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Habib Perez O, Chan K, Martin S, Marinho-Buzelli A, Singh H, Musselman KE. The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study. Disabil Rehabil 2024; 46:3937-3945. [PMID: 37732508 DOI: 10.1080/09638288.2023.2259311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 09/06/2023] [Accepted: 09/10/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE To understand the circumstances, causes and consequences of falls experienced by individuals with subacute SCI, and to explore their perspectives on how falls/fall risk impacted their transition to community living. MATERIALS AND METHODS Sixty adults with subacute SCI participated. A sequential explanatory mixed methods design was adopted. In Phase I, falls were monitored for six months post-inpatient rehabilitation discharge through a survey. In Phase II, a qualitative focus group (n = 5) was held to discuss participants' perspectives on Phase I results and falls/fall risk. Descriptive statistics and thematic analysis were used to analyze Phase I and II data, respectively. RESULTS Falls commonly occurred in the daytime, at home and about half resulted in minor injury. Three themes reflecting participants' perspectives were identified in Phase II. 1) Lack of preparedness to manage fall risk upon returning home from inpatient rehabilitation. 2) Adjusting to increased fall risk following discharge from inpatient rehabilitation. 3) Psychological impact of the transition to living at home with an increased fall risk. CONCLUSIONS The findings highlight the need for fall prevention initiatives during subacute SCI, when individuals are learning to manage their increased fall risk.
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Affiliation(s)
- Olinda Habib Perez
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Katherine Chan
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Samantha Martin
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Hardeep Singh
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kristin E Musselman
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Bluvshtein V, Catz A, Benjamini Y, Refaeli D, Front L, Bizzarini E, Margalho P, Soeira TP, Kesiktas N, Aidinoff E. Assessment of ability realization using the 4th version of the Spinal Cord Independence Measure. J Spinal Cord Med 2024:1-8. [PMID: 39037152 DOI: 10.1080/10790268.2024.2374132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
CONTEXT Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities after spinal cord lesions (SCL). OBJECTIVE To adapt a Spinal Cord Ability Realization Measurement Index (SCI-ARMI) formula to the new Spinal Cord Independence Measure version 4 (SCIM4). METHODS Using data from 156 individuals for whom American Spinal Injury Association Motor Score (AMS) and SCIM4 scores were collected, we obtained an estimate for the highest possible SCIM4 given the patient's AMS value, using the 95th percentile of SCIM4 values at discharge from rehabilitation (SCIM95) for patients with any given AMS at discharge. We used the statistical software environment R to implement the quantile regression method for linear and quadratic formulas. We also compared the computed model with the SCIM95 model obtained using data from the present study group, positioned in the SCIM95 formula developed for SCIM3. RESULTS The coefficients of the computed SCIM95 formula based on SCIM4 scores were statistically non-significant, which hypothetically reflects the small sample relative to the goal of estimating SCIM4 95th percentile. Predicting the ability using SCIM4 scores positioned in the SCIM95 formula used for SCIM3, however, yielded SCIM95 values, which are very close to those of the new SCIM95 formula (Mean difference 2.16, 95% CI = 1.45, 4.90). CONCLUSION The SCI-ARMI formula, which is based on the SCIM95 formula developed for SCIM3, is appropriate for estimating SCI-ARMI at present, when SCIM4 scores are available. When sufficient additional data accumulates, it will be appropriate to introduce a modified SCI-ARMI formula.
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Affiliation(s)
- Vadim Bluvshtein
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amiram Catz
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Benjamini
- School of Mathematical Sciences, Tel Aviv University, Tel Aviv, Israel
| | - David Refaeli
- School of Mathematical Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Lilach Front
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | | | | | | | - Nur Kesiktas
- Istanbul Physical Medicine and Rehabilitation Hospital, University of Health Sciences, Istanbul, Turkey
| | - Elena Aidinoff
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Catz A, Watts Y, Amir H, Front L, Gelernter I, Michaeli D, Bluvshtein V, Aidinoff E. The role of comprehensive rehabilitation in the care of degenerative cervical myelopathy. Spinal Cord 2024; 62:200-206. [PMID: 38438531 PMCID: PMC11176072 DOI: 10.1038/s41393-024-00965-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To find out if comprehensive rehabilitation itself can improve daily performance in persons with DCM. SETTING The spinal department of a rehabilitation hospital. METHODS Data from 116 DCM inpatients who underwent comprehensive rehabilitation after spinal surgery were retrospectively analyzed. The definitions of the calculated outcome variables made possible analyses that distinguished the effect of rehabilitation from that of spinal surgery. Paired t-tests were used to compare admission with discharge outcomes and functional gains. Spearman's correlations were used to assess relationships between performance gain during rehabilitation and between time from surgery to rehabilitation. RESULTS The Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) increased during rehabilitation from 57 (24) to 78 (19) (p < 0.001). The Spinal Cord Independence Measure 3rd version (SCIM III) gain attributed to neurological improvement (dSCIM-IIIn) was 6.3 (9.2), and that attributed to rehabilitation (dSCIM-IIIr) 16 (18.5) (p < 0.001). dSCIM-IIIr showed a rather weak negative correlation with time from spinal surgery to rehabilitation (r = -0.42, p < 0.001). CONCLUSIONS The study showed, for the first time, that comprehensive rehabilitation can achieve considerable functional improvement for persons with DCM of any degree, beyond that of spinal surgery. Combined with previously published evidence, this indicates that comprehensive rehabilitation can be considered for persons with DCM of any functional degree, before surgery.
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Affiliation(s)
- Amiram Catz
- The Spinal Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel.
- The Rehabilitation Department, Tel-Aviv University, Tel-Aviv, Israel.
| | - Yaron Watts
- The Spinal Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Hagay Amir
- The Orthopedic Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Lilach Front
- The Spinal Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Ilana Gelernter
- The Statistical Laboratory, School of Mathematics, Tel-Aviv University, Tel-Aviv, Israel
| | - Dianne Michaeli
- The Spinal Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
| | - Vadim Bluvshtein
- The Spinal Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
- The Rehabilitation Department, Tel-Aviv University, Tel-Aviv, Israel
| | - Elena Aidinoff
- The Rehabilitation Department, Tel-Aviv University, Tel-Aviv, Israel
- The Intensive Care for Consciousness Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Raanana, Israel
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Bluvshtein V, Catz A, Gelernter I, Kfir A, Front L, Michaeli D, Bizzarini E, Margalho P, Soeira TP, Kesiktas N, Aidinoff E. The net contribution of rehabilitation to improvement in performance in patients with spinal cord lesions in five countries. J Spinal Cord Med 2023:1-7. [PMID: 37861289 DOI: 10.1080/10790268.2023.2271200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
CONTEXT Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities in patients with spinal cord lesions (SCL). OBJECTIVE To assess the net effect of rehabilitation of patients with SCL and compare it between countries. METHODS We calculated the Spinal Cord Ability Realization Measurement Index (SCI-ARMI) and its change from admission to rehabilitation to discharge, for inpatients admitted to SCL units in five countries, between 2016 and 2019. We used chi-square tests, analysis of variance (ANOVA), McNemar's test, Pearson's correlations, and analysis of covariance (ANCOVA) to compare countries and patient groups and assess the relationships of various factors with SCI-ARMI gain during rehabilitation. RESULTS The study included 218 inpatients (67% males, age 52 ± 17). In Brazil, Israel, Italy, Portugal, and Turkiye, respectively, SCI-ARMI gain was 2 (SD = 15), 19 (SD = 17), 31 (SD = 23), 13 (SD = 15), and 16 (SD = 12). Yet, after controlling for admission SCI-ARMI and the time from SCL onset to the examination, the effect of the country on ability realization gain was found non-significant (P = 0.086). CONCLUSION The study confirmed that rehabilitation makes a net contribution to improvement in performance in patients with SCL, beyond the contribution of neurological recovery. After controlling for affecting factors, this contribution was quite similar in the participating units from different countries.
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Affiliation(s)
- Vadim Bluvshtein
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amiram Catz
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilana Gelernter
- School of Mathematical Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Adi Kfir
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | - Lilach Front
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | - Dianne Michaeli
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | | | | | | | - Nur Kesiktas
- Istanbul Physical Medicine and Rehabilitation Hospital, University of Health Sciences, Turkiye
| | - Elena Aidinoff
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Weber L, Voldsgaard NH, Holm NJ, Schou LH, Biering-Sørensen F, Møller T. Exploring the contextual transition from spinal cord injury rehabilitation to the home environment: a qualitative study. Spinal Cord 2021; 59:336-346. [PMID: 33564119 PMCID: PMC7943422 DOI: 10.1038/s41393-020-00608-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022]
Abstract
Study design Explorative qualitative study based on an interpretative phenomenological approach. Objectives This study explored the possibility of transferring knowledge and skills from a spinal cord injury (SCI) unit to the home environment; the individual and structural factors that potentially influenced this transfer; and its compatibility with a meaningful everyday life. Setting Hospital-based rehabilitation unit and community in Denmark. Methods Fourteen individuals with SCI were selected with maximum variation according to age, sex, marital status, and level of injury. In-depth, semi-structured interviews were conducted in the participants’ homes, 2–10 months after discharge from an SCI unit. Data analysis involved taking an interpretative phenomenological approach combined with a template analysis and applying the transfer of training theory to the discussion. Results Transitioning from the SCI unit to the home environment involved a multidimensional change of context in which most of the participants’ previous life roles had changed. This overarching theme had a decisive influence on: balancing loss and acceptance, facing external structural barriers, and the strength of social relationships when the knowledge and skills acquired at the unit were applied in a meaningful everyday life. Conclusions Transition from the SCI unit to the home environment is influenced by a multidimensional change of context that may restrict the use of acquired skills post-discharge, provide distant prospects for tertiary health promotion, and aggravate the experience of loss in people with SCI. Maintaining relationships is a strong mediator for transferring skills and re-establishing a meaningful everyday life.
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Affiliation(s)
- Lene Weber
- The University Hospitals Centre for Health Research (UCSF), Rigshospitalet, Copenhagen University Hospital, Department, 9701, Copenhagen, Denmark. .,Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), Department of Neurorehabilitation, Traumatic Brain Injury Unit, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Nanna Hoffgaard Voldsgaard
- The University Hospitals Centre for Health Research (UCSF), Rigshospitalet, Copenhagen University Hospital, Department, 9701, Copenhagen, Denmark
| | - Nicolaj Jersild Holm
- Department of Spinal Cord Injuries, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lone Helle Schou
- Department of Nursing and Nutrition, University College Copenhagen, Copenhagen, Denmark
| | - Fin Biering-Sørensen
- Department of Spinal Cord Injuries, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tom Møller
- The University Hospitals Centre for Health Research (UCSF), Rigshospitalet, Copenhagen University Hospital, Department, 9701, Copenhagen, Denmark
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Gillett JL, Duff J, Eaton R, Finlay K. Psychological outcomes of MRSA isolation in spinal cord injury rehabilitation. Spinal Cord Ser Cases 2020; 6:63. [PMID: 32665604 PMCID: PMC7358562 DOI: 10.1038/s41394-020-0313-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
STUDY DESIGN Retrospective secondary analysis with a quantitative, matched-pairs design. Patients isolated due to methicillin-Resistant Staphylococcus aureus (MRSA) were matched with controls without MRSA infection admitted to a multi-bedded ward, based on: gender, injury level, injury severity (AIS grade), age at the time of injury and year of admission. OBJECTIVES Determine the implications of MRSA-related infection isolation on spinal cord injury patients' anxiety, depression, appraisals of disability, perceived manageability and pain intensity. Hypotheses predicted patients who were isolated due to MRSA during inpatient stay would demonstrate poorer psychological health outcomes at discharge in comparison with non-isolated matched controls. SETTING National Spinal Injuries Centre, England, UK. METHODS Secondary analyses were conducted on pre-existing data based on patients' first admission for primary rehabilitation. Psychometric scales were used to measure outcome variables. Assessments were repeated at the time of admission and discharge. RESULTS Nonparametric longitudinal analyses using the nparLD package in R were conducted. Relative treatment effects demonstrated that there were no significant differences between groups across all outcome measures. There was a significant effect of time (admission vs discharge) on perceived manageability and pain intensity, indicating improved outcomes at discharge. There was no difference in the overall length of stay between the isolated and non-isolated groups. CONCLUSIONS Isolation experienced by rehabilitation inpatients with spinal cord injury with MRSA had no effect on a series of psychological outcomes. Engaging with rehabilitation had a positive impact in reducing pain unpleasantness and increasing perceived manageability of spinal cord injury, irrespective of infection isolation.
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Affiliation(s)
- Jenna L Gillett
- The University of Buckingham, Buckingham, Buckinghamshire, UK.
| | - Jane Duff
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | - Rebecca Eaton
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
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Traumatic spinal cord injury in Italy 20 years later: current epidemiological trend and early predictors of rehabilitation outcome. Spinal Cord 2020; 58:768-777. [PMID: 31996778 DOI: 10.1038/s41393-020-0421-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 01/10/2020] [Accepted: 01/10/2020] [Indexed: 12/18/2022]
Abstract
STUDY DESIGN Multicenter prospective observational study of people with acute traumatic spinal cord injury (TSCI) admitted to rehabilitation. OBJECTIVES To update epidemiological characteristics of a TSCI Italian population and verify the impact of patient characteristics at admission on two outcomes: functional gain (SCIM III) and discharge destination. SETTING Thirty-one SCI centers for comprehensive rehabilitation in 13 Italian regions. METHODS All consecutive individuals admitted with acute TSCI were enrolled from October 1, 2013 to September 30, 2014; data were recorded on rehabilitation admission and discharge. Functional gain and discharge destination were identified as outcome measures and statistically analyzed with patient characteristics at admission to identify early outcome predictors. RESULTS Five hundred and ten individuals with TSCI met inclusion criteria; falls represented the most frequent etiology (45%). On admission, AIS A-B-C tetraplegia was reported in 35% of cases; AIS A-B-C paraplegia in 40%; AIS D paraplegia/tetraplegia in 25%. The majority were discharged home (72%). The mean (SD) SCIM gain was 38 ± 26 points. A predictive model was found for discharge setting: individuals with fall-related injuries, severe SCI (AIS A-B-C tetraplegia), tracheal cannula or indwelling catheter on admission, were less likely to be discharged home (OR 95% CI 0.15 [0.06, 0.35]). A model with a lower predictive power was found for SCIM gain, with lower score expected for females, older age, higher severity of SCI, a longer onset of injury admission interval (OAI), and mechanical ventilation on admission. CONCLUSIONS Prognostic factors in early rehabilitation are still hard to identify, making it difficult to correctly approach customized rehabilitation.
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Pattanakuhar S, Kammuang-Lue P, Kovindha A, Komaratat N, Mahachai R, Chotiyarnwong C. Is admission to an SCI specialized rehabilitation facility associated with better functional outcomes? Analysis of data from the Thai Spinal Cord Injury Registry. Spinal Cord 2019; 57:684-691. [PMID: 30842632 DOI: 10.1038/s41393-019-0267-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/02/2019] [Accepted: 02/05/2019] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective cohort study of the Thai Spinal Cord Injury Registry. OBJECTIVE To determine whether being admitted to a spinal cord injury (SCI) specialized rehabilitation facility (SSRF) is associated with better functional outcomes. SETTING Four rehabilitation facilities in Thailand; one a SSRF and the others non-SSRFs. METHODS Data from the one SSRF and three non-SSRFs were extracted from the Thai Spinal Cord Injury Registry. Multivariate regression analysis was used to exclude the effect of confounding factors and prove the independent association of SSRF admission with respect to Spinal Cord Independence Measurement (SCIM) at discharge. RESULTS Among the 234 new SCI inpatients enrolled, 167 persons (71%) had been admitted to the SSRF. The SSRF had a greater proportion of persons with AIS A, B, C tetraplegia and people with AIS D, whereas the non-SSRFs had a higher proportion of patients with AIS A, B or C paraplegia. Patients discharged from the SSRF demonstrated a greater SCIM score improvement than those from the non-SSRFs (24.1 vs 17.0; p = 0.003). By using multivariate regression analysis controlling for age, time from injury to rehabilitation, severity of injury and SCIM score on admission, SSRF admission was found to be an independent predictive factor of SCIM score improvement at discharge (p = 0.008). CONCLUSION Admission to an SSRF is associated with better rehabilitation outcomes. This finding supports the importance of SSRF access to improve the functional outcome of patients with SCI.
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Affiliation(s)
- Sintip Pattanakuhar
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Pratchayapon Kammuang-Lue
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichana Kovindha
- Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Rungarun Mahachai
- Department of Rehabilitation Medicine, Ratchaburi Hospital, Ratchaburi, Thailand
| | - Chayaporn Chotiyarnwong
- Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Catharine Craven B, Kurban D, Farahani F, Rivers CS, Ho C, Linassi AG, Gagnon DH, O'Connell C, Ethans K, Bouyer LJ, Noonan VK. Predicting rehabilitation length of stay in Canada: It's not just about impairment. J Spinal Cord Med 2017; 40:676-686. [PMID: 28899285 PMCID: PMC5778931 DOI: 10.1080/10790268.2017.1368962] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
INTRODUCTION Current tertiary Spinal Cord Injury (SCI) rehabilitation funding and rehabilitation length of stay (R-LOS) in most North American jurisdictions are linked to an individual's impairment. Our objectives were to: 1) describe the impact of relevant demographic, impairment and medical complexity variables at rehabilitation admission on R-LOS among adult Canadians with traumatic SCI; and 2) identify factors which extend R-LOS. METHODS Data from 1,376 adults with traumatic SCI were obtained via chart abstraction and administrative data linkage from 15 Rick Hansen SCI Registry sites (2004-2014). Variables included age, sex, neurological impairment (level, severity), rehabilitation onset days, R-LOS, Glasgow Coma Score (GCS) at admission, prior ventilation or endotracheal tube (Vent/ETT), or indwelling bladder catheter at acute discharge, pain interference score, intensive care unit (ICU) length of stay (LOS), and lower extremity motor scores (LEMS) at rehabilitation admission. Variables related to R-LOS in bivariate analysis were included in multivariate analysis to determine their impact on R-LOS. RESULTS Prior Vent/ETT tube, indwelling bladder catheter, GCS, LEMS, and neurological impairment were related to R-LOS in bivariate analysis. Multivariate linear regression analyses identified five variables as significant predictors: age, Vent/ETT for >24 hours in acute care, indwelling bladder catheter at acute discharge, LEMS, and NLI/AIS subgroup at rehabilitation admission explained 32% of the variation in R-LOS (p<0.001). CONCLUSIONS Based on the enclosed formula, and knowledge of an individual's age at injury, spinal cord impairment (level and severity), prior Vent/ETT, presence of an indwelling bladder catheter, and LEMS at admission, administrators and clinicians may readily identify patients for whom an extended R-LOS beyond conventional LOS targets is likely.
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Affiliation(s)
- B. Catharine Craven
- Brain and Spinal Cord Rehabilitation Program, Toronto, ON, Canada,Neural Engineering & Therapeutics Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada,Dept. of Medicine, Division of PM&R, University of Toronto, Toronto, ON, Canada,University Health Network Toronto Rehab Lyndhurst Centre, Toronto, ON, Canada
| | | | - Farnoosh Farahani
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Carly S. Rivers
- Rick Hansen Institute, Vancouver, BC, Canada,Correspondence to: Carly S. Rivers, Rick Hansen Institute, 6400 Blusson Spinal Cord Centre, Vancouver, BC, Canada.
| | - Chester Ho
- Allied Health, AHS Calgary Zone, Calgary, AB, Canada,Division of Physical Medicine & Rehabilitation, Dept of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - A. Gary Linassi
- Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, SK, Canada,Spinal Cord Injury and Amputation Programs, Saskatoon Health Region, Saskatoon, SK, Canada
| | - Dany H. Gagnon
- École de réadaptation, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Colleen O'Connell
- Physical Medicine & Rehabilitation, Dalhousie University, Faculty of Medicine, Fredericton, NB, Canada
| | - Karen Ethans
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Laurent J. Bouyer
- Department of Rehabilitation, Université Laval & Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Québec City, QC, Canada
| | - Vanessa K. Noonan
- Rick Hansen Institute, Vancouver, BC, Canada,University of British Columbia, Vancouver, BC, Canada
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Noonan VK, Chan E, Santos A, Soril L, Lewis R, Singh A, Cheng CL, O'Connell C, Truchon C, Paquet J, Christie S, Ethans K, Tsai E, Ford MH, Drew B, Linassi AG, Bailey CS, Fehlings MG. Traumatic Spinal Cord Injury Care in Canada: A Survey of Canadian Centers. J Neurotrauma 2017; 34:2848-2855. [PMID: 28367684 PMCID: PMC5653141 DOI: 10.1089/neu.2016.4928] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Specialized centers of care for persons sustaining a traumatic spinal cord injury (tSCI) have been established in many countries, but the ideal system of care has not been defined. The objective of this study was to describe care delivery, with a focus on structures and services, for persons with tSCI in Canada. A survey was sent to 26 facilities (12 acute, 11 rehabilitation, and three integrated) from eight provinces participating in the Access to Care and Timing project. The survey included questions about: 1) care provision; 2) structural attributes and; 3) service availability. Survey completion rate was 100%. Data sources used to complete the survey were the Rick Hansen Spinal Cord Injury Registry, other hospital databases, clinical protocols, and subject matter experts. Acute and rehabilitation care provided by integrated facilities were described separately, resulting in data from 15 acute and 14 rehabilitation facilities. The number of admissions for tSCI over a 12-month period between 2009-2011 ranged from 17 to 104 (median 39), and 11 to 96 (median 32), for acute and rehabilitation facilities, respectively. Grouping of patients was reported by 8/15 acute and 10/14 rehabilitation facilities. Criteria for admission to the inpatient rehabilitation facilities varied among facilities (25 different criteria reported). Results from the survey revealed similarities in the basic structure and the provision of general services, but also some differences in the degree of specialization of care for persons with tSCI. Continued work on the impact of specialized care for both the patient and healthcare system is needed.
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Affiliation(s)
| | - Elaine Chan
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Argelio Santos
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Lesley Soril
- Rick Hansen Institute, Vancouver, British Columbia, Canada
| | - Rachel Lewis
- Centre for Operations Excellence, Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anoushka Singh
- Spinal Cord Injury Clinical Research Unit, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Colleen O'Connell
- Division of Physical Medicine and Rehabilitation, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Catherine Truchon
- Trauma and Critical Care Evaluation Unit, Institut national d'excellence en santé et en services sociaux, Québec City, Québec, Canada
| | - Jérôme Paquet
- Department of Surgery, Université Laval, Québec City, Québec, Canada
| | - Sean Christie
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karen Ethans
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eve Tsai
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael H. Ford
- Orthopedic Spine and Trauma, Integrated Spine Unit, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Brian Drew
- Department of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - A. Gary Linassi
- Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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Ponfick M. Outcome after post-acute spinal cord specific rehabilitation: a German single center study. Spinal Cord Ser Cases 2017; 3:17055. [PMID: 28890805 PMCID: PMC5587790 DOI: 10.1038/scsandc.2017.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 11/08/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study was to analyze single center outcome measures of spinal cord injury (SCI)-specific rehabilitation (SCISR) in Germany. SETTING The study was conducted at an SCI specialized rehabilitation center. METHODS Nonparametric tests for outcome description such as SCIM and length of stay. Logistic regression for outcome prediction was used. RESULTS One hundred and sixty patients (113 men, 47 women) with a mean age of 64.4 years were included. Non-traumatic etiologies, such as vascular diseases, tumors, infections or degenerative diseases accounted for 55.6% of SCI (89/160). Men experienced significantly more cervical lesions (P=0.02) and presented with lower SCIMstart values (P=0.04). Patients with AIS D (incomplete SCI) had significantly higher SCIMstart and SCIMend (P<0.01, each). Age correlated negatively with SCIMstart and SCIMend (r=-0.21; P<0.05; r=-0.21; P<0.05; respectively). The chance to reach an SCIMend ⩾50 points (milestone for starting post-primary rehabilitation) increased with every SCIM point at the beginning of rehabilitation by 12.2% (95% CI 7.3-17.3%) and for every day in rehabilitation by 1.4% (95% CI 0.5-2.3%). Every additional day in acute medical care, however, decreased the chance for this by 2.2% (95% CI -3.6 to -0.8%). CONCLUSIONS This is the first study giving outcomes for post-acute SCISR in Germany. The obtained data support that even in an older cohort, early admission to SCISR after SCI and longer LOSreha increases the chance for higher independence at the end of the rehabilitation period.
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Reed R, Mehra M, Kirshblum S, Maier D, Lammertse D, Blight A, Rupp R, Jones L, Abel R, Weidner N, Curt A, Steeves J. Spinal cord ability ruler: an interval scale to measure volitional performance after spinal cord injury. Spinal Cord 2017; 55:730-738. [DOI: 10.1038/sc.2017.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 12/22/2022]
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Spinal cord injury rehabilitation in Riyadh, Saudi Arabia: time to rehabilitation admission, length of stay and functional independence. Spinal Cord 2017; 55:509-514. [PMID: 28139661 DOI: 10.1038/sc.2016.165] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 10/06/2016] [Accepted: 10/14/2016] [Indexed: 11/09/2022]
Abstract
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.
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Scivoletto G, Miscusi M, Forcato S, Ricciardi L, Serrao M, Bellitti R, Raco A. The Rehabilitation of Spinal Cord Injury Patients in Europe. ACTA NEUROCHIRURGICA SUPPLEMENT 2017; 124:203-210. [DOI: 10.1007/978-3-319-39546-3_31] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge. Spinal Cord 2016; 55:208-212. [PMID: 27527239 DOI: 10.1038/sc.2016.122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/10/2016] [Accepted: 07/01/2016] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective follow-up study. OBJECTIVES To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers. SETTING The national referral hospital in Gaborone, Botswana. METHODS The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics. RESULTS Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care. CONCLUSIONS Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.
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Maharaj MM, Hogan JA, Phan K, Mobbs RJ. The role of specialist units to provide focused care and complication avoidance following traumatic spinal cord injury: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:1813-20. [PMID: 27037920 DOI: 10.1007/s00586-016-4545-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 03/22/2016] [Accepted: 03/22/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Current recommendations for traumatic spinal cord injury treatment recommend immediate transfer to a spinal injury unit (SIU) where available following patient stabilisation. Although transfer is dependent on a variety of factors, the largest review was unable to justify implementation of such units on the basis of insufficient and lack of quality data in favour of care at the SIU as opposed to non-SIU centres. Our study sought to investigate: are subspecialty spinal injury units (SIUs) able to provide superior care compared with traditional trauma/rehab units? Is the standard of care of acute spinal cord injured patients to be managed in SIU's? METHOD A literature search was conducted across five major databases using the key terms: "spinal cord injury" AND "Spinal Injury Unit" OR "spinal rehabilitation" OR "spinal injury centre" OR "specialist care" OR "care requirements." RESULTS After review of over 500 studies, only 9 met inclusion criteria, 3 of which were past reviews. There were no relevant RCT's obtained. Standardised roles of global SIU units are needed to deliver equitable and high quality care as current evidence demonstrates variable standards of care and service (mean LOS range: 16-174 days). There is low quality evidence supporting earlier admission into SIU units being associated with improved neurological outcome, complication rates and reduced LOS, despite variations in the definition of "early admission" across studies. CONCLUSIONS Our review demonstrates a lack of standardisation within SIU on a global scale, with significantly different outcomes reported across published studies. New and higher quality evidence directly comparing SIU to non-SIU based care is required. Earlier transfer (<24 h) to SIU following initial injury and stabilisation is advised.
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Affiliation(s)
- Monish M Maharaj
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia. .,NeuroSpineClinic, Suite 7, Level 7, Prince of Wales Private Hospital, Randwick, NSW, 2031, Australia. .,NeuroSpine Surgery Research Group (NSURG), Sydney, NSW, Australia.
| | - Jarred A Hogan
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia.,NeuroSpineClinic, Suite 7, Level 7, Prince of Wales Private Hospital, Randwick, NSW, 2031, Australia.,NeuroSpine Surgery Research Group (NSURG), Sydney, NSW, Australia
| | - Kevin Phan
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia.,NeuroSpineClinic, Suite 7, Level 7, Prince of Wales Private Hospital, Randwick, NSW, 2031, Australia.,NeuroSpine Surgery Research Group (NSURG), Sydney, NSW, Australia
| | - Ralph J Mobbs
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia.,NeuroSpineClinic, Suite 7, Level 7, Prince of Wales Private Hospital, Randwick, NSW, 2031, Australia.,NeuroSpine Surgery Research Group (NSURG), Sydney, NSW, Australia
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New PW, Townson A, Scivoletto G, Post MWM, Eriks-Hoogland I, Gupta A, Smith É, Reeves RK, Gill ZA. International comparison of the organisation of rehabilitation services and systems of care for patients with spinal cord injury. Spinal Cord 2012; 51:33-9. [DOI: 10.1038/sc.2012.82] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Functional outcome of patients 12 and 48 weeks after acute traumatic tetraplegia and paraplegia: data analysis from 2004–2009. Spinal Cord 2012; 50:517-20. [DOI: 10.1038/sc.2011.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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A new grading for easy and concise description of functional status after spinal cord lesions. Spinal Cord 2011; 50:42-50. [PMID: 21808258 DOI: 10.1038/sc.2011.84] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING Multi-center study at 13 spinal units in 6 countries. METHODS Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.
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Whiteneck G, Gassaway J, Dijkers M, Backus D, Charlifue S, Chen D, Hammond F, Hsieh CH, Smout RJ. The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med 2011; 34:133-48. [PMID: 21675353 PMCID: PMC3066504 DOI: 10.1179/107902611x12971826988011] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/30/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND/OBJECTIVE Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs. METHODS Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline. RESULTS Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics. CONCLUSIONS Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.
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Affiliation(s)
- Gale Whiteneck
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - Julie Gassaway
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
| | - Marcel Dijkers
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Deborah Backus
- Shepherd Center, Atlanta, GA, USA
- Emory University School of Medicine, Atlanta, GA, USA
| | - Susan Charlifue
- Rocky Mountain Regional Spinal Injury System, Craig Hospital, Englewood, CO, USA
| | - David Chen
- Rehabilitation Institute of Chicago, Chicago, IL, USA
| | - Flora Hammond
- Carolinas Rehabilitation, Charlotte, NC, USA
- Indiana University, Indianapolis, IN, USA
| | - Ching-Hui Hsieh
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington, DC, USA
| | - Randall J. Smout
- Institute for Clinical Outcomes Research, Salt Lake City, UT, USA
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Divanoglou A, Westgren N, Bjelak S, Levi R. Medical conditions and outcomes at 1 year after acute traumatic spinal cord injury in a Greek and a Swedish region: a prospective, population-based study. Spinal Cord 2009; 48:470-6. [DOI: 10.1038/sc.2009.147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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