Association of various comorbidity measures with spinal cord injury rehabilitation outcomes

Racial/Ethnic Associations With Morbidity and Mortality in Adults With Acute Traumatic Cervical Spinal Cord Injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

This study aimed to investigate the association of race with morbidity and mortality in acute cervical spinal cord injury (cSCI) patients.

BACKGROUND

Racial disparities in spine surgery are associated with adverse outcomes, however, the impact of race on cSCI is understudied.

MATERIALS AND METHODS

We retrospectively reviewed the American College of Surgeons Trauma Quality Programs database to compare outcomes for acute cSCI patients between racial/ethnic identities: non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic/Latino (HIS), and other (OTH). Demographics, comorbidities, injury type, treatment modality, and adverse events (AEs) were assessed. Multivariable logistic regression was used to identify independent predictors of AEs, non-routine discharge (NRD), and in-hospital mortality.

RESULTS

There were 71,048 patients stratified by race/ethnicity: 44,639 (62.8%) NHW, 13,555 (19.1%) NHB, 5820 (8.2%) HIS, and 7034 (9.9%) OTH. NHB and HIS-identifying patients had the greatest rates of any AE (NHW: 20.7% vs. NHB: 25.0% vs. HIS: 24.6% vs. OTH: 22.0%, P < 0.001) and the longest mean length of stay (NHW: 11.3 ± 13.5 d vs. NHB: 15.5 ± 20.2 d vs. HIS: 15.0 ± 20.5 d vs. OTH: 12.6 ± 17.5 d, P < 0.001). NRDs were lowest for HIS-identifying patients (NHW: 74.8% vs. NHB: 75.5% vs . HIS: 69.5% vs . OTH: 75.4%, P < 0.001), whereas, in-hospital mortality was lowest for NHB-identifying patients (NHW: 12.8% vs . NHB: 10.1% vs . HIS: 12.4% vs . OTH: 13.4%, P < 0.001). On multivariable analyses, NHB odds ratio (OR: 1.16, P < 0.001), HIS (OR: 1.22, P < 0.001), and OTH (OR: 1.14, P = 0.004) cohorts had significantly increased odds of AEs. The NHB cohort had significantly increased odds (OR: 1.25, P < 0.001), whereas, the HIS cohort had significantly decreased odds (OR: 0.78, P = 0.001) of NRD. Only the NHB cohort had significantly decreased odds of in-hospital mortality (OR: 0.69, P <0 .001).

CONCLUSION

Our study suggests there may be racial disparities in outcomes and discharge disposition for acute cSCI patients.

The influencing factors for tracheostomy decannulation after traumatic cervical spinal cord injury: a retrospective study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the outcomes and influencing factors of tracheostomy decannulation (TD) in persons with traumatic cervical spinal cord injury (SCI).

SETTING

China Rehabilitation Research Center (CRRC) in Beijing, China.

METHODS

From January 2017 to December 2021, 365 persons with traumatic cervical SCI were admitted to the China Rehabilitation Research Center. During hospitalization, tracheostomy patients were enrolled and divided into the TD group and non-TD group. Demographic and clinical data, as well as functional assessments, were collected and recorded for all persons. The factors influencing TD were analyzed using both univariate and multivariate logistic regression.

RESULTS

A total of 78 persons with traumatic cervical SCI from CRRC were enrolled in this study. Of these, 48 persons (61.5%) underwent successful decannulation, with a median time of 93.5 days (IQR: 62.0-143.8 days). Multivariate logistic regression revealed that AIS A (P = 0.021, OR: 5.378, 95% CI, 1.287-22.474) and Charlson comorbidity index (CCI) (P = 0.003, OR: 1.836, 95% CI, 1.230-2.740) were significant risk factors of reduced success in TD. PEF in the TD group was 145.44 ± 50.56 L/min. Middle-aged and young persons with traumatic cervical SCI at C3 to C5 neurological level did not satisfy the criterion of PEF (over 160 L/min), but they can still attempt tracheostomy decannulation.

CONCLUSION

AIS A and a high CCI will reduce the success rate of tracheostomy decannulation in persons suffering from traumatic cervical SCI.

Long-term prediction of functional independence using adjusted and unadjusted single items of the functional independence measure (FIM) at discharge from rehabilitation

CONTEXT

Being able to survive in the long-term independently is of concern to patients with spinal cord injury (SCI), their relatives, and to those providing or planning health care, especially at rehabilitation discharge. Most previous studies have attempted to predict functional dependency in activities of daily living within one year after injury.

OBJECTIVES

(1) build 18 different predictive models, each model using one FIM (Functional Independence Measure) item, assessed at discharge, as independent predictor of total FIM score at chronic phase (3-6 years post-injury) (2) build three different predictive models, using in each model an item from a different FIM domain with the highest predictive power obtained in objective (1) to predict "good" functional independence at chronic phase and (3) adjust the 3 models from objective (2) with known confounding factors.

METHODS

This observational study included 461 patients admitted to rehabilitation between 2009 and 2019. We applied regression models to predict total FIM score and "good" functional independence (FIM motor score ≥ 65) reporting adjusted R2, odds ratios, ROC-AUC (95% CI) tested using 10-fold cross-validation.

RESULTS

The top three predictors, each from a different FIM domain, were Toilet (adjusted R2 = 0.53, Transfers domain), Toileting (adjusted R2 = 0.46, Self-care domain), and Bowel (adjusted R2 = 0.35, Sphincter control domain). These three items were also predictors of "good" functional independence (AUC: 0.84-0.87) and their predictive power increased (AUC: 0.88-0.93) when adjusted by age, paraplegia, time since injury, and length of stay.

CONCLUSIONS

Discharge FIM items accurately predict long-term functional independence.

Machine Learning Web Application for Predicting Functional Outcomes in Patients With Traumatic Spinal Cord Injury Following Inpatient Rehabilitation

Accurately predicting functional outcomes in patients with spinal cord injury (SCI) helps clinicians set realistic functional recovery goals and improve the home environment after discharge. The present study aimed to develop and validate machine learning (ML) models to predict functional outcomes in patients with SCI and deploy the models within a web application. The study included data from the Japan Association of Rehabilitation Database from January 1, 1991, to December 31, 2015. Patients with SCI who were admitted to an SCI center or transferred to a participating post-acute rehabilitation hospital after receiving acute treatment were enrolled in this database. The primary outcome was functional ambulation at discharge from the rehabilitation hospital. The secondary outcome was the total motor Functional Independence Measure (FIM) score at discharge. We used binary classification models to predict whether functional ambulation was achieved, as well as regression models to predict total motor FIM scores at discharge. In the training dataset (70% random sample) using demographic characteristics and neurological and functional status as predictors, we built prediction performance matrices of multiple ML models and selected the best one for each outcome. We validated each model's predictive performance in the test dataset (the remaining 30%). Among the 4181 patients, 3827 were included in the prediction model for the total motor FIM score. The mean (standard deviation [SD]) age was 50.4 (18.7) years, and 3211 (83.9%) patients were male. There were 3122 patients included in the prediction model for functional ambulation. The CatBoost Classifier and regressor models showed the best performances in the training dataset. On the test dataset, the CatBoost Classifier had an area under the receiver operating characteristic curve of 0.8572 and an accuracy of 0.7769 for predicting functional ambulation. Likewise, the CatBoost Regressor performed well, with an R2 of 0.7859, a mean absolute error of 9.2957, and a root mean square error of 13.4846 for predicting the total motor FIM score. The final models were deployed in a web application to provide functional predictions. The application can be found at http://3.138.174.54:8501. In conclusion, our prediction models developed using ML successfully predicted functional outcomes in patients with SCI and were deployed in an open-access web application.

Comparison of One-Year Postinjury Mobility Outcomes Between Locomotor Training and Usual Care After Motor Incomplete Spinal Cord Injury

Objectives

To compare 1-year mobility outcomes of individuals with traumatic motor incomplete spinal cord injury (miSCI) who participated in standardized locomotor training (LT) within the first year of injury to those who did not.

Methods

This retrospective case-control analysis conducted with six US rehabilitation hospitals used SCI Model Systems (SCIMS) data comparing 1-year postinjury outcomes between individuals with miSCI who participated in standardized LT to those who received usual care (UC). Participants were matched on age, gender, injury year, mode of mobility, and rehabilitation center. The primary outcome is the FIM Total Motor score. Other outcomes include the FIM Transfer Index, FIM Stairs, and self-reported independence with household mobility, community mobility, and stairs.

Results

LT participants reported significantly better FIM Total Motor (difference = 2.812, 95% confidence interval [CI] = 5.896, 17.282) and FIM Transfer Index scores (difference = 0.958, 95% CI = 0.993, 4.866). No significant between-group differences were found for FIM Stairs (difference = 0.713, 95% CI = -0.104, 1.530) or self-reported household mobility (odds ratio [OR] = 5.065, CI = 1.435, 17.884), community mobility (OR = 2.933, 95% CI = 0.868, 9.910), and stairs (OR = 5.817, 95% CI = 1.424, 23.756) after controlling for multiple comparisons.

Conclusion

LT participants reported significantly greater improvements in primary and secondary measures of mobility and independence (FIM Total Motor score; FIM Transfer Index) compared to UC participants. Self-reported mobility outcomes were not significant between groups.

Effects of early mobilization within 48 hours of injury in patients with incomplete cervical spinal cord injury

OBJECTIVE

To investigate the effects of early mobilization within 48 h of injury on motor function and walking ability in patients with incomplete cervical spinal cord injury (SCI).

DESIGN

A retrospective observational study.

SETTING

Intensive care unit or high care unit of a university hospital emergency center.

PARTICIPANTS

Of 224 patients with SCI having American Spinal Injury Association impairment scale grades C and D, 158 consecutive patients hospitalized for at least 3 weeks after injury were included.

INTERVENTIONS

Patients were categorized into two groups: an early mobilization group in which patients were mobilized within 48 h of injury and a delayed mobilization group in which they were mobilized after 48 h of injury.

OUTCOME MEASURES

The upper extremity motor score (UEMS), lower extremity motor score (LEMS), and Walking Index for Spinal Cord Injury II (WISCI II) were compared using propensity score matching analysis.

RESULTS

Of the 158 patients who met the eligibility criteria, 32 were matched between the groups. There was a significant difference in the change in LEMS from the initial assessment to the assessment 2 weeks postoperatively in the early mobilization group (median 9 points vs. 3 points, p < 0.05). There were no significant differences in UEMS or WISCI II.

CONCLUSION

Early mobilization within 48 h may improve lower extremity motor function in patients with acute incomplete cervical SCI.

Influences of comorbidities on perioperative rehabilitation in patients with gastrointestinal cancers: a retrospective study

BACKGROUND

Older patients are more likely to have comorbidities than younger patients, and multiple comorbidities are associated with mortality in patients with cancer. Therefore, we hypothesized that a functional comorbidity index could predict the therapeutic effects of rehabilitation.

OBJECTIVES

In this study, we investigate whether the comorbidities influenced the execution and therapeutic effects of rehabilitation.

METHODS

A consecutive cohort of 48 patients with gastrointestinal cancer who underwent surgery between January 1 and November 30, 2020, was analyzed. Charlson Comorbidity Index (CCI) scores were calculated based on data derived from medical records. The primary outcomes were ambulation status, duration (days) from the start of postoperative rehabilitation, and length of hospital stay. We investigated the relationship between CCI scores and primary outcomes.

RESULTS

The CCI did not correlate with the duration of rehabilitation or the length of hospital stay. Subsequently, patients with functional recovery problems were evaluated, and we identified the conditions that were not included in the list using CCI scores. Most conditions are associated with surgical complications. Furthermore, using the Clavien-Dindo classification (CDC), we assessed the clinical features of the severity of complications. We found that the length of stay and the duration to start rehabilitation were significantly longer in the patients with higher severity of surgical complications (CDC≧III) than in those with lower severity (CDC≦II).

CONCLUSIONS

Treatment-related conditions may significantly impact the perioperative period more than the original comorbidities. In addition to original comorbidities, events related to surgical complications should be assessed to determine the therapeutic effects of rehabilitation in patients with gastrointestinal cancer.

The Nursing Home Severity Index and Application to Pressure Injury Risk: Measure Development and Validation Study

BACKGROUND

An assessment tool is needed to measure the clinical severity of nursing home residents to improve the prediction of outcomes and provide guidance in treatment planning.

OBJECTIVE

This study aims to describe the development of the Nursing Home Severity Index, a clinical severity measure targeted for nursing home residents with the potential to be individually tailored to different outcomes, such as pressure injury.

METHODS

A retrospective nonexperimental design was used to develop and validate the Nursing Home Severity Index using secondary data from 9 nursing homes participating in the 12-month preintervention period of the Turn Everyone and Move for Ulcer Prevention (TEAM-UP) pragmatic clinical trial. Expert opinion and clinical literature were used to identify indicators, which were grouped into severity dimensions. Index performance and validation to predict risk of pressure injury were accomplished using secondary data from nursing home electronic health records, Minimum Data Sets, and Risk Management Systems. Logistic regression models including a resident's Worst-Braden score with/without severity dimensions generated propensity scores. Goodness of fit for overall models was assessed using C statistic; the significance of improvement of fit after adding severity components to the model was determined using the likelihood ratio chi-square test. The significance of each component was assessed with odds ratios. Validation based on randomly selected 65% training and 35% validation data sets was used to confirm the reliability of the severity measure. Finally, the discriminating ability of models was evaluated using propensity stratification to evaluate which model best discriminated between residents with/without pressure injury.

RESULTS

Data from 1015 residents without pressure injuries on admission were used for the Nursing Home Severity Index-Pressure Injury and included laboratory, weights/vitals/pain, underweight, and locomotion severity dimensions. Logistic regression C statistic measuring predictive accuracy increased by 19.3% (from 0.627 to 0.748; P<.001) when adding four severity dimensions to Worst-Braden scores. Significantly higher odds of developing pressure injuries were associated with increasing dimension scores. The use of the three highest propensity deciles predicting the greatest risk of pressure injury improved predictive accuracy by detecting 21 more residents who developed pressure injury (n=58, 65.2% vs n=37, 42.0%) when both severity dimensions and Worst-Braden score were included in prediction modeling.

CONCLUSIONS

The clinical Nursing Home Severity Index-Pressure Injury was successfully developed and tested using the outcome of pressure injury. Overall predictive capacity was enhanced when using severity dimensions in combination with Worst-Braden scores. This index has the potential to significantly impact the quality of care decisions aimed at improving individual pressure injury prevention plans.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02996331; http://clinicaltrials.gov/ct2/show/NCT02996331.

A comparison of one year outcomes between standardized locomotor training and usual care after motor incomplete spinal cord injury: Community participation, quality of life and re-hospitalization

CONTEXT/OBJECTIVE

Spinal cord injury (SCI) often results in a significant loss of mobility and independence coinciding with reports of decreased quality of life (QOL), community participation, and medical complications often requiring re-hospitalization. Locomotor training (LT), the repetition of stepping-like patterning has shown beneficial effects for improving walking ability after motor incomplete SCI, but the potential impact of LT on psychosocial outcomes has not been well-established. The purpose of this study was to evaluate one year QOL, community participation and re-hospitalization outcomes between individuals who participated in a standardized LT program and those who received usual care (UC).

DESIGN/SETTING/PARTICIPANTS

A retrospective (nested case/control) analysis was completed using SCI Model Systems (SCIMS) data comparing one year post-injury outcomes between individuals with traumatic motor incomplete SCI who participated in standardized LT to those who received UC.

OUTCOME MEASURES

Outcomes compared include the following: Satisfaction with Life Scale (SWLS™), Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF™), and whether or not an individual was re-hospitalized during the first year of injury.

RESULTS

Statistically significant improvements for the LT group were found in the following outcomes: SWLS (P = 0.019); and CHART subscales [mobility (P = <0.001)]; occupation (P = 0.028); with small to medium effects sizes.

CONCLUSION

Individuals who completed a standardized LT intervention reported greater improvements in satisfaction with life, community participation, and fewer re-hospitalizations at one year post-injury in comparison to those who received UC. Future randomized controlled trials are needed to verify these findings.

Rehabilitation length of stay and functional improvement among patients with traumatic spinal cord injury

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Investigate the association between rehabilitation length of stay (LOS) and motor FIM® (mFIM) between rehabilitation admission and discharge among patients with traumatic spinal cord injury (SCI).

SETTING

Seventeen SCI Model Systems (SCIMS) centers in the United States.

METHODS

A total of 3386 patients with traumatic SCI enrolled in the SCIMS Database from 2011 to 2018. The main outcome measure was the mean change in mFIM (12 items) between rehabilitation admission and discharge by twelve neurological categories (C1-C4 American Spinal Injury Association impairment scale (AIS) A-B, AIS C, AIS D, and C5-C8 AIS A-B, AIS C, AIS D, and T1-T10 AIS A-B, AIS C, AIS D, and T11-S3 AIS A-B, C, D). Linear regression models were applied to estimate changes across rehabilitation LOS groups (shortest LOS, quarter2, quarter3, and longest LOS) after adjusting for covariables for each neurological category.

RESULTS

The mean age of study patients was 44.5 years. Patients were predominantly men (78.5%), non-Hispanic white (64.8%), and had private insurance (57.1%). The median LOS was 42 days across the entire sample. Longer LOS was associated with a higher mFIM score compared to the shortest LOS among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D after adjusting for demographics and clinical characteristics.

CONCLUSION

Among patients with C1-C4 AIS D; C5-C8 AIS D; T1-T10 AIS A-B; and T11-S3 AIS A-B, C, and D injuries, those with longer rehabilitation stays tended to have more motor function improvement.

Acute inpatient rehabilitation improves function independent of comorbidities in medically complex patients

Objectives

(1) To evaluate the benefits of acute inpatient rehabilitation for a medically complex patient population and (2) to assess the effect of comorbid conditions on rehabilitation outcomes.

Design

Retrospective cohort study.

Setting

Freestanding inpatient rehabilitation facility.

Participants

A total of 270 medically complex adult patients including those with cardiac, pulmonary, and orthopedic conditions, with mean age of 73.6 years; 52.6% were female and 47.4% were male (N=270).

Interventions

Not applicable.

Main Outcome Measures

Functional Independence Measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), home discharge rate, and readmission to acute care (RTAC).

Results

Among 270 medically complex patients, mean total FIM gain, mean RLOS, and mean FIM efficiency with SD were 26.0±13.6 points, 12.6±5.9 days, and 2.3±1.6, respectively. A total of 71.9% of patients were discharged to home, 12.2% for RTAC, and 15.9% to a skilled nursing facility (SNF). Hypertension (HTN) was the only comorbidity significantly associated with FIM gain (53.7% [total FIM gain ≥27] vs 67.2% [total FIM gain <27]; P=.024) and FIM efficiency (53.3% [FIM efficiency ≥2.12] vs 67.4% [FIM efficiency <2.12]; P=.025), independent of age, body mass index, sex, race, ethnicity, insurance type, and Charlson Comorbidity Index. The 5 most common reasons for RTAC were cardiac, pulmonary, acute blood loss anemia, infection, and neurologic conditions.

Conclusions

Among 270 medically complex patients, 71.9% were discharged to home, 15.9% to an SNF, and 12.2% for RTAC with a mean RLOS 12.6 days, mean total FIM gain of 26 points, and mean FIM efficiency of 2.3, which were all better than those of all admissions at our facility in 2018. Furthermore, RLOS, total FIM gain and FIM efficiency in this study were all better than their corresponding eRehabData weighted national benchmarks (RLOS, 15.82 days; FIM gain, 25.57; FIM efficiency, 2.13) for a total of 202,520 discharges in 2018. These findings support acute inpatient rehabilitation for this patient population. With the exception of HTN, no medical comorbidities or demographic variables were associated with rehabilitation outcomes.

Traumatic and non-traumatic spinal cord injury: Demographic characteristics, neurological and functional outcomes. A 7-year single centre experience

Objective

The aim of this study is to evaluate demographic and clinical characteristics of a population affected by traumatic and non-traumatic spinal cord injury (SCI) and to analyze functional outcomes after rehabilitation.

Methods

This study involved 112 SCI patients (75 male and 37 female) admitted at the Neurorehabilitation Unit of the University Hospital of Messina. The neurological outcomes were evaluated according to the American Spinal Injury Association Impairment Scale (AIS) and by using length of stay, Functional Independence Measure (FIM) and Barthel Index (BI).

Results

NT-SCI patients were significantly older, numerous (75,89%) and affected by greater lesions when admitted, than T-SCI ones. Most of lesions were incomplete (93%) and associated with paraplegia (71%). FIM and BI outcomes are similar in both groups, even if T-SCI patients showed greater improvement when discharged. No significant differences were found in the length of stay. The most common complication in non-traumatic SCI group was urinary tract infection and this was observed in 25 patients (29,41%). Linear regression models explained 26% of the variance of LOS and 38% of the variance of functional outcome. Functional status on admission was the strongest determinant of LOS and completeness of the lesion was the strongest determinant of functional outcome. Etiology (traumatic versus non-traumatic) was a weak independent determinant of LOS but was not an independent determinant of functional outcome.

Conclusion

SCI patient's rehabilitation should be carried out by taking into account etiology of the injury. It is important to consider this information while developing the targets and planning of the rehabilitation program. In particular, older age negatively influence the degree of disability on admission and the entity of functional recovery in both populations. Non-traumatic lesions could have minor benefits after rehabilitation therapy if compared with traumatic ones.

Physical Function Recovery Trajectories following Spinal Cord Injury

OBJECTIVE

Explore trajectories of functional recovery that occur during the first two years after spinal cord injury (SCI).

DESIGN

Observational cohort study.

SETTING

Eight SCI Model System sites.

PARTICIPANTS

479 adults with SCI completed four Spinal Cord Injury-Functional Index (SCI-FI) item banks within 4 months of injury and again at 2 weeks, 3, 6, 12, and 24 months following baseline assessment.

INTERVENTION

None.

MAIN OUTCOME MEASURES

SCI-FI Basic Mobility/Capacity (C), Fine Motor Function/C, Self-Care/C, and Wheelchair Mobility/Assistive Technology (AT) item banks.

RESULTS

Growth mixture modeling was used to identify groups with similar trajectory patterns. For the Basic Mobility/C and Wheelchair Mobility/AT domains, models specifying 2 trajectory groups were selected. For both domains, a majority class exhibited average functional levels and gradual improvement, primarily in the first six months. A smaller group of individuals made gradual improvements but had greater initial functional limitations. The Self Care/C domain exhibited a similar pattern; however, a third, small class emerged that exhibited substantial improvement in the first six months. Finally, for individuals with tetraplegia, trajectories of Fine Motor Function/C scores followed two patterns, with individuals reporting generally low initial scores and then making either modest or large improvements. In individual growth curve models, injury/demographic factors predicted initial functional levels but less so with regard to rates of recovery.

CONCLUSIONS

Trajectories of functional recovery followed a small number of change patterns, though variation around these patterns emerged. During the first two years after initial hospitalization, SCI-FI scores showed modest improvements; however, substantial improvements were noted for a small number of individuals with severe limitations in fine motor and self-care function. Future studies should further explore the personal, medical, and environmental characteristics that influence functional trajectories during these first two years and beyond.

The Longitudinal Effects of Comorbid Health Burden on Functional Outcomes for Adults With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate the impact of physical, mental, and total health condition burden on functional outcome and life satisfaction up to 10 years after moderate to severe traumatic brain injury (TBI).

SETTING

Six TBI Model Systems centers.

PARTICIPANTS

Three hundred ninety-three participants in the TBI Model Systems National Database.

DESIGN

Retrospective cohort study.

MAIN MEASURES

Self-reported physical and mental health conditions at 10 years postinjury. Functional Independence Measure Motor and Cognitive subscales and the Satisfaction With Life Scale measured at 1, 2, 5, and 10 years.

RESULTS

In 10-year longitudinal individual growth curve models adjusted for covariates and inverse probability weighted to account for selection bias, greater physical and mental health comorbidity burden was negatively associated with functional cognition and life satisfaction trajectories. Physical, but not mental, comorbidity burden was negatively associated with functional motor trajectories. Higher total health burden was associated with poorer functional motor and cognitive trajectories and lower life satisfaction.

CONCLUSIONS

This study offers evidence that comorbidity burden negatively impacts longitudinal functional and life satisfaction outcomes after TBI. The findings suggest that better identification and treatment of comorbidities may benefit life satisfaction, functional outcome, reduce healthcare costs, and decrease reinjury. Specific guidelines are needed for the management of comorbidities in TBI populations.

Early clinical predictors of functional recovery following traumatic spinal cord injury: a population-based study of 143 patients

BACKGROUND

Traumatic spinal cord injuries (TSCI) are associated with uncertainty regarding the prognosis of functional recovery. The aim of the present study was to evaluate the potential of early clinical variables to predict the degree of functional independence assessed by Spinal Cord Independence Measure III (SCIM-III) up to 1 year after injury.

METHODS

Prospectively collected data from 143 SCI patients treated in Western Denmark during 2012-2019 were retrospectively analysed. Data analysis involved univariate methods and multivariable linear regression modelling total SCIM-III scores against age, gender, body mass index (BMI), comorbidity, American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades A-B and C-D, ASIA Motor Score (AMS), timing of surgical treatment and occurrence of medical complications. Statistical significance was set at p < .05.

RESULTS

Univariate analyses indicated that variables significantly associated with decreased functional independence included increased age (p = .023), increased BMI (p = .012), pre-existing comorbidity (p = .001), AIS grades A-B (p < .001), decreased AMS (p < .001) and occurrence of medical complications (p < .001). However, in the multivariable regression model were pre-existing comorbidity (p = .010), AIS grades A-B (p < .001), low AMS (p < .001) and late surgical treatment (p = .018) significant predictors of decreased functional independence 1 year after injury.

CONCLUSION

TSCI patients with greatest potential for functional recovery up to 1 year after injury seem to be patients that immediately after trauma present with few or no comorbidities, who sustain motor-incomplete injuries and undergo early decompressive surgery.

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.

The Impact of a Comorbid Spinal Cord Injury on Cognitive Outcomes of Male and Female Patients with Traumatic Brain Injury

INTRODUCTION

Evidence of the effect of comorbid spinal cord injury (SCI) on cognitive outcomes in persons undergoing rehabilitation following newly diagnosed traumatic brain injury (TBI) is limited. We conducted a population-based study to investigate this effect.

OBJECTIVE

To compare cognitive outcomes in patients with TBI with and without a comorbid SCI.

SETTING/PARTICIPANTS

Adult patients diagnosed with TBI were identified and followed for 1 year through provincial health administrative data; those who entered inpatient rehabilitation were studied.

DESIGN

A retrospective matched cohort study using the National Rehabilitation Reporting System data of all acute care and freestanding rehabilitation hospitals in Ontario, Canada.

MAIN MEASURES

The exposure was a comorbid SCI in patients with diagnosed TBI. Exposed patients were matched to unexposed (TBI-only) on sex, age, injury severity, and income, in a ratio of one to two. Gain differences in the cognitive subscale of the Functional Independence Measure were compared between exposed and unexposed patients using multivariable mixed linear model, controlling for comorbidity propensity score, gains in motor function, and rehabilitation care indicators.

RESULTS

Over the first year post injury, 12 750 (0.84%) of all TBI patients entered inpatient rehabilitation, of whom 1359 (10.66%) had a comorbid SCI. A total of 1195 exposed patients (65.4% male, mean age 50.9 ± 20.6 for male and 61.8 ± 21.8 for female patients) were matched to 2390 unexposed patients. Controlling for confounding, exposed patients had lower cognitive gain (beta -0.43; 95% CI -0.72, -0.15), for both male (beta -0.39; 95% CI -0.75, -0.03) and female (beta -0.51; 95% CI -0.97, -0.05) patients. The adverse effects of comorbid SCI were driven largely by lower gains in problem solving and comprehension.

CONCLUSIONS

Adult patients with TBI and comorbid SCI showed a lower cognitive domain response to inpatient rehabilitation than patients with TBI alone. Identifying patients at risk for worse cognitive outcomes may facilitate the development of targeted strategies that improve cognitive outcomes.

Toward Improving the Prediction of Functional Ambulation After Spinal Cord Injury Though the Inclusion of Limb Accelerations During Sleep and Personal Factors

OBJECTIVE

To determine if functional measures of ambulation can be accurately classified using clinical measures; demographics; personal, psychosocial, and environmental factors; and limb accelerations (LAs) obtained during sleep among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models.

DESIGN

Cross-sectional, 1-5 days of data collection.

SETTING

Community-based data collection.

PARTICIPANTS

Adults with chronic (>1 year), motor incomplete SCI (N=27).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ambulatory ability based on the 10-m walk test (10MWT) or 6-minute walk test (6MWT) categorized as nonambulatory, household ambulator (0.01-0.44 m/s, 1-204 m), or community ambulator (>0.44 m/s, >204 m). A random forest model classified ambulatory ability using input features including clinical measures of strength, sensation, and spasticity; demographics; personal, psychosocial, and environmental factors including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; and LAs measured during sleep. Machine learning methods were used explicitly to avoid overfitting and minimize the possibility of biased results.

RESULTS

The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10MWT=70.4%, 6MWT=81.5%). Adding LAs, personal, psychosocial, and environmental factors, or both increased the accuracy of classification compared with the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models.

CONCLUSIONS

The addition of LA and personal, psychosocial, and environmental features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA; personal, psychosocial, and environmental factors; and advanced analyses to improve clinical prediction rules for functional mobility outcomes.

Buspirone for functional improvement after acute traumatic spinal cord injury: a propensity score-matched cohort study

STUDY DESIGN

Retrospective analysis of treated inpatients compared to expected neurorecovery from a propensity score-matched national database cohort.

OBJECTIVE

Evaluate the effectiveness of buspirone on clinical neurorecovery following traumatic SCI when started during acute inpatient rehabilitation.

SETTING

University-based hospital in Boston, USA.

METHODS

Chart review yielded thirty-one individuals with acute, traumatic SCI treated with buspirone during inpatient rehabilitation from 2011-2017. Propensity score matching to a cohort of individuals from the spinal cord injury model systems (SCIMS) national database was completed. Changes in upper extremity motor score (UEMS), lower extremity motor score (LEMS), American Spinal Injury Association Impairment Scale (AIS), neurological level of injury (NLI), and functional impairment measure (FIM) from admission to discharge and discharge to 1 year were computed and compared between matched pairs (buspirone and mean national SCIMs cohort). A local control cohort not treated with buspirone was similarly compared to a matched mean national SCIMs group to identify location-specific effects.

RESULTS

From admission to discharge from inpatient rehabilitation, 95% confidence intervals of changes in UEMS (-2.43 to +2.78), LEMS (-1.02 to +6.02), AIS (-0.04 to +0.35), NLI (-0.42 to +1.08), and FIM (-4.42 to +6.40) were not significantly different between those individuals who received buspirone and their propensity-matched SCIMS cohort. Similarly, changes in these metrics were not significantly different at 1-year follow up. Buspirone group individuals with initial clinically complete SCI demonstrated a higher 1-year conversion rate to incomplete injury (6 out of 14; 42.9%) compared to the matched national SCIMS cohort (14 out of 70; 21.2%, p = 0.047) though this was not significantly different from non-buspirone local controls (p = 0.25).

CONCLUSIONS

Retrospective analysis shows no statistically significant difference in gross markers of neurorecovery following acute traumatic SCI when buspirone is initiated indiscriminately during acute inpatient rehabilitation. In individuals with clinically complete SCI, findings suggest possible increased rates of 1-year conversion to incomplete injury.

Prioritization of rehabilitation Domains for establishing spinal cord injury high performance indicators using a modification of the Hanlon method: SCI-High Project

Objectives: To prioritize Domains of SCI Rehabilitation Care (SCI-Care) based on clinical importance and feasibility to inform the development of indicators of quality SCI-Care for adults with SCI/D in Canada. Methods: A 17-member external advisory committee, comprised of key stakeholders, ranked 15/37 Domains of rehabilitation previously flagged by the E-scan project team for gaps between knowledge generation and clinical implementation. Priority scores (D) were calculated using the Hanlon formula: D=[A+(2×B)]×C , where A is prevalence, B is seriousness, and C is the effectiveness of available interventions. A modified "EAARS" (Economic, Acceptability, Accessibility, Resources, and Simplicity) criterion was used to rank feasibility on a scale of 0-4 (4 is high). The product of these two scores determined the initial Domain ranking. Following the consensus process, further changes were made to the Domain rankings. Results: Despite a low feasibility score, Sexual Health was ranked as high priority; and, the Community Participation and Employment Domains were merged. The 11 final prioritized Domains in alphabetic order were: Cardiometabolic Health; Community Participation and Employment; Emotional Well-Being; Reaching, Grasping, and Manipulation; Self-Management; Sexual Health; Tissue Integrity; Urinary Tract Infection; Urohealth; Walking, and Wheeled Mobility. Conclusions: The modified Hanlon method was used to facilitate prioritization of 11 of 37 Domains to advance the quality of SCI-care by 2020. In future, the Spinal Cord Injury Rehabilitation Care High Performance Indicators (SCI-High) Project Team will develop structure, process and outcome indicators for each prioritized Domain.

Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review

Accurately predicting functional recovery is an asset for all clinicians and decision makers involved in the care of patients with acute traumatic spinal cord injury (TSCI). Unfortunately, there is a lack of information on the relative importance of significant predictors of global functional outcome. There is also a need for identifying functional predictors that can be timely optimized by the medical and rehabilitation teams throughout the hospitalizations phases. The main objective of this work was to systematically review and rate early factors that are consistently and independently associated with global functional outcome in individuals with TSCI. A literature search using MEDLINE, EMBASE, and Cochrane databases from January 1, 1970 to April 1, 2017 was performed. Two authors independently reviewed the titles and abstracts yielded by this literature search and subsequently selected studies to be included based on predetermined eligibility criteria. Disagreements were resolved by a consensus-based discussion, and if not, by an external reviewer. Data were extracted by three independent reviewers using a standardized table. The quality of evidence of the individual studies was assessed based on the Oxford Center for Evidence-Based Medicine modified by Wright and colleagues (2000) as well as the National Institutes of Health (2014). Fifteen articles identifying early clinical predictors of functional outcome using multiple regression analyses were included in this systematic review. Based on the compiled data, this review proposes a rating of early factors associated to global functional outcome according to their importance and their potential to be modified by the medical/rehabilitation team throughout the early phases of hospitalization. It also proposes a new conceptual framework that illustrates the impact of specific categories of factors and their interaction with each other. Ultimately, this review aims to guide clinicians and researchers in improving the continuum of care throughout early phases post-SCI.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparing Comorbidity Indices to Predict Post-Acute Rehabilitation Outcomes in Older Adults

OBJECTIVE

Compare 5 comorbidity indices to predict community discharge and functional status following post-acute rehabilitation.

DESIGN

This was a retrospective study of Medicare beneficiaries with stroke, lower-extremity fracture, and joint replacement discharged from inpatient rehabilitation in 2011 (N = 105,275). Community discharge and self-care, mobility, and cognitive function were compared using the Charlson, Elixhauser, Tier, Functional Comorbidity, and Hierarchical Condition Category comorbidity indices.

RESULTS

Of the patients, 64.4% were female, and 84.6% were non-Hispanic white. Mean age was 79.3 (SD, 7.5) years. Base regression models including sociodemographic and clinical variables explained 56.6%, 42.2%, and 23.0% of the variance (R) for discharge self-care; 47.4%, 30.9%, and 18.6% for mobility; and 62.0%, 55.3%, and 37.3% for cognition across the 3 impairment groups. R values for self-care, mobility, and cognition increased by 0.2% to 3.3% when the comorbidity indices were added to the models. The base model C statistics for community discharge were 0.58 (stroke), 0.61 (fracture), and 0.62 (joint replacement). The C statistics increased more than 25% with the addition of discharge functional status to the base model. Adding the comorbidity indices individually to the base model resulted in C-statistic increases of 1% to 2%.

CONCLUSION

Comorbidity indices were poor predictors of community discharge and functional status in Medicare beneficiaries receiving inpatient rehabilitation.

Impact of Therapy on Recovery during Rehabilitation in Patients with Traumatic Spinal Cord Injury

Evidence-based planning of rehabilitation interventions is important to improving cost efficiency while maintaining patient and system outcomes. This article aims to explore the relationship between rehabilitation therapy, functional outcome, bed utilization, and care costs after traumatic spinal cord injury (tSCI). A retrospective review of 262 persons with tSCI admitted to an inpatient rehabilitation facility from 2005–2012 was conducted. Treatment variables and outcome measures included rehabilitation length of stay (LOS), days to rehabilitation (onset), hours and intensity of therapy, and Functional Independence Measure (FIM). Polynomial regression models and generalized additive models were applied to explore the relationship between therapy hours and motor FIM change. Simulation modeling was used to assess the impact of hypothetically increasing therapy intensity. Patients were grouped by injury as: C1–4 American Spinal Injury Association (ASIA) Impairment Scale (AIS) A,B,C; C5–8 AIS A,B,C; T1–S5 AIS A,B,C; and AIS D. The sample was 85% male, mean age 45.9, median LOS 102 days, and mean therapy intensity 5.7 h/week. Motor FIM change was positively associated with total hours of therapy (β = 0.40, p < 0.0001) up to a certain time point, adjusted for age, gender, injury, complications, and rehabilitation onset. Hypothetically increasing therapy intensity by 50% and 100% resulted in average motor FIM efficiency gain ranging between 0.04–0.07 and 0.1–0.17, respectively, across injury groups. The hypothetical changes resulted in reductions in the average LOS and bed utilization rate, translating to cost savings of $20,000 and $50,000 (2011 CAD) for the +50% and +100% scenarios, respectively. The results highlight the importance of monitoring functional change throughout rehabilitation after tSCI and the need for customized therapeutic strategies.

Predictors of functional outcomes in adults with traumatic spinal cord injury following inpatient rehabilitation: A systematic review

CONTEXT

Despite functional improvements during rehabilitation, variable functional outcomes were reported when patients with Spinal Cord Injury (SCI) return to society. Higher functioning individuals at discharge can experience a decrease in independent mobility (i.e. Motor Functional Independence Measure (mFIM) Score) by one-year follow-up. However, functional gains after discharge have also been reported and associated with recovery.

OBJECTIVE

To identify, categorize and rank predictors of mFIM score for patients with SCI following inpatient rehabilitation, both at the time of discharge and at one-year follow-up.

METHODS

Data sources included CINAHL, PubMed, ERIC, Google Scholar, and Medline for literature published from February 2000 to February 2015. Quality and risk of bias of included studies was assessed using the Risk of Bias Assessment Instrument for Prognostic Factor Studies (QUIPS). Significant predictors of mFIM score were categorized using the domains of the International Classification of Function and Disability model ICF and ranked based on how frequently they were significant predictors of mFIM score.

RESULTS

Twenty-seven predictors of mFIM score spanning the ICF domains were identified among seven studies. At discharge, variables in the Body Structure and Function domain were the most consistent predictors of mFIM score. At one-year follow-up, variables in the Activity and Participation domain were the most consistent predictors of mFIM score. Contextual factors were the least frequent predictors at both discharge and one-year follow-up.

CONCLUSION

This systematic-review assists clinicians setting realistic goals that maximize functional independence at the time of discharge and after reintegrating to society.

Biomechanical properties of the spinal cord: implications for tissue engineering and clinical translation

Spinal cord injury is a severely debilitating condition which can leave individuals paralyzed and suffering from autonomic dysfunction. Regenerative medicine may offer a promising solution to this problem. Previous research has focused primarily on exploring the cellular and biological aspects of the spinal cord, yet relatively little remains known about the biomechanical properties of spinal cord tissue. Given that a number of regenerative strategies aim to deliver cells and materials in the form of tissue-engineered therapies, understanding the biomechanical properties of host spinal cord tissue is important. We review the relevant biomechanical properties of spinal cord tissue and provide the baseline knowledge required to apply these important physical concepts to spinal cord tissue engineering.

Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury

OBJECTIVE

To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury.

DESIGN

Retrospective cohort study.

SETTING

Facilities designated as Spinal Cord Injury Model Systems.

PARTICIPANTS

Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury.

RESULTS

After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], -2.43 to -0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, -7.66 to -0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.

CONCLUSIONS

Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.

Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes

OBJECTIVES

To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population.

DESIGN

Prospective, longitudinal, observational study.

SETTING

Ten inpatient rehabilitation centers.

PARTICIPANTS

Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being.

RESULTS

The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations.

CONCLUSIONS

This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.

Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty

BACKGROUND

Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups.

OBJECTIVE

To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission.

DESIGN

Multicenter prospective observational cohort, practice-based evidence, study.

SETTING

Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States.

PARTICIPANTS

A total of 226 patients with hip fractures treated with hip arthroplasty.

METHODS

Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster).

MAIN OUTCOME MEASURE(S)

Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity).

RESULTS

The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group.

CONCLUSIONS

Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.

Postacute rehabilitation quality of care: toward a shared conceptual framework

There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers' experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum.

Using Rasch motor FIM individual growth curves to inform clinical decisions for persons with paraplegia

STUDY DESIGN

A longitudinal retrospective study.

OBJECTIVE

To better understand individual-level temporal change in functional status for participants with paraplegia in the National Spinal Cord Injury Database (NSCID), as measured by Rasch Transformed Motor Functional Indepedence Measure (FIM) scores.

SETTING

Multicenter/Multistate longitudinal study across the United States.

METHODS

Non-linear random effects modeling, that is, individual growth curve analysis of retrospective data obtained from the National Institute on Disability and Rehabilitation Research (NIDRR) NSCID.

RESULTS

We generated non-linear individual level trajectories of recovery for Rasch Transformed Motor FIM scores that rise rapidly from inpatient rehabilitation admission to a plateau. Trajectories are based on relationships between growth parameters and patient and injury factors: race, gender, level of education at admission, age at injury, neurological level at discharge, American Spinal Injury Association Impairment Scale (AIS) at discharge, days from injury to first system inpatient rehabilitation admission, rehabilitation length of stay, marital status and etiology. On the basis of study results, an interactive tool was developed to represent individual level longitudinal outcomes as trajectories based upon an individual's given baseline characteristics, that is, information supplied by the covariates and provides a robust description of temporal change for those with paraplegia within the NSCID.

CONCLUSIONS

This methodology allows researchers and clinicians to generate and better understand patient-specific trajectories through the use of an automated interactive tool where a nearly countless number of longitudinal paths of recovery can be explored. Projected trajectories holds promise in facilitating planning for inpatient and outpatient services, which could positively impact long term outcomes.

Role of body weight in therapy participation and rehabilitation outcomes among individuals with traumatic spinal cord injury

OBJECTIVE

To examine the association between body weight, therapy participation, and functional outcomes among people with spinal cord injury (SCI).

DESIGN

Multisite prospective observational cohort study.

SETTING

Six acute rehabilitation facilities.

PARTICIPANTS

Patients (N=1017) aged ≥ 12 years admitted for their initial rehabilitation after SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Motor FIM at inpatient rehabilitation discharge and 1 year postinjury.

RESULTS

Underweight and overweight/obese patients consisted of 2 different clusters of SCI patients. Underweight patients were more likely to be younger, black, less educated, single, have Medicaid as a primary payer, and more likely to have had a cervical level injury because of violence and vehicular-related events than their overweight and obese counterparts. We found few significant differences in hours of therapy during inpatient rehabilitation across weight groups. Among patients with C5-8 ASIA Impairment Scale (AIS) grades A, B, and C injuries, underweight patients received fewer hours of physical therapy per week than patients with a healthy weight (P=.028). Obese patients with paraplegia AIS grades A, B, and C received more hours of occupational therapy during their rehabilitation stay (P<.001) than other weight groups. A higher percentage of underweight patients had pressure ulcers during inpatient rehabilitation in C5-8 AIS grades A, B, and C and paraplegia AIS grades A, B, and C groups. Only in the paraplegia AIS grades A, B, and C group did we find a significant association between weight groups and discharge motor FIM score. Regression models showed that among C1-4 AIS grades A, B, and C patients, the overweight group had better 1-year follow-up motor FIM scores than other weight groups.

CONCLUSIONS

Patients who had an unhealthy body weight, that is, being underweight or obese, often have therapy participation and profiles different from those deemed healthy, or just overweight. For patients with paraplegia AIS grades A, B, and C, being overweight or obese was associated with diminished motor FIM outcomes at discharge from rehabilitation. The relation between body weight status, therapy participation, and outcomes are not consistent among study group participants.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation

OBJECTIVE

To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization.

DESIGN

Prospective observational cohort study.

SETTING

Six geographically dispersed rehabilitation centers in the U.S.

PARTICIPANTS

Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations.

RESULTS

More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered.

CONCLUSIONS

Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

CER, PBE, SCIRehab, NIDRR, and other important abbreviations

Comparative effectiveness research (CER) has been receiving much attention (and government funding) in recent years, stemming from dissatisfaction with much medical and health care research, which does not produce actionable evidence that can be used by clinicians, patients, and policymakers. Rehabilitation research has been characterized by similar weaknesses and by often inadequate research designs. The SCIRehab study of the outcomes of inpatient spinal cord injury rehabilitation is one of a small number of rehabilitation practice-based evidence (PBE) studies in recent years that allows for the comparison of interventions by all disciplines for relevant real-life outcomes. This introduction to a series of articles resulting from the SCIRehab project discusses the need for and the nature of CER, and places the SCIRehab study and other PBE studies in the light of CER. After a description of the highlights of the analyses in this supplement, we provide a preliminary evaluation of SCIRehab, counting the articles and presentations from the study, the resources that went into this vast project, and the lessons learned that may benefit future rehabilitation PBE investigators.