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

A Rasch-Based Comparison of the Functional Independence Measure and Spinal Cord Independence Measure for Outcome and Quality in the Rehabilitation of Persons with Spinal Cord Injury

Objective

The Functional Independence Measure (FIM™) and spinal cord injury (SCI)-specific Spinal Cord Independence Measure (SCIM) are commonly used tools for outcome measurement and quality reporting in rehabilitation. The objective of this study was to investigate the psychometric properties of FIM™ and SCIM and to equate the 2 scales.

Methods

First, content equivalence of FIM™ and SCIM was established through qualitative linking with the International Classification for Functioning, Disability and Health (ICF). Secondly, a Rasch analysis of overlapping contents determined the metric properties of the scales and provided the empirical basis for scale equating. Furthermore, a transformation table for FIM™ and SCIM was created and evaluated.

Subjects

Patients with SCI in Swiss inpatient rehabilitation in 2017–18.

Results

The ICF linking and a separate Rasch analysis of FIM™ restricted the analysis to the motor scales of FIM™ and SCIM. The Rasch analysis of these scales showed good metric properties. The co-calibration of FIM™ and SCIM motor scores was supported with good fit to the Rasch model. The operational range of SCIM is larger than for FIM™ motor scale.

Discussion

This study supports the advantage of using SCIM compared with FIM™ for assessing the functional independence of patients with SCI in rehabilitation.

Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions

STUDY DESIGN

Prospective, observational study.

OBJECTIVES

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI.

SETTING

Three Italian rehabilitation hospitals.

METHODS

The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM).

RESULTS

The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score.

CONCLUSIONS

Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.

Cross-cultural validation of a Brazilian version of the adapted manual wheelchair circuit (AMWC-Brazil)

Purpose: To translate, culturally adapt and validate the Adapted Manual Wheelchair Circuit (AMWC) into Brazilian-Portuguese. Design: Cross-sectional study. Methods: Sixty-six men (median age of 30.5 years [percentiles 25 and 75: 24.0; 38.3 years]) with traumatic spinal cord injury were consecutively enrolled and divided into two groups: tetraplegia (TP) and paraplegia (PP). The participants performed the AMWC-Brazil and were evaluated by the Spinal Cord Injury Measure version III (SCIM-III). Translation, translation synthesis, back-translation, committee review and construct validity were adopted for the cross-cultural adaptation. Construct validity was performed by testing whether the test scores were significantly correlated (Spearman's correlation coefficient) to the subjects' injury level, age, time since injury, body mass index (BMI) and SCIM-III scale. Results: All the AMWC-Brazil's outcomes were significantly correlated with SCIM-III total score and subscales (P ≤ 0.01). However, when the analyses were stratified over injury level, only the TP showed a high correlation between the AMWC-Brazil's outcomes and the SCIM-III. For construct validity, 4 of 5 hypotheses were confirmed. Only BMI was not a significant predictor of the AMWC-Brazil outcomes. Conclusion: The AMWC was successfully translated to the Brazilian-Portuguese (AMWC-Brazil) and presented high and satisfactory construct validity.

Sensitivity of the SCI-FI/AT in Individuals With Traumatic Spinal Cord Injury

OBJECTIVE

To examine the ability of the Spinal Cord Injury-Functional Index/Assistive Technology (SCI-FI/AT) measure to detect change in persons with spinal cord injury (SCI).

DESIGN

Multisite longitudinal (12-mo follow-up) study.

SETTING

Nine SCI Model Systems programs.

PARTICIPANTS

Adults (N=165) with SCI enrolled in the SCI Model Systems database.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

SCI-FI/AT computerized adaptive test (CAT) (Basic Mobility, Self-Care, Fine Motor Function, Wheelchair Mobility, and/or Ambulation domains) completed at discharge from rehabilitation and 12 months after SCI. For each domain, effect size estimates and 95% confidence intervals were calculated for subgroups with paraplegia and tetraplegia.

RESULTS

The demographic characteristics of the sample were as follows: 46% (n=76) individuals with paraplegia, 76% (n=125) male participants, 57% (n=94) used a manual wheelchair, 38% (n=63) used a power wheelchair, 30% (n=50) were ambulatory. For individuals with paraplegia, the Basic Mobility, Self-Care, and Ambulation domains of the SCI-FI/AT detected a significantly large amount of change; in contrast, the Fine Motor Function and Wheelchair Mobility domains detected only a small amount of change. For those with tetraplegia, the Basic Mobility, Fine Motor Function, and Self-Care domains detected a small amount of change whereas the Ambulation item domain detected a medium amount of change. The Wheelchair Mobility domain for people with tetraplegia was the only SCI-FI/AT domain that did not detect significant change.

CONCLUSIONS

SCI-FI/AT CAT item banks detected an increase in function from discharge to 12 months after SCI. The effect size estimates for the SCI-FI/AT CAT vary by domain and level of lesion. Findings support the use of the SCI-FI/AT CAT in the population with SCI and highlight the importance of multidimensional functional measures.

Pre- and Postintervention Factor Structure of Functional Independence Measure in Patients with Spinal Cord Injury

Objective

To evaluate the factor structure of Functional Independence Measure (FIM®) scale amongst people with spinal cord injury (SCI).

Methods

This was a retrospective, register-based cohort study on 155 rehabilitants with SCI. FIM was assessed at the beginning and at the end of multidisciplinary inpatient rehabilitation. The internal consistency of the FIM was assessed with Cronbach's alpha and exploratory factor analysis was employed to approximate the construct structure of FIM.

Results

The internal consistency demonstrated high Cronbach's alpha of 0.95 to 0.96. For both pre- and postintervention assessments, the exploratory factor analysis resulted in 3-factor structures. Except for two items (“walking or using a wheelchair” and “expression”), the structures of the identified three factors remained the same from the beginning to the end of rehabilitation. The loadings of all items were sufficient, exceeding 0.3. Both pre- and postintervention chi-square tests showed significant p values < 0.0001. The “motor” domain was divided into two factors with this 2-factor structure enduring through the intervention period.

Conclusions

Amongst rehabilitants with SCI, FIM failed to demonstrate unidimensionality. Instead, it showed a 3-factor structure that fluctuated only little depending on the timing of measurement. Additionally, when measured separately, also motor score was 2-dimensional, not 1-dimensional. Using a total or subscale FIM, scores seem to be unjustified in the studied population.

Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence

OBJECTIVES

(1) To describe functional status, length of stay (LOS) and time to rehabilitation admission trends. (2) To identify independent predictors of motor function following rehabilitation.

STUDY DESIGN

Retrospective cohort study.

SETTING

Spinal injury rehabilitation unit at King Fahad Medical City, Riyadh, Saudi Arabia.

METHODS

From chart review of 312 traumatic and 106 nontraumatic adult patients with spinal cord injury (SCI) we extracted information on time from injury to rehabilitation admission, rehabilitation LOS, Functional Independence Measure (FIM) motor score (admission and discharge), American Spinal Injury Association Impairment Scale (AIS) grade and demographics. Hierarchical regression was employed to investigate variables associated with discharge FIM motor score for traumatic and nontraumatic SCI.

RESULTS

Mean±s.d., median days from injury to rehabilitation admission were 377±855, 150 days for traumatic SCI and 288±403, 176 days for nontraumatic SCI. For individuals with traumatic SCI, after accounting for admission FIM motor score, tetraplegia and time from injury to rehabilitation admission had a significant but small negative association with discharge FIM motor score. For individuals with nontraumatic SCI, increasing age and higher AIS grade had a significant negative association with discharge FIM motor score.

CONCLUSIONS

Shorter time from injury to rehabilitation admission may improve outcomes for those with traumatic SCI. As time spent in rehabilitation was shorter than in most other countries, a change in practice in this area may be warranted. Developing strategies to improve outcomes for older patients with nontraumatic SCI would also be beneficial.

Influence of Relative Strength on Functional Independence of Patients With Spinal Cord Injury

OBJECTIVE

To investigate the influence of strength values and fat mass on functional independence of men with different spinal cord injury (SCI) levels.

DESIGN

Cross-sectional study.

SETTING

Hospital network.

PARTICIPANTS

Men with SCI (N=45).

INTERVENTIONS

Subjects were assessed in functional independence scales, a 1 repetition maximum (1RM) test, and body composition to detect absolute and relative strength: 1RM divided by body mass (BM) and lean body mass (LBM), respectively.

MAIN OUTCOME MEASURES

Stepwise multiple regression analysis was used to verify the influence of predictors on functional independence (FIM and Spinal Cord Independence Measure [SCIM] scale and subscales). Receiver operating characteristic curves were created to identify cutoff points of strength for functional independence.

RESULTS

The best models for FIM total, FIM mobility, and SCIM total used 1RM as the best predictor (adjusted R²=.75, .67, and .65, respectively; P<.05). Relative strength (1RM/LBM) was the best predictor for SCIM mobility (adjusted R²=.62, P<.05). A FIM score of 69 has a 1RM cutoff point of 50.1kg, and a FIM score of 76 has cutoff points of .73 for 1RM/BM and .91 for 1RM/LBM. A SCIM score of 68 has cutoff points for 1RM, 1RM/BM, and 1RM/LBM of 50.1kg, .77, and .92, respectively.

CONCLUSIONS

Cutoff points of relative strength should be used as determinant variables for independence, health, or sports performance. This study may contribute to more adequate guidance of physical activity during a rehabilitation program and after discharge.

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.

Development of the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP): reviewing measurement specific to the upper limb in tetraplegia

OBJECT

Primary outcome measures for the upper limb in trials concerning human spinal cord injury (SCI) need to distinguish between functional and neurological changes and require satisfying psychometric properties for clinical application.

METHODS

The Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP) was developed by the International GRASSP Research and Design Team as a clinical outcome measure specific to the upper limbs for individuals with complete and incomplete tetraplegia (that is, paralysis or paresis). It can be administered across the continuum of recovery after acute cervical SCI. An international multicenter study (involving centers in North America and Europe) was conducted to apply the measure internationally and examine its applicability.

RESULTS

The GRASSP is a multimodal test comprising 5 subtests for each upper limb: dorsal sensation, palmar sensation (tested with Semmes-Weinstein monofilaments), strength (tested with motor grading of 10 muscles), and prehension (distinguishes scores for qualitative and quantitative grasping). Thus, administration of the GRASSP results in 5 numerical scores that provide a comprehensive profile of upper-limb function. The established interrater and test-retest reliability for all subtests within the GRASSP range from 0.84 to 0.96 and from 0.86 to 0.98, respectively. The GRASSP is approximately 50% more sensitive (construct validity) than the International Standards of Neurological Classification of SCI (ISNCSCI) in defining sensory and motor integrity of the upper limb. The subtests show concurrence with the Spinal Cord Independence Measure (SCIM), SCIM self-care subscales, and Capabilities of Upper Extremity Questionnaire (CUE) (the strongest concurrence to impairment is with self-perception of function [CUE], 0.57-0.83, p < 0.0001).

CONCLUSIONS

The GRASSP was found to demonstrate reliability, construct validity, and concurrent validity for use as a standardized upper-limb impairment measure for individuals with complete or incomplete tetraplegia. Responsiveness (follow-up from onset to 1 year postinjury) is currently being tested in international studies (in North America and Europe). The GRASSP can be administered early after injury, thus making it a tool that can be administered in acute care (in the ICU), rehabilitation, and outpatient clinics.

Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project

BACKGROUND/OBJECTIVE

Describe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury.

METHODS

Occupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined.

RESULTS

OT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes.

CONCLUSION

OT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings. Note: This is the third of nine articles in the SCIRehab series.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project

BACKGROUND/OBJECTIVE

Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury.

METHODS

Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia.

RESULTS

PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries.

CONCLUSION

Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

Assessment of impairment in patients with acute traumatic spinal cord injury: a systematic review of the literature

The most common primary end-point of the trial on treatment of traumatic spinal cord injury (SCI) is the degree of impairment. The American Spinal Injury Association (ASIA) Standards have been widely used to assess motor function and pin-prick and light-touch sensory function. In addition, pain assessment is another clinically relevant aspect of the impairment in individuals with SCI. Given this, we sought to systematically review the studies that focused on the psychometric properties of ASIA Standards and all previously used outcome measures of pain in the SCI population in the acute care setting. For the primary literature search strategy, the MEDLINE, CINAHL, EMBASE, and Cochrane databases were sought out. Subsequently, a secondary search strategy was carried out using the articles listed in the references of meta-analysis, systematic, and non-systematic review articles. Two reviewers (JCF and VN) independently selected the articles that fulfill the inclusion and exclusion, assessed the level of evidence of each article, and appraised the psychometric properties of each instrument. Divergences during those steps were solved by consensus between both reviewers. Of 400 abstracts captured in our primary search strategy on the ASIA Standards, 16 full articles fulfilled the inclusion and exclusion criteria. An additional 40 references were obtained from two prior systematic reviews on ASIA Standards. While 45 of 56 of the studies on ASIA Standards provided level 4 evidence, there were 11 level 2b evidence studies. Convergent construct validity (n = 34), reliability (n = 12), and responsiveness (n = 10) were the most commonly studied psychometric properties of the ASIA Standards, but two prior studies examined their content validity. Of the 267 abstracts yielded in our primary search on pain assessment, 24 articles with level 4 evidence fulfilled the inclusion and exclusion criteria. There was no study that examined pain assessment in the acute care setting. While 18 of 24 articles studied an instrument for assessment of pain intensity, the remaining six studies were focused on classifications of pain in the SCI population. In conclusion, the ASIA Standards represent an appropriate instrument to categorize and evaluate spinal cord injured adults over time with respect to their motor and sensory function. Nevertheless, further investigation of the psychometric properties of the ASIA Standards is recommended due to a lack of studies focused on some key elements of responsiveness, including minimal clinically important difference. The visual analog scale (VAS) is the most commonly studied instrument of assessment of pain intensity in the SCI population. However, further investigation is required with regard to its reliability and responsiveness in the SCI population. Our results also suggest that there is no instrument with appropriate psychometric properties for this particular population.

Assessment of disability in patients with acute traumatic spinal cord injury: a systematic review of the literature

Given the importance of accurately and reliably assessing disability in future clinical trials, which will test therapeutic strategies in acute spinal cord injury (SCI), we sought to appraise comprehensively studies that focused on the psychometric properties (i.e., reliability, validity, and responsiveness) of all previously used outcome measures in the SCI population. The search strategy included Medline, CINAHL, EMBASE, and Cochrane databases. Two reviewers independently assessed each study regarding eligibility, level of evidence (using Sackett's criteria), and quality. Of 363 abstracts captured in our search, 36 full articles fulfilled the inclusion and exclusion criteria. Eight different outcome measures were used to assess disability in the SCI population, including Functional Independence Measure (FIM), Spinal cord Injury Measure (SCIM), Walking Index for Spinal Cord Injury (WISCI), Quadriplegia Index of Function (QIF), Modified Barthel Index (MBI), Timed Up & Go (TUG), 6-min walk test (6MWT), and 10-m walk test (10MWT). While 19 of 36 studies provided level-4 evidence, the remaining 17 articles were classified as level-2b evidence. Most of the instruments showed convergent construct validity in the SCI population, but criterion validity was not examined due to the lack a gold standard for assessment of disability. All instruments were tested in the rehabilitation and/or community setting, but only FIM was examined in the acute care setting. Based on our results of quality assessment, the SCIM has the most appropriate performance regarding the instrument's psychometric properties. Nonetheless, further investigations are required to confirm the adequate performance of the SCIM as a comprehensive measure of functional recovery in patients with SCI in rehabilitative care. The expert panel of the Spinal Cord Injury Solutions Network (SCISN) that participated in the modified Delphi process endorsed these conclusions.

Issues for the selection of wheelchair-specific activity and participation outcome measures: a review

OBJECTIVES

To use the World Health Organization's International Classification of Functioning, Disability and Health as a framework to identify and to evaluate wheelchair-specific outcome instruments that are useful for measuring activity and participation.

DATA SOURCES

CINHAL, PsychInfo, EMBASE, Google Scholar, Dissertation Abstracts Medline databases, and conference proceedings.

STUDY SELECTION

Activity and participation measures that were specifically intended for adults who use wheelchairs and that were published in English in a peer-reviewed journal were included in this review. Based on electronic database searches using a variety of search terms, articles were identified by title, and appropriate abstracts were retrieved. Articles were obtained for all relevant abstracts. For peer-reviewed measures included in the review, we obtained any instruction manuals and related publications, frequently published in conference proceedings and theses or available electronically, on the development and testing of the measure.

DATA EXTRACTION

Tools included in the review were evaluated based on their conceptual coverage, reliability, validity, responsiveness, usefulness, and wheelchair contribution, which indicated how well the tool isolated the effect of the wheelchair on activity and participation outcomes.

DATA SYNTHESIS

A number of conceptual, psychometric, and applicability issues were identified with the 11 wheelchair-specific measures included in the review. A majority of the measures were mobility focused. No single tool received excellent ratings in all areas of the review. Some of the most frequent issues identified included a failure to account for differences attributable to different wheelchairs and wheelchair seating, limited psychometric testing, and high administrative and respondent burden.

CONCLUSIONS

Good reliability evidence was reported for most of the measures, but validity information was only available for 6 of the 11 measures, and responsiveness information for 3. This review suggests that these measures could be improved with further psychometric testing and with some modification to ensure that the contribution of the wheelchair to activity and participation outcomes is clearly identified.

Functional recovery measures for spinal cord injury: an evidence-based review for clinical practice and research

BACKGROUND/OBJECTIVE

The end goal of clinical care and clinical research involving spinal cord injury (SCI) is to improve the overall ability of persons living with SCI to function on a daily basis. Neurologic recovery does not always translate into functional recovery. Thus, sensitive outcome measures designed to assess functional status relevant to SCI are important to develop.

METHOD

Evaluation of currently available SCI functional outcome measures by a multinational work group.

RESULTS

The 4 measures that fit the prespecified inclusion criteria were the Modified Barthel Index (MBI), the Functional Independence Measure (FIM), the Quadriplegia Index of Function (QIF), and the Spinal Cord Independence Measure (SCIM). The MBI and the QIF were found to have minimal evidence for validity, whereas the FIM and the SCIM were found to be reliable and valid. The MBI has little clinical utility for use in the SCI population. Likewise, the FIM applies mainly when measuring burden of care, which is not necessarily a reflection of functional recovery. The QIF is useful for measuring functional recovery but only in a subpopulation of people with SCI, and substantial validity data are still required. The SCIM is the only functional recovery outcome measure designed specifically for SCI.

CONCLUSIONS

The multinational work group recommends that the latest version of the SCIM (SCIM III) continue to be refined and validated and subsequently implemented worldwide as the primary functional recovery outcome measure for SCI. The QIF may continue to be developed and validated for use as a supplemental tool for the nonambulatory tetraplegic population.

Changes in Activity After a Complete Spinal Cord Injury as Measured by the Spinal Cord Independence Measure II (SCIM II)

Background. The assessment of rehabilitation efficacy in spinal cord injury (SCI) should be based on a combination of neurological and functional outcome measures. The Spinal Cord Independence Measure II (SCIM II) is an independence scale that was specifically developed for subjects with SCI. However, little is known about the changes in SCIM II scores during and after rehabilitation. Objective. The aims of this study were to evaluate changes in functional recovery during the first year after a complete SCI as measured by the SCIM II compared with neurological recovery (motor scores according to the American Spinal Injury Association [ASIA]). Methods. SCIM II data and ASIA motor scores at 1, 3, 6, and 12 months after injury (derived from the database of the European Multicenter Study of Human Spinal Cord Injury) of 64 patients with complete paraplegia and 36 patients with complete quadriplegia were analyzed. Results. In patients with complete paraplegia, the SCIM II total score improved significantly during the 1-year follow-up, even after discharge from rehabilitation. In contrast, the ASIA motor scores showed little recovery. In patients with quadriplegia, functional and motor recovery developed in parallel during rehabilitation and after discharge. Conclusions. The SCIM II is responsive to functional changes in patients with a persistent motor complete SCI. It is clinically useful for monitoring functional improvement during rehabilitation and after discharge. The SCIM II and the clinical examination based on the ASIA protocol are of complementary value and separately describe changes in independence and sensorimotor deficits in SCI patients.

Cross-diagnostic validity in a generic instrument: an example from the Functional Independence Measure in Scandinavia

Background

To analyse the cross-diagnostic validity of the Functional Independence Measure (FIM™) motor items in patients with spinal cord injury, stroke and traumatic brain injury and the comparability of summed scores between these diagnoses.

Methods

Data from 471 patients on FIM™ motor items at admission (stroke 157, spinal cord injury 157 and traumatic brain injury 157), age range 11–90 years and 70 % male in nine rehabilitation facilities in Scandinavia, were fitted to the Rasch model. A detailed analysis of scoring functions of the seven categories of the FIM™ motor items was made prior to testing fit to the model. Categories were re-scored where necessary. Fit to the model was assessed initially within diagnosis and then in the pooled data. Analysis of Differential Item Functioning (DIF) was undertaken in the pooled data for the FIM™ motor scale. Comparability of sum scores between diagnoses was tested by Test Equating.

Results

The present seven category scoring system for the FIM™ motor items was found to be invalid, necessitating extensive rescoring. Despite rescoring, the item-trait interaction fit statistic was significant and two individual items showed misfit to the model, Eating and Bladder management. DIF was also found for Spinal Cord Injury, compared with the other two diagnoses. After adjustment, it was possible to make appropriate comparisons of sum scores between the three diagnoses.

Conclusion

The seven-category response function is a problem for the FIM™ instrument, and a reduction of responses might increase the validity of the instrument. Likewise, the removal of items that do not fit the underlying trait would improve the validity of the scale in these groups. Cross-diagnostic DIF is also a problem but for clinical use sum scores on group data in a generic instrument such as the FIM™ can be compared with appropriate adjustments. Thus, when planning interventions (group or individual), developing rehabilitation programs or comparing patient achievements in individual items, cross-diagnostic DIF must be taken into account.

Choice-Based Evaluation for the Improvement of Upper-Extremity Function Compared With Other Impairments in Tetraplegia

OBJECTIVES

To assess preference of reconstructive treatment of upper extremities in subjects with tetraplegia compared with preference of treatment of 3 other impairments and to determine the effect of subjects' characteristics on preference of upper-extremity reconstruction.

DESIGN

Survey.

SETTING

Two specialized spinal cord injury centers in the Netherlands.

PARTICIPANTS

A consecutive sample of 47 patients with tetraplegia in stable condition.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The quality weight of 5 tetraplegic health states determined with the time trade-off technique and expressed as a single value (the "utility") on a scale between 0 (worst possible situation) and 1 (best possible situation).

RESULTS

The response rate was 92%. The utility of tetraplegia +/- standard deviation was .57+/-.30. The utilities of tetraplegia without impairment in one of the following functions were .69+/-.33 for sexuality, .69+/-.33 for standing/walking, .63+/-.31 for bladder and bowel function, and .65+/-.32 for upper-extremity function. The differences between these utilities and the utility of tetraplegia were significant (P<.05). No significant differences were found between the utilities of the impairments. Improvement of a specific impairment contributed between 14% and 28% to the potential overall gain in the tetraplegic health state utility.

CONCLUSIONS

The combination of impairments determines the low utility of the tetraplegic health state. No priority for improvement of any of the investigated impairments was found. This emphasizes the need for the meticulous selection of patients for treatment of specific conditions. Further research should try to determine the crucial factors in the decision-making process of patients for specific interventions.

[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.

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).

Reliability of the Catz-Itzkovich Spinal Cord Independence Measure assessment by interview and comparison with observation

OBJECTIVE

To examine the reliability of assessment with the Catz-Itzkovich Spinal Cord Independence Measure II (SCIM II) by interview and compare the findings with assessment by observation.

DESIGN

In a cohort, comparative study, 28 inpatients with spinal cord lesions were assessed by two nurses using the Catz-Itzkovich SCIM II (interview) and by a multidisciplinary team (observation).

RESULTS

Total agreement between interviewers ranged from 50% to 80% (Kappa coefficients 0.40-0.60). Pearson's coefficients of the correlation between scores obtained for the various SCIM subscales by interview or observation were 0.765-0.940 (P < 0.0001). The differences in mean scores obtained between the interview and observation methods were small and not statistically significant for most of the subscales.

CONCLUSIONS

The results support the reliability of the Catz-Itzkovich SCIM assessment by interview and show it to be comparable with assessment by observation. The SCIM II interview may serve as an accurate measure of daily function in patients with spinal cord injury. However, with the sample of the study being relatively small, a larger scale examination is needed to generalize the results.

Methylprednisolone and acute spinal cord injury: an update of the randomized evidence

OBJECTIVES

Randomized trials are widely recognized as providing the most reliable evidence for assessing efficacy and safety of therapeutic interventions. This evidence base is used to evaluate the current status of methylprednisolone (MPSS) in the early treatment of acute spinal cord injury.

METHODS

Medline, CINAHL, and other specified databases were searched for MeSH headings "methylprednisolone and acute spinal cord injury." The Cochrane Library and an existing systematic review on the topic were also searched.

RESULTS

Five randomized controlled trials were identified that evaluated high-dose MPSS for acute spinal cord injury. Three trials by the NASCIS group were of high methodologic quality, and a Japanese and French trial of moderate to low, methodologic quality. Meta-analysis of the final result of three trials comparing 24-hour high-dose MPSS with placebo or no therapy indicates an average unilateral 4.1 motor function score improvement (95% confidence interval 0.6-7.6, P = 0.02) in patients treated with MPSS. This neurologic recovery is likely to be correlated with improved functional recovery in some patients. The safety of this regimen of MPSS is evident from the spinal cord injury trials and a systematic review of 51 surgical trials of high-dose MPSS.

CONCLUSION

High-dose MPSS given within 8 hours of acute spinal cord injury is a safe and modestly effective therapy that may result in important clinical recovery for some patients. Further trials are needed to identify superior pharmacologic therapies and to test drugs that may sequentially influence the postinjury cascade.

The self-reported functional measure: Predictive validity for health care utilization in multiple sclerosis and spinal cord injury

OBJECTIVE

To examine the predictive validity of the Self-Reported Functional Measure (SRFM), a new measure derived from the FIMtrade mark instrument, for health care utilization in multiple sclerosis (MS) and spinal cord injury (SCI).

DESIGN

Prospective cohort study using a mailed survey in 1995 and administrative records from 1996 and 1997.

SETTING

Veterans Health Administration hospitals and outpatient clinics.

PATIENTS

A total of 6361 veterans with SCI and 1789 veterans with MS.

MAIN OUTCOME MEASURES

SRFM score was compared with subsequent outpatient visits, hospitalizations, hospital lengths of stay (LOSs), and residence peri-hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these variables.

RESULTS

A total of 3836 subjects (47.6%) were hospitalized during 1996-1997, and all but 874 (10.7%) had 1 or more outpatient visits. SRFM score predicted inpatient, but not outpatient health care utilization. Persons in the lowest SRFM quartile were over 90% (OR = 1.91, 95% CI = 1.71-2.13) more likely to be hospitalized compared with those in the highest SRFM quartile; also, they were over 2 times (OR = 2.18, 95% CI = 1.85-2.57) more likely to have a LOS greater than 7 days, were over 2 times (OR = 2.41, 95% CI = 1.62-3.58) more likely to die in hospital, and were nearly 3 times (OR = 2.86, 95% CI = 2.00-4.08) more likely to be discharged to an institution.

CONCLUSIONS

SRFM had excellent predictive validity for hospitalization, LOS, and discharge destination among patients with MS or SCI.

Clinician judgments of functional outcomes: how bias and perceived accuracy affect rating

OBJECTIVE

To evaluate the accuracy of clinician judgments of patient function, the susceptibility of judges to bias, and the relation between a judge's degree of belief in his/her accuracy of classification to observed accuracy when using the FIM instrument.

PARTICIPANTS

Fifty rehabilitation professionals.

SETTING

3 urban medical centers.

DESIGN

Four randomized experiments among subjects to examine the effect of potentially biasing information on FIM ratings of patient vignettes. Participants answered 60 true/false questions regarding patient function and FIM score and indicated confidence in the accuracy of their answers.

INTERVENTIONS

Manipulation of patient information.

MAIN OUTCOME MEASURES

The standard FIM 7-point scale, observed proportion of correct responses to the 60 true/false questions, and a 6-category confidence scale for each of the 60 questions were used as dependent measures.

RESULTS

FIM ratings assigned to others biased participants' FIM ratings of patient vignettes. Functional ability was overestimated when ratings in other domains were high and underestimated when they were low. Participants were overconfident in their ability to answer FIM questions accurately across all professional disciplines.

CONCLUSION

Bias and poor judgment of level accuracy play a significant role in clinician ratings of patient functioning. Blind ratings and training in debiasing are potential solutions to the problem.

Recovery of upper-extremity strength in complete and incomplete tetraplegia: a multicenter study

OBJECTIVE

To examine upper-extremity motor recovery of subjects with tetraplegia with both complete and incomplete injuries, to predict which patients and at what time they would recover a motor level.

DESIGN

Prospective, multicenter clinical study of upper-extremity motor recovery in subjects with acute traumatic spinal cord injury.

SETTING

Three regional spinal cord injury centers.

SUBJECTS

One hundred sixty-seven individuals with acute traumatic tetraplegia (144 males [86%], and 23 females [14%]) between the ages of 15 and 75 years (mean age, 35.5 yrs).

METHODS

Subjects were examined and classified using sequential manual muscle tests performed on admission, 72 hours, 1, 2, and 3 weeks, and 1, 2, 3, 6, 12, 18, and 24 months postinjury. C5 biceps, C6 extensor carpi radialis, C7 triceps, and C8 flexor digitorum profundus were evaluated using a 0-5 scale. Analyses of the right motor levels used a series of logistic regression models, and for multiple measurements on each subject, models were estimated using generalized estimating equations.

RESULTS

The analysis for recovery of the biceps for the C4 group showed 70% of complete compared with 90% of incomplete injuries recovered (p < .001); of the extensor carpi radialis in the C5 group, 75% complete and 90% incomplete recovered (p < .002); and of the triceps in the C6 group, 85% of complete and 90% of incomplete injuries recovered (p < .16).

CONCLUSION

Predicting future potential for upper-extremity motor recovery and for independence in self-care in groups of patients at a specific motor level is possible within the first week of injury.

Neurological level effect on the discharge functional status of spinal cord injured persons after rehabilitation

OBJECTIVE

To determine the relation between neurological level and functional status, measured by individual Functional Independence Measure (FIM) item scores, at discharge after rehabilitation in individuals with acute spinal cord injury (SCI).

DESIGN

A cohort of spinal cord injured individuals (ASIA Impairment Scale grades A, B, and C) were classified in groups for analysis of variance (ANOVA) according to neurological level at discharge (C1-4, C5, C6, C7-8, T1-6, T7 and below).

SETTING

A 20-bed SCI rehabilitation unit.

PATIENTS

One hundred twelve individuals admitted between January 1993 and December 1996.

INTERVENTION

Multidisciplinary rehabilitation program.

MAIN OUTCOME MEASURES

FIM item scores at discharge after rehabilitation.

RESULTS

ANOVA and post hoc testing showed significant differences and a systematic change in discharge FIM item scores between adjacent neurological groupings for the tetraplegic and T1-6 paraplegic groups for all the self-care items and between the high and low paraplegic groups for the mobility items. A systematic relation was also seen between lesion level and discharge FIM score for the sphincter control items but not for the locomotion and cognitive items.

CONCLUSIONS

The finding of an inverse relationship between FIM score and neurological level for certain motor items supports clinical observations that functional performance in spinal cord injured individuals is reduced with greater neurological impairment. However, results for the locomotion and cognitive subscale items indicate a need for other measures, in addition to the FIM, for outcome measurement in SCI.

Voluntary muscle weakness and co-activation after chronic cervical spinal cord injury

Muscle strength was assessed from the maximum force that could be exerted voluntarily by triceps brachii muscles of 72 people with chronic cervical spinal cord injury (SCI) at or above C7, and 18 able-bodied (A-B) subjects. The magnitude of co-activation was estimated from the ratio of biceps brachii surface EMG to triceps plus biceps brachii surface EMG (biceps EMG/ triceps + biceps EMG). Maximum voluntary forces exerted by triceps brachii muscles of SCI subjects were significantly lower than those of controls (p < 0.01). Strength differences between muscles of SCI men and women were not evident. Significant positive relationships were found (linear or curvilinear) between triceps surface EMG and force for all control muscles (n = 19) and for 54% of the muscles of SCI subjects (n = 73). The remaining muscle of SCI subjects (n = 63) were either so weak that only one EMG and force value could be measured or EMG occurred without detectable force. For control muscles (n = 19), the mean triceps-biceps EMG ratio was 0.15+/-0.05 for all voluntary contraction force levels. For muscles of SCI subjects, 41 had EMG ratios similar to those of controls, co-activity largely attributed to EMG cross talk; 19 muscles had constant EMG ratios, but these were three standard deviations above the control means; 13 muscles had EMG ratios that decreased or increased as force increased. Muscles of SCI subjects with greater than control levels of co-activity during maximum voluntary contractions (high EMG ratios) were as strong as muscles with EMG ratios similar to controls. These results provide quantitative descriptions of voluntary muscle weakness after SCI and a database from which to evaluate improvements in muscle strength. These data also show that, for many SCI subjects, any triceps-biceps co-activation is similar to that of controls and does not necessarily distort muscle control unduly.

Measurement, nature, and implications of skeletal muscle strength in patients with neurological disorders

Muscle strength is frequently impaired in patients with neurological disorders. Numerous instrumented and non-instrumented options exist for measuring the strength of such patients. Such measurements are useful for clarifying patient status and documenting changes over time. Moreover the measurements are often informative of present or future function among a variety of diagnostic groups. Measurements of muscle strength are an essential component of the neurological evaluation and provide information of substantial importance to clinical care.