a retrospective review of medical records. Depression was assessed using the Beck Depression Inventory (BDI). Patients with 14 or more points were classified as depressed and those with scores of 13 or less as non-depressed group.

Results

Of the 76 patients, 33 were in the depressed group with an average BDI of 21.27±6.17 and 43 patients included in the non-depressed group with an average BDI of 4.56±4.20. The BDI score of patients cared by unlicensed assistive personnel (UAP) was significantly higher than that of patients cared by their families (p=0.020). Univariate regression analysis showed that motor complete injury (p=0.027), UAP caregiving (p=0.022), and Ambulatory Motor Index (p=0.019) were associated with depression after SCI. Multivariate binary logistic regression analysis showed that motor completeness (p=0.002) and UAP caregiving (p=0.002) were independent risk factors.

Conclusion

Compared with UAP, family caregivers lowered the prevalence of depression in the first 3 months after SCI.

Type and Timing of Rehabilitation Following Acute and Subacute Spinal Cord Injury: A Systematic Review

OBJECTIVES

The objective of this study was to conduct a systematic review of the literature to address the following clinical questions: In adult patients with acute and subacute complete or incomplete traumatic SCI, (1) does the time interval between injury and commencing rehabilitation affect outcome?; (2) what is the comparative effectiveness of different rehabilitation strategies, including different intensities and durations of treatment?; (3) are there patient or injury characteristics that affect the efficacy of rehabilitation?; and (4) what is the cost-effectiveness of various rehabilitation strategies?

METHODS

A systematic search was conducted for literature published through March 31, 2015 that evaluated rehabilitation strategies in adults with acute or subacute traumatic SCI at any level. Studies were critically appraised individually and the overall strength of evidence was evaluated using methods proposed by the GRADE (Grades of Recommendation Assessment, Development and Evaluation) working group.

RESULTS

The search strategy yielded 384 articles, 19 of which met our inclusion criteria. Based on our results, there was no difference between body weight-supported treadmill training and conventional rehabilitation with respect to improvements in Functional Independence Measure (FIM) Locomotor score, Lower Extremity Motor Scores, the distance walked in 6 minutes or gait velocity over 15.2 m. Functional electrical therapy resulted in slightly better FIM Motor, FIM Self-Care, and Spinal Cord Independence Measure Self-Care subscores compared with conventional occupational therapy. Comparisons using the Toronto Rehabilitation Institute Hand Function Test demonstrated no differences between groups in 7 of 9 domains. There were no clinically important differences in Maximal Lean Test, Maximal Sidewards Reach Test, T-shirt Test, or the Canadian Occupational Performance Measure between unsupported sitting training and standard in-patient rehabilitation.

CONCLUSION

The current evidence base for rehabilitation following acute and subacute spinal cord injury is limited. Methodological challenges have contributed to this and further research is still needed.

Self-Blame Following a Traumatic Event: The Role of Perceived Avoidability

People who have experienced a traumatic life event may blame themselves, in part, because they perceive that they could have avoided the event. A study of respondents with spinal cord injuries shows that their causal attributions for the event are distinguishable from their perceptions of avoidability, the latter frequently focusing on mutable aspects of their own behavior. Respondents with spinal cord injuries and trained raters attributed the same degree of causal significance to the respondent but differed in their assignment of blame: Respondents assumed more personal blame than raters gave them. Regression analyses suggest that a significant portion of respondents' self-blame can be attributed to their self-implicating perceptions of avoidability. The degree to which respondents believed that they could have avoided their accident predicted self-blame even after controlling for their causal attributions for the event. Implications for the study of self-blame and perceived avoidability are discussed.

Functional assessment in spinal cord injury: a comparison of the Modified Barthel Index and the 'adapted' Functional Independence Measure

The Modified Barthel Index (MBI) and the Functional Independence Measure (FIM) have been used to provide objective measures of functional status and change of spinal cord injured (SCI) patients. To compare rating scores on the MBI and FIM, the functional abilities of 41 SCI patients were rated by one trained nurse-clinician using both scales at admission to initial rehabilitation (ADM), discharge from rehabilitation (DC) and at follow-up (FU) 12 months after rehabilitation. An 'adapted' FIM score was used, and total MBI and FIM scores were divided into self-care and mobility subscores. Comparisons were made between each MBI score and each FIM score at each point in time (ADM, DC, FU) using simple linear regression, which was also used to compare changes in the MBI and FIM scores from ADM to DC and from DC to FU. Excellent correlations ( p<0.0005) were found between MBI and FIM scores at all points in time and between changes in MBI scores and changes in FIM scores over each time interval.

One-year follow-up of Chinese people with spinal cord injury: a preliminary study

BACKGROUND

A tertiary spinal cord injury (SCI) center was established in the northern region of Hong Kong, China and a multidisciplinary SCI rehabilitation program was developed to reintegrate patients into the community.

OBJECTIVE

To investigate functional outcomes for Chinese people with SCI across a 1-year period.

DESIGN

Longitudinal prospective design.

METHODS

Thirty community-dwelling participants with traumatic SCI were recruited. Functional status was measured using functional independence measure (FIM) on admission, upon discharge, 1-month, 3-month, 6-month, and 1-year post-discharge. Information on use of assistive devices and life role were also obtained.

RESULTS

Twenty-three (76.67%) participants were men. Seventeen participants (10 with tetraplegia and 7 with paraplegia) were classified ASIA A, B, or C; 13 (7 with tetraplegia and 6 with paraplegia) were classified as ASIA D. Significant differences in FIM motor scores were only found between the tetraplegia group and three other diagnostic groups using Bonferroni post-hoc tests of repeated measure ANOVA (analysis of variance) (P < 0.05). Longitudinally, contrast tests of repeated measure ANOVA showed significant differences during the hospitalization period for all diagnostic groups. People in the ASIA D group showed significant functional improvement even after 1-year post-discharge (P < 0.05). At 1-year post-discharge, only two participants were engaged in either remunerative employment or academic pursuit.

CONCLUSION

Despite functional status improvement, few people with traumatic SCI were re-engaged in productive life role 1 year after discharge. Studies with longer follow-up would be beneficial.

Properties and outcomes of spinal rehabilitation units in four countries

OBJECTIVE

Compare rehabilitation after spinal cord lesions (SCL) in different countries.

DESIGN

Multicenter comparative study.

SETTING

Four spinal rehabilitation units, in Denmark, Russia, Lithuania and Israel.

SUBJECTS

199 SCL patients.

INTERVENTIONS

Information was collected about unit properties, rehabilitation objectives, American Spinal Injury Association (ASIA) scale and spinal cord independence measure (SCIM) assessments, and patient data. chi (2)-test, t-test, ANOVA and ANCOVA were used for statistical analysis.

MAIN OUTCOME MEASURES

Time from lesion onset to admission for rehabilitation (TAR), length of stay in rehabilitation (LOS), SCIM and spinal cord ability realization measurement index (SCI-ARMI) scores, SCIM gain, SCI-ARMI gain and rehabilitation efficiency (RE).

RESULTS

Differences were found between the units in rehabilitation objectives, facilities and special equipment for rehabilitation. Staff/bed ratio was 1.7 in Lithuania and Denmark, 1.1 in Israel and 0.9 in Russia. Russian patients were the youngest and had the most severe lesions among participating units. Admission SCIM and SCI-ARMI were the lowest in Israel: 25.1+/-17.2 and 34.3+/-17.3. TAR was highest in Russia (12.4 month) and lowest in Israel (2 weeks; P<0.01). LOS was longest in Denmark (176.9 days; P<0.001). SCIM score at the end of rehabilitation was highest in Denmark (67.3+/-23). SCIM gain and SCI ARMI gain were highest in Israel (36.9+/-18.3 and 38.5+/-19.4, respectively) and lowest in Russia (P<0.001). RE was highest in Lithuania and lowest in Denmark (P<0.001).

CONCLUSIONS

In the participating units, SCL rehabilitation outcomes depend on SCL severity and unit-specific properties. A moderately delayed rehabilitation with long LOS achieved high functioning, and early or slightly delayed rehabilitation combined with shorter LOS achieved high functional gain or efficiency.

The assessment of walking capacity using the walking index for spinal cord injury: self-selected versus maximal levels

OBJECTIVES

To assess (1) the frequency and magnitude of differences between self-selected and maximal walking capacity following spinal cord injury (SCI) by using the Walking Index for Spinal Cord Injury (WISCI) and (2) how these levels differ in efficiency and velocity.

DESIGN

Prospective cohort.

SETTING

Academic medical center.

PARTICIPANTS

Fifty people with chronic incomplete SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Subjects ambulated at the level used in the community (self-selected WISCI) and the highest level possible (maximal WISCI). Velocity (in m/s), Physiological Cost Index (PCI), and Total Heart Beat Index (THBI) were calculated. Differences were compared using the paired t test (parametric) or Wilcoxon signed-rank test (nonparametric).

RESULTS

For 36 subjects, maximal WISCI was higher than self-selected WISCI; 21 subjects showed an increase of 3 levels or more. Ambulatory velocity was higher for self-selected WISCI compared with maximal WISCI (.68 m/s vs .56 m/s, P<.001). PCI and THBI at self-selected WISCI were lower than at maximal WISCI (PCI, 0.99 beats/m vs 1.48 beats/m, P<.001; THBI, 3.39 beats/m vs 4.75 beats/m, P<.001).

CONCLUSIONS

Many people with chronic SCI are capable of ambulating at multiple levels. For these people, ambulation at self-selected WISCI was more efficient as evidenced by greater velocity and decreased PCI and THBI. The findings have implications for assessing walking capacity within the context of clinical trials.

How do C6/C7 tetraplegic patients grasp balls of different sizes and weights? Impact of surgical musculo-tendinous transfers

STUDY DESIGN

Prospective control cohort study.

OBJECTIVES

To develop a new test to analyse qualitatively grasping strategies in C6/C7 tetraplegic patients, and to quantify the effect of musculo-tendinous transfers.

SETTING

France.

METHODS

Twelve C6/C7 tetraplegic adults (17 arms; 31.3+/-7.9 years) and 17 healthy subjects (30.9+/-9.4 years) completed the study. We assessed participants' ability to grasp, move and release standardized balls of variable sizes and weights.

OUTCOME MEASURES

Failures, movement duration (MD), grip patterns, forearm orientation during transport.

RESULTS

In patients as well as in controls, the number of digits involved in prehension increased proportionally to the size and weight of the ball. C6 non-operated tetraplegic patients failed 38.2% of the tasks. They frequently used supine transport (51.4% of successful tasks). MD was longer, with a large distribution of values. The presence of active elbow extension poorly influenced the amount of failure nor grip configuration, but significantly reduced MD and supine transport (34%). Patients who were evaluated after hand surgery showed a trend towards improved MD and more frequent completion (failure 30%), especially for middle-sized and middle-weighted balls. Grip patterns were deeply modified, and all transports were made in pronation.

CONCLUSION

The 'Tetra Ball Test' evidences the characteristics of grasping in tetraplegic patients and those influenced by surgery. It may be useful in understanding effects of surgical procedures. This preliminary study must be completed to evaluate the quantitative responsiveness and reproducibility of this test and to develop instrumented electronic balls to optimise it.

The discriminative power of the Wolf motor function test in assessing upper extremity functions in persons with stroke

The Wolf motor function test is a new time-based method to evaluate upper extremity function both on a joint-specific level and on total limb movements, while performing some functional tasks. The purpose of this paper is to investigate the discriminating power of the Wolf motor function test in classifying individuals with stroke into different levels according to Brunnstrom's stages of recovery. Discriminant analysis was used and the results showed that the Wolf motor function test can classify 86.7% of original grouped cases into the correct groupings. A high correlation was found between the Wolf motor function test, the Brunnstrom stages of recovery and the Fugl-Meyer Assessment. The Wolf motor function test is found to be an instrument capable of discriminating the upper extremity motor function of the individuals with stroke into different functional groups.

Long-term follow-up of patients with spinal cord injury

OBJECTIVE

The aim of this study was to evaluate the motor, sensory, and functional recovery in patients with spinal cord injury (SCI).

METHODS

Forty-one patients with SCI participated in this study. Twenty patients were evaluated after discharge. Each patient was evaluated by the American Spinal Injury Association (ASIA) impairment scale and the Functional Independence Measure (FIM) at admission, before discharge, and at least at 6 months after discharge. Friedman, Dunn, and Mann-Whitney U tests were used for statistical analysis.

RESULTS

There were 17 male and 3 female patients. Seven patients had complete SCI, and 13 patients had incomplete SCI. The evaluation of motor, sensory, and FIM scores at admission showed significant improvement in all of the patients during the follow-up period (P < 0.0001). Five incompletely injured cases improved with regard to ASIA staging. Motor and FIM scores significantly increased at follow-up for converted and unconverted patients. All parameters increased at follow-up in patients who were complete and incomplete. Motor scores significantly increased at discharge and at follow-up. FIM scores also increased significantly at follow-up in incomplete patients.

CONCLUSION

Motor, sensory, and FIM scores increased in patients with SCI after a follow-up period of 18 months. Improvement to a higher ASIA stage could be accomplished by 25% of the patients. Although both complete and incomplete patients recovered significantly at the follow-up period, only incompletely injured cases could convert to a higher ASIA stage.

[Assessment of functional abilities, handicap and quality of life in patients with spinal cord injuries]

OBJECTIVES

A literature review of the methods of evaluating function, handicap and quality of life in patients with spinal cord injuries.

METHODS

The literature review was based on the available French and English articles published since 1990 in 3 databases: MEDLINE, Pascal and Embase.

RESULTS

The literature is dominated by descriptions of tools for evaluating functional limitations in motor deficiencies. Such descriptions involve the validation of generic tools for patients with spinal cord injuries or of specific tools during the evaluation of a particular intervention such as surgery of the tetraplegic hand or adaptation of technical help.

CONCLUSION

The tools to assess patients with spinal-cord injuries are sufficiently numerous and varied to allow us to evaluate physical, functional and psychosocial dimensions. Rigorous methodological validation is continuously at the base of those proposed tools and thus reinforces our choice to use them. Unfortunately, few evaluation tools for patients with spinal cord injuries have been published, translated into French and validated.

Evidence for inpatient rehabilitation as an effective intervention

Rehabilitation in inpatient settings is expensive and staff-intensive. It is necessary for such services to demonstrate effectiveness to justify this. In contrast to popular notions, evidence for the effectiveness of inpatient rehabilitation does exist and is reviewed in this article. In particular, there is very good evidence for specialized inpatient stroke care and rehabilitation.

Impact of injury level and self-monitoring on free time boredom of people with spinal cord injury

PURPOSE

The purpose of this study was to determine whether or not level of injury and personality characteristics creates an interaction effect that impacts the free time boredom of individuals with spinal cord injury (SCI).

METHOD

Using a survey method, a packet containing a cover letter, a consent form, research questionnaires, and a self-addressed, stamped envelope was sent to 500 individuals with SCI who were randomly selected by computer at one of the rehabilitation centres in USA. The research questionnaires included the measures of self-monitoring (SM) and free time boredom (FTB) along with some demographic factors such as gender, ethnicity, age, injury level, and etc.

RESULTS

This study found that a significant interaction effect between injury level and SM on FTB. That is, low self-monitors with tetraplegia reported higher levels of boredom in free time than high self-monitors with paraplegia.

CONCLUSION

Not all individuals with similar injury levels rate FTB in a similar degree. Individuals' personality characteristics play an important role in experiencing FTB. In particular, the significant interaction effect indicates a potential risk factor for clients with tetraplegia who are low in SM which should be an important consideration in the lives of people with tetraplegia following rehabilitation.

Analyse critique des modalités d’évaluation des résultats de la chirurgie fonctionnelle du membre supérieur tétraplégique. Revue de la littérature sur les 50 dernières années

OBJECTIVE

To study the methods of assessment of upper limb functional surgery in the literature.

METHODS

The literature review relating to the years 1950-2002 was carried out with three data bases: Medline, Pascal, Embase. This review also involved a thorough study of non-indexed references.

RESULTS

Although many instruments or tests are used to assess outcome after surgery, their reliability, validity and responsiveness have not been adequately proven. Methodology appears to be the major failing of the various scales used to assess these patients. The conceptual models underlying the evaluation are all too often unspecified. There is a lack of pertinence of the selected tasks for tetraplegics. There is limited documentation of the guiding framework or conceptualisation. Furthermore, the process of item selection is often unknown. Scales or instruments are also deemed to be too insensitive to document the small but meaningful functional gains made by tetraplegics after functional surgery.

CONCLUSION

To answer the need for a specific assessment tool for tetraplegics who undergo functional surgery, we have developed a national, multicenter, prospective and longitudinal study based on two concepts: the first concept is related to Life Habits that are the activities of daily living and social roles recognised by the socio-cultural context of a person according to age, sex and social and personal identity. They include activities that should be accomplished on a daily basis (nutrition, fitness, personal care, communication, mobility, etc.). Life Habits presenting a significant level of disruption can create handicap situations. The second concept is in relation with Motor Capacities that correspond to the abilities of a patient to perform basic and functional tasks regardless of contextual factors (environmental and personal factors).

Functional improvement after pediatric spinal cord injury

OBJECTIVE

To describe the functional gain (FGain) with pediatric spinal cord injury inpatient rehabilitation and to identify the relationship of various factors to FGain in pediatric spinal cord injury inpatient rehabilitation.

DESIGN

Retrospective chart review of a series of 91 children with spinal cord injury admitted from 1993 to 1998 in a freestanding rehabilitation hospital. Admission and discharge functional status were assessed with the Pediatric Functional Independence Measure (WeeFIM) instrument for children <or=7 yr and the Adult Functional Independence Measure (FIM) instrument for children >7 yr. The outcome measure is the FGain (difference between the discharge and admission functional status).

RESULTS

Significant gains in functional status were observed in all patients. FGain was not significantly related to age, sex, length of inpatient rehabilitation, pathogenesis, or completeness or neurologic level of injury. However, there was a trend for higher FGain for patients with incomplete spinal cord injury and traumatic spinal cord injury.

CONCLUSIONS

Functional improvement occurs with pediatric spinal cord injury inpatient rehabilitation. There is a trend for higher FGain in patients with less severe injury and traumatic injury. The lack of relationship between FGain and length of inpatient rehabilitation suggests that a variety of other factors influence the relationship between FGain and length of inpatient rehabilitation.

Socio-economic outcome of paraplegia compared to lower limb amputation

STUDY DESIGN

The socio-economic outcome was retrospectively compared between patients with traumatic lower limb amputation and those with paraplegia due to a spinal cord injury (SCI).

OBJECTIVE

To evaluate the effect of specific rehabilitative procedures on the socio-economic outcome.

SETTING

Paraplegic Centre at the University Hospital in Zurich, Switzerland.

METHODS

Accidents occurring in a collective of 1.9 million persons in Switzerland over 3 years were included in the study. Fifty-six persons with unilateral amputation of lower limbs were compared with 54 persons with paraplegia. The follow-up was assessed over 5 years.

RESULTS

The following data was obtained in patients with amputations compared to those with SCI (median values): (1) hospital stay: 150 versus 164 days; (2) the work was taken up after 689 versus 616 days; (3) the global average case costs amounted to SFr. 491.000 versus SFr. 606.000 during the first 5 years after injury; (4) the permanent degree of disability was determined to 40% versus 42%. Except for the global costs, all differences were not significant.

CONCLUSIONS

There are only a few differences between the socio-economic outcomes between patients with lower limb amputations and those with paraplegia. It remains unclear if the highly specialised rehabilitation services provided for patients with SCI accounts for the similarity since individuals with SCI have additional neurogenic dysfunction of the bladder and bowel. Alternatively, the data may suggest a need for greater rehabilitation services for amputees or may reflect a threshold effect in rehabilitation outcomes.

Spinal cord injury medicine. 3. Rehabilitation outcomes

This self-directed learning module highlights rehabilitation outcomes in spinal cord injury (SCI). It is part of the chapter on SCI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on the multiple concerns for functional recovery after SCI, chiefly, the potential for ambulation, upper-extremity recovery, options for functional neuromuscular stimulation (FNS), sexual activity, and optimal outcome after a metastatic lesion. Motor incomplete patients have a better prognosis for ambulation than persons with sensory incomplete injury. Positive predictors for ambulation, including pinprick and lower-extremity motor scores greater than 20, are discussed. Meaningful recovery can occur in the upper extremities for at least 1 year. FNS options have been developed to promote functional control of the upper extremities for persons with tetraplegia, phrenic pacing, and bladder continence. A critical component of an individual's expression of self is his/her sexuality; sexual function after SCI is described in detail, including options for treatment of erectile dysfunction and various birth control methods for women. Expectations for an appropriate rehabilitation stay for a person with metastatic SCI differ for an individual with traumatic SCI. Differences may include changing routine pathways and timelines to focus on patient-centered quality of life for transition to home.

OVERALL ARTICLE OBJECTIVE

To identify potential outcomes in ambulation, upper-extremity function, FNS, and sexual function after SCI and after metastatic cancer.

Evaluation of upper extremity motor function tests in tetraplegics

OBJECTIVE

To provide an overview of arm-hand function tests useful in tetraplegic subjects. Considerations for selection of an appropriate test are also provided.

DATA SOURCES

A Medline literature search was conducted covering the period from 1967 to March 2001. Relevant references cited in the selected papers were also considered, regardless of the year of publication.

STUDY SELECTION

This review was restricted to strength tests, functional and ADL tests. Only general tests and tests designed specifically to test tetraplegic persons written in English, or in Dutch were included in the review.

RESULTS

Information is provided on four types of strength tests, 10 general and five specific functional tests and eight ADL tests.

CONCLUSION

Many tests are available to measure upper extremity motor function in tetraplegics. Selection of a test is at first determined by the outcome value in which the investigator is interested. When the type of outcome value has been determined, the most suitable test has to be selected from the range of available tests. When two tests appear to be equally suitable, the availability of information on psychometric properties of the test when used in tetraplegic patients is a decisive factor. When information on the reliability, validity and sensitivity of a test is missing, it should be gathered before using the test.

Spinal cord patients benefit from massage therapy

The present study assessed the effects of massage therapy on depression, functionality, upper body muscle strength and range of motion on spinal cord injury patients. Twenty C5 through C7 spinal cord injury individuals recruited from a University outpatient clinic were randomly assigned to a massage therapy group or an exercise group. Patients in the massage therapy group received two 40-min massage therapy sessions per week for 5 weeks. Patients in the control group practiced a range of motion exercise routine targeting the arms, neck, shoulders, and back 2 times per week for 5 weeks. Although both the massage and exercise group appeared to benefit from treatment, only the massage group showed lower anxiety and depression scores and significantly increased their muscle strength and wrist range of motion.

The order of reacquirement of activity of daily living functions in people with spinal cord injury during rehabilitation after initial medical treatment and its affecting factors

The purpose of this study was to investigate the order of reacquisition of activity of daily living (ADL) functions during inpatient rehabilitation at our spinal cord injury unit following the individual's initial medical care and to investigate what initial medical and biological factors would affect the ADL functions which the individual with spinal cord injury could perform 14 weeks after the beginning of inpatient rehabilitation. Fifty-two patients with spinal cord injuries who were hospitalized in the rehabilitation unit after their initial medical care participated in this study. The participants' ADL abilities were measured using the Barthel Index every four weeks after hospitalization for a period of 26 weeks. The order of reacquisition of ADL functions included in the Barthel Index was analyzed. Multiple regression analysis was performed to analyze the initial medical and biological factors affecting ADL reacquisition 14 weeks after hospitalization. The order of reacquisition of the ADL functions was almost the same in each individual. The multiple regression equations of the Barthel Index score and number of ADL functions after 14 weeks were both significant and the explanatory variables in both equations included the patients' age, complications on the initial stage and traumatic brain injury as an associated injury with spinal cord injury. We concluded that the patient's score on the Barthel Index and what the patient could actually perform 14 weeks after hospitalization could be predicted from the patient's status at hospitalization in the rehabilitation unit. This predictable correlation can contribute to the rehabilitation management for spinal cord injuries.

Adaptation of the Functional Independence Measure for use in Turkey

OBJECTIVE

To adapt the Functional Independence Measure (FIM) for use in Turkey and to assess its validity and reliability.

DESIGN

After the translation procedure, reliability was assessed using internal consistency, inter-rater reliability (kappa) and the intraclass correlation coefficient (ICC). Construct validity was tested by association with impairments and by fit of data to the Rasch model.

SETTING

The study was undertaken in an inpatient rehabilitation unit of the Department of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Ankara.

SUBJECTS

Consecutive stroke (n = 51) and spinal cord injury (SCI) (n = 62) patients admitted for rehabilitation over a period of three years were assessed at admission and discharge.

RESULTS

Internal consistency was good for stroke, and for SCI. The level of agreement between two raters was sufficient with kappa levels of above 0.48 for SCI and above 0.44 for stroke. Minimum ICC found was 0.90. Construct validity showed expected associations with the impairment scales. However, Rasch analysis showed that bladder and bowel items compromise unidimensionality in the motor scale.

CONCLUSION

Adaptation of the FIM has been successful and it can be used in Turkey as long as the limitations are recognized.

The tools of disability outcomes research functional status measures

OBJECTIVE

To review the major functional status measures currently used in rehabilitation research, including the domains and scope of functional status measures, as well as the psychometric properties of selected functional status measures and their use in adult rehabilitation populations.

DATA SOURCES

Measures of physical functioning widely used in rehabilitation research.

STUDY SELECTION

Major generic measures included the following activities of daily living and instrumental activities of daily living: the FIM instrument, the Katz Activities of Daily Living Scale, the Level of Rehabilitation Scale, the Barthel index, and the Patient Evaluation and Conference System. Measures were evaluated based on published evidence of validity, reliability, and sensitivity.

DATA EXTRACTION

Measures were chosen on the basis of the amount and quality of published research on the functional measures widely used in rehabilitation medicine. Independent research of computer databases and reviews of functional measures were conducted to determine suitability for inclusion. The quality and validity of the measures were assessed using standard psychometric guidelines.

DATA SYNTHESIS

Measures were evaluated based on published evidence of validity, reliability, sensitivity response and administrative burdens and instrument bias. Each criterion was graded on a 3-point scale reflecting the level of evidence.

CONCLUSION

Researchers in the field of disabilities research need to consider carefully study objectives when measuring physical functioning in people with disabilities.

Functional changes in persons aging with spinal cord injury

Declines in general physical function and the effect of these changes on activities of daily living and needs for assistance were assessed in 150 individuals with spinal cord injury (SCI). The sample consisted of outpatients returning for follow-up at the spinal cord injury clinic at Rancho Los Amigos National Rehabilitation Center in Downey, CA. The average duration of injury of the sample was 13 years (range 1-37), and average age was 38 years (range 18-64). Twenty-four percent of those sampled experienced a decline or change in their physical function within the last 5 years. Individuals experiencing declines were significantly older than those without changes, averaging 45 years versus 36 years. The group with change also had a longer duration of injury, averaging 18 years versus 11 years compared to the group reporting no declines. Fatigue was the most frequently reported problem, followed by pain and weakness. Over half of the group with changes required additional assistance with activities of daily living (ADLs). Family members were the primary helpers for both ADLs and instrumental activities of daily living (IADLs) for those persons experiencing changes. The use of assistive technology, primarily equipment for bathing, toileting, and low technology devices, increased with time. The increased vulnerability to loss of function in persons with advancing age and duration of injury in this population with SCI suggests the need for early preventative measures, routine assessments to detect changes, and access to health care and supportive services to alleviate or minimize the effect of these changes.

Functional outcome of patients with spinal cord injury: rehabilitation outcome study

OBJECTIVE

To increase our knowledge of neurological recovery and functional outcome of patients with spinal cord injuries in order to make more successful rehabilitation programmes based on realistic goals.

DESIGN

Descriptive analysis of data gathered in an information system.

SETTING

Rehabilitation centre in The Netherlands with special department for patients with spinal cord injuries.

SUBJECTS

Fifty-five patients with traumatic spinal cord lesions admitted to the rehabilitation centre from 1988 to 1994.

MAIN OUTCOME MEASURES

The functional improvement was presented in terms of progress in independence in nine daily activity skills. Independence was rated on a four-point scale.

RESULTS

From admission to discharge, lesions in 100% of patients with tetraplegia and 96% of patients with paraplegia remained complete. Significant progress in independence was made in self-care, ambulation and bladder and bowel care. Differences were found in the extent of functional improvement between subgroups of patients with different levels and extent of lesion. Contrary to expectations based on theoretical models, patients with complete paraplegia did not achieve maximal independence in self-care. Independent walking was only attained by patients with incomplete lesions. Regarding outcome of bladder and bowel care, poor results were found, especially the independence in defaecation and toilet transfers.

CONCLUSIONS

The results of this study provided more insight into the functional outcome of a group of patients with traumatic spinal cord injury. More research is needed to evaluate the rehabilitation programmes for these patients.

Measuring the impairment consequences of spinal cord injury

The objectives of this study were to develop and validate an equal-interval measure of neurologic impairment from the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients developed by the American Spinal Injury Association. These standards were used to rate impairment at admission and discharge to Model System facilities. The results demonstrate that the standards fulfill their purpose of characterizing sensory-motor impairment. Developed was a self-scoring key that rehabilitation clinicians can use to obtain a measure of severity that combines sensory and motor level ratings and completeness classifications to describe impairment more precisely and illustrate the magnitude of reductions in impairment. This measure can be used to monitor improvement over time and compare severity across individuals or groups.

Muscle strength changes as measured by dynamometry following functional rehabilitation in individuals with spinal cord injury

OBJECTIVE

To objectively quantify muscle strength changes over the course of functional rehabilitation and up to 15 months postdischarge in individuals with spinal cord injury (SCI).

METHOD

Hand-held dynamometry was used to evaluate the strength of six muscle groups in 31 individuals after acute SCI (tetraplegia, n = 13, paraplegia, n = 18). Assessment was performed by a single research therapist at admittance and discharge from functional rehabilitation and 3 months and 15 months after discharge.

RESULTS

There were significant increases of mean strength values for all muscle groups between admittance and discharge in individuals with parapalegia (median value between 13% and 22%) and tetraplegia (median value between 33% and 83%). Three months after discharge, only individuals with tetraplegia continued to significantly improve their mean strength for four muscle groups (elbow flexors-extensors and shoulder flexors-extensors). One year later, elbow flexors were significantly improved in both paraplegic and tetraplegic persons, while shoulder extensors showed significant gains only in individuals with paraplegia. Study results showed a large variability in the individual profiles of upper limb strength recovery, particularly in tetraplegic individuals. Although some individuals showed strength gains exceeding 200%, some strength decreases were noted.

CONCLUSION

Recovery of muscle strength in individuals with tetraplegia over individuals with parapalegia continues for a longer period since it depends initially on recovery of muscle innervation. This study quantified strength improvements during rehabilitation and clearly showed that these gains can be maintained or even increased when the person returns to community living.

Effectiveness of spinal cord Injury Rehabilitation

As in other areas of rehabilitation, relatively small numbers and diversity –both of condition and of patients' goals – hinder the assimilation of robust evidence for the effectiveness of rehabilitation. Patients with spinal cord injury (SCI) tend to be gathered together in a small number of regional services, each with their own philosophy and each with different attitudes to outcome measurement, and thus collection of the existing trials for meta-analysis is problematic.

The marked improvement in outcome from SCI that has occurred with the development of specialist rehabilitation programmes argues strongly for the effectiveness of rehabilitation, and we have progressed beyond the point where randomized controlled trials that deny a group such intervention could be considered ethical. Current research is aimed at teasing apart the aspects of different care models that are most effective, or the evidence for the usefulness of interventions for control of symptoms such as spasticity and pain. This evidence is reviewed and discussed.

A crash course in spinal cord injury

The complex management issues related to spinal cord injury traditionally have been the purview of physical medicine and rehabilitation specialists. However, changes in the healthcare system now offer primary care physicians an expanded role in helping affected patients live a healthier and more functional life. With proper understanding of the mechanisms of spinal cord injury, primary care physicians can become important members of the medical management team. Dr Yu presents a comprehensive overview of medical care issues and common complications in spinal cord injury.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Clinical experience in rehabilitation of spinal cord injury associated with schizophrenia

OBJECTIVE

To identify the clinical features and rehabilitation outcomes in spinal cord injury (SCI) patients with preexisting schizophrenia.

DESIGN

A retrospective study conducted by reviewing the charts of all patients diagnosed with both SCI and schizophrenia hospitalized from 1987 throughout 1994 in 2 rehabilitation units.

SETTING

Rehabilitation wards of two hospitals in Taiwan.

PATIENTS

Seventeen traumatic SCI patients with schizophrenia, including 7 men and 10 women. Patients without neurological deficits were excluded.

INTERVENTION

All subjects received psychiatric intervention and intensive rehabilitation programs during hospitalization.

MAIN OUTCOME MEASURES

The injury pattern and psychiatric condition were described. Abilities of locomotion, management of activities of daily living, and bladder control were measured.

RESULTS

Fifteen injuries caused by a voluntary fall subsequently resulted in thoracolumbar insult. Ten incomplete paraplegics were able to ambulate with or without a device on discharge. Four subjects had poor bladder control. The outcome of self-care skills was worse in those with high level injury. Psychiatric symptoms were one of the main obstacles during rehabilitation.

CONCLUSION

Voluntary fall that caused thoracolumbar injuries was the main cause of injuries in these patients. Psychiatric symptoms were present in the majority and might hinder the prognosis of treatment. Nevertheless rehabilitation programs were found to benefit subjects after their psychiatric problems were under control.

A study of the factors affecting the outcome of vertebromedullary injuries

Between 1982 and 1991, 194 patients were treated for cervical vertebromedullary injuries in the Department of Neurosurgery, Cerrahpasa Medical Faculty of the University of Istanbul. The data were evaluated with the multiple regression method using the SPSS/PC statistical package to predict the factors influencing the outcome. In the initial neurological examination, motor deficit was detected in 63.4% of the patients, sensorial deficit was seen in 53.6% of the patients and respiratory failure in 12.9%. Of these patients 46.4% were treated surgically and 53.6% medically. Evaluating the findings and outcomes with the Frankel scale, no change in neurological status was detected in 44.8% of the patients. Improvement was detected in 36.1% and deterioration in 19.1%, the mortality rate being 18.6%. It is concluded that the main factor predicting the outcome of patients with vertebromedullary injury is the initial neurological status (P < 0.0001).

The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury--observed benefits during gait studies

The benefits of a functional electrical stimulation (FES) gait programme were assessed in a group of 6 incomplete spinal cord injured subjects. Measurements were made of quadriceps spasticity, lower limb muscle strength, postural stability in standing, spatial and temporal values of gait, physiological cost of gait and independence in activities of daily living. The subjects were assessed before commencement of the programme and after a period of gait training using FES. The benefits derived as a result of the FES gait programme included a reduction in quadriceps tone, an increase in voluntary muscle strength, a decrease in the physiological cost of gait and an increase in stride length.

Assessing selfcare status in quadriplegia: comparison of the quadriplegia index of function (QIF) and the functional independence measure (FIM)

The purpose of this study was to compare the quadriplegia index of function (QIF) to the functional independence measure (FIM) in assessing the daily performance of selfcare activities by individuals with cervical spinal cord injury. This study evaluated feeding, grooming and bathing activities in 22 C4-C7, Frankel A-D spinal cord injury patients between 3 and 12 months postinjury. The manual muscle test (MMT) was performed on 17 of these subjects during the same window of time as the QIF and the FIM. An upper extremity motor score (UEMS) was derived from the MMT. In order to relate motor power to functional ability, the UEMS was used as a measure of neurological function to test the hypothesis that the QIF scores are more highly correlated to motor power than are the FIM scores for this population. Spearman coefficients were calculated to correlate the QIF, the FIM and the UEMS. For the bathing and grooming categories, both the QIF and the FIM showed significant and similar correlations to the UEMS. For the feeding category, however, the QIF had a significantly better correlation to the UEMS than did the FIM (Rho = 0.90 vs 0.53, p < 0.01). Use of the QIF feeding scale may allow the detection of changes in function as individuals recover that the FIM scale would miss. Further evaluation of the remaining selfcare and mobility scales is needed. Modification of the FIM with more sensitive portions of the QIF would improve the discriminative ability of outcome studies and program evaluations.

Spinal cord injuries in Iceland 1973-1989. A follow up study

All traumatic SCI patients in Iceland come to the Neurosurgical Department of Borgarspítalinn, the City Hospital in Reykjavík for their initial treatment. From 1973-1989, 79 (93%) were rehabilitated at Borgarspítalinn. The purpose of this study was to look at the most common complications and the social functions of SCI patients after discharge from the Rehabilitation Department. A questionnaire was sent to 59 of the 79 patients. They represent almost the whole population of the spinal cord injured population in Iceland. Forty-five patients (76.3%) answered the questionnaire, 69% male, 31% female. Sixty-seven percent were under the age of 30 years at the time of injury. Twenty-nine percent had a complete spinal cord injury; 53.3% were wheelchairbound (Frankel grade A, B, C); 55.6% were quadriplegic, and 44.4% paraplegic. The commonest complications were pain (64.4%), urinary tract infections (62.2%) and spasticity (60%); and 58% of the wheelchairbound patients had had pressure sores. Fifty-five point five percent were married; 71% had an active sexual life after the injury; 54% of the wheelchairbound patients were not quite independent and required some assistance with activities of daily living (ADL) tasks; and 29% were not working or studying compared to 11%, who were, before the injury. No significant changes were seen in social function after the injury. The results show that more emphasis must be placed on the prevention of complications such as urinary tract infections and pressure sores and on the treatment of chronic pain and spasticity.

[Evaluating the independence of paraplegic patients at the end of the first rehabilitation--a multicenter project of computer-assisted quality control in rehabilitation]

Rehabilitation of patients who became handicapped due to illness or trauma is a difficult process, involving many therapeutic sections. The necessity to document the results of different rehabilitation programs led to the development of numerous scoring systems in the USA within the last 25 years, considering mainly functional results. The present functional assessment score (DMGP-Selbständigkeitserfassung für Tetraplegiker) for the documentation of self-sufficiency in tetraplegic patients after primary rehabilitation has been designed to record the quality of rehabilitation programs and has been exclusively designed for patients with quadriplegia, it there fore has the advantage of a better and more precise documentation over other general functional scoring systems, especially for the interests of different sections (occupational therapy, physiotherapy) being involved in this special rehabilitation program. The aim of the documentation is to record the degree of independence of tetraplegic patients after primary rehabilitation, considering the individual requirements of aids and the assumption of circumstances suitable for wheel-chairs. Since all data are collected on a computer-readable form each participating clinic has the opportunity for an individual analysis of the own results, as well as the opportunity of comparing it with the collective results.

A second traumatic spinal cord injury: associated risk factors. Case report and review

Despite advances in acute care and long term management, traumatic spinal cord injury remains a devastating and disabling event. This report describes the case of a second traumatic spinal cord injury in a previously rehabilitated and functionally independent paraplegic. Factors potentially associated with the second spinal cord injury in this patient include wheelchair use, previous spinal fusion, alcohol use and sensation-seeking behavior. These factors, which are common to many spinal cord injured patients, could potentially be risk factors for a second traumatic spinal injury.

Traumatic cervical Brown-Sequard and Brown-Sequard-plus syndromes: the spectrum of presentations and outcomes

Brown-Sequard syndrome (BSS) and Brown-Sequard-plus syndrome (BSPS) are characterised by asymmetrical paresis with hypalgesia more marked on the less paretic side. This study examined the clinical features of 38 patients (30 males and 8 females; mean age = 32 years) with traumatic cervical BSS or BSPS who underwent comprehensive inpatient rehabilitation. Twenty two injuries were caused by road traffic accidents, 8 by penetrating injuries, 5 by diving injuries, and 3 by other causes. After an average of 35 days in acute care and 79 days in rehabilitation, 37 patients had increased muscle strength, all 38 patients improved functional abilities, 29 patients walked independently, 34 had spontaneous bladder emptying, 36 were discharged home, and 14 were employed. Statistically significant increases (p less than 0.001) were made in modified Barthel index functional scores between admission and discharge. Patients with BSPS had a better prognosis than did those with 'pure' BSS. Patients with predominant upper limb weakness had more favourable outcomes than did those with predominant lower limb weakness. Few other potentially predictive demographic, injury, or neurological factors were associated with functional outcome. Patients with BSS or BSPS generally have a good prognosis for neurological and functional improvement.

The value of magnetic resonance imaging (MRI) in the follow-up management of spinal injury

Twenty-seven patients with spinal injury have been studied with follow-up Magnetic Resonance Imaging (MRI). MRI has helped (a) to determine the extent of cord injury; (b) to detect continuing compression to the spinal cord; (c) to discover unexpected pathologies and most importantly (d) to detect the development of post traumatic syrinx. MRI was most valuable in patients with post-traumatic syrinxes to evaluate any changes in the size, and, in those who had a shunting procedure, to assess the efficacy of the procedure. MRI also aided in planning complicated one stage operations by giving a 'complete' picture of the injury inflicted to the vertebrae, soft tissue structures and the spinal cord. As well as advantages in clinical audit it makes financial sense. It provides more information than CT myelography and is non-invasive. When compared to the cost of neurological deterioration it is much more cost effective to follow-up spinal injury patients with MRI. It is the authors' contention that after the acute phase all patients with spinal injury should have at least one MRI.

Spinal cord injury care system: fifteen-year experience at the Rehabilitation Institute of Chicago

A statistical study of 15 years of the spinal cord injury care system of the Rehabilitation Institute of Chicago is reported. The Rehabilitation Institute of Chicago (RIC) is the rehabilitation component of the Midwest Regional Spinal Cord Injury Care System, a collaborative programme with Northwestern Memorial Hospital and Northwestern University. Data are reported on 1382 patients, a representative sample of the over 2000 patients treated since the inception of the centre. The sample was predominantly male (83%, N = 1147) and caucasian (64%, N = 888). The most common aetiology was motor vehicle accidents (36%, N = 505). During the 15-year period there were significant decreases in both acute and rehabilitation lengths of stay. Ninety three per cent of the patients were discharged home. Rehabilitation benefits were demonstrated by improvements in the Modified Barthel Index. The research, educational and clinical programmes are described.

The relationship between sponsorship and rehabilitation outcome following spinal cord injury

The effect of sources of support on rehabilitation outcomes of 866 patients treated at the University of Alabama at Birmingham Spinal Cord Injury Care System since 1973 was assessed using multiple linear and logistic regression. System admission was delayed for Medicaid beneficiaries, while patients who were responsible for at least a portion of their incurred charges were admitted sooner than other patients. Increased lengths of stay were noted among vocational rehabilitation clients and patients with either Workers' Compensation or private insurance coverage. Patients with Workers' Compensation also had significantly higher average hospital charges. Medicaid patients were more likely to be rehospitalised after discharge from rehabilitation. Vocational rehabilitation clients averaged fewer days in nursing homes after injury while Medicaid and Medicare patients experienced longer stays in nursing homes. We conclude that source of support has a significant impact on numerous measures of outcome.

Rehabilitation outcome for patients with spinal cord injury

A follow-up study of 58 patients with spinal cord injury was conducted. As measure of function the Barthel index was used. There was correlation between functional capacity and ability of self-care as well as some social determinants. However, no association was found with employment rate or certain other determinants of independent living, such as going on a holiday. We conclude that the severity of the lesion is a fundamental factor in determining the outcome, but factors related to personal and psychosocial variables, not easily measured, also have great influence on the rehabilitation process.