Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury

Optimizing length of hospital stay among inpatients with spinal cord injury: An observational study

INTRODUCTION AND OBJECTIVES

Despite the importance of length of stay (LOS) following spinal cord injury, it remains underexplored in the literature. This study aims to bridge this gap by investigating the association between rehabilitation LOS and functional gains among patients with traumatic (TSCI) or non-traumatic (NTSCI) spinal cord injuries.

METHODS

We conducted a retrospective observational cohort study assessing functional gains using the motor Functional Independence Measure (mFIM) and the Spinal Cord Independence Measure (SCIM III) from rehabilitation admission to discharge. Outcomes were analyzed across four neurological categories based on the American Spinal Injury Association Impairment Scale (AIS): C1-C4 AIS A-C; C5-8 AIS A-C; T1-S5 AIS A-C; and AIS D. Linear regression models estimated changes across rehabilitation LOS quarters (Q1-Q4), adjusting for covariates.

RESULTS

We included 1036 patients admitted for rehabilitation between 2007 and 2023 (46.3% TSCI, 53.7% NTSCI). TSCI: age 42.7, 80.2% male, 41.8% AIS A, LOS 90.5. NTSCI: age 55.7, 54.2% male, 14.2% AIS A, LOS 69.6. For TSCI, mFIM and SCIM III gains increased significantly from Q1 to Q2 (T1-S5-ABC, n=214) and Q2 to Q3 (AIS D, n=129). For NTSCI, gains increased from Q2 to Q3 (T1-S5-ABC, n=195) and from Q1 to Q2 as well as from Q2 to Q3 (AIS D, n=304). Adjusted models showed decreasing gains for Q2 and Q3 vs. Q1 (TSCI) but increasing gains for Q2-Q4 vs. Q1 (NTSCI) for both measures. No significant gains were observed from Q3 to Q4.

CONCLUSIONS

We identified specific neurological categories and LOS quarters yielding to significant functional gains.

Unveiling the mosaic: comparing demographics and outcomes in traumatic vs. non-traumatic spinal cord injuries

BACKGROUND

This study analyzed the percentage of patients with nontraumatic spinal cord injury (SCI) which is increasing with the increase of population age. However, little is known about the effect of the etiology of SCI on the outcome of these subjects.

AIM

The aim of this study was to investigate functional and neurological outcomes in patients with traumatic and nontraumatic spinal cord lesions, with a focus on factors influencing rehabilitation outcomes.

DESIGN

The design of this study was that of a retrospective analysis of prospectively recorded data.

SETTING

The setting of this analysis was a single Spinal Unit in Italy.

POPULATION

The population included 1080 subjects, of which 599 (55%) had injuries of traumatic origin and 481 (45%) had nontraumatic injuries.

METHODS

International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), the Spinal Cord Independence Measure (SCIM) and the Walking Index for Spinal Cord Injury (WISCI) were utilized as measurement tools. Multivariate (backwards selection, P=0.20) logistic regression was used to assess the associations of "complication during hospitalization," "bowel management autonomy," "spontaneous micturition," "home destination" and "neurological improvement" with the following variables: etiology, age, sex, lesion level and severity and length of stay. Multivariate (backwards selection, P=0.20) negative binomial regression was used to assess the relative risks of higher SCIM and WISCI Scores at discharge after adjusting for the abovementioned variables.

RESULTS

Our work highlighted several significant differences between the traumatic and nontraumatic groups (including age, sex, lesion severity, and time from lesion onset to admission). Both groups exhibited comparable improvements in neurological and functional status, although some data were in favor of subjects with traumatic lesions. However, the regression analyses demonstrated that the main factors impacting the neurological and functional status at discharge were age, lesion level and severity, rather than the etiology of the lesion.

CONCLUSIONS

Our study provides valuable insights into the rehabilitation trajectories of traumatic and nontraumatic spinal cord injuries and demonstrates that the cause of SCI has no impact on rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An understanding of neurological and functional recovery after spinal cord lesions is essential for answering patients' questions about their potential functional capabilities. It also assists in determining the necessary resources for inpatient rehabilitation and post discharge care. Moreover, the possession of a thorough grasp of the course and factors influencing the natural recovery of a spinal cord lesion is now a scientific necessity and is crucial for assessing the efficacy of new pharmacological and rehabilitative methods.

The experience of falls and fall risk during the subacute phase of spinal cord injury: a mixed methods study

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.

Are early-onset spasms predictive of poor neurological recovery after traumatic spinal cord injury?

CONTEXT

Following spinal cord injury (SCI), early spasms are associated with decreased functional recovery. It has also been hypothesized that early spasticity might sign underlying maladaptive neuroplasticity, which could translate in worse neurological outcomes.

OBJECTIVE

In this context, this paper aims to evaluate if early-onset spasms are also associated with neurological outcomes after SCI.

METHODS

A retrospective review of 196 cases from a prospective SCI database was conducted. The presence of early spasms during the acute hospitalization was assessed by a single physiatrist. The characteristics and long-term neurological outcomes of individuals with and without early spasms were first compared. Multivariate regression analyses were then performed to determine the relationship between early spasms and neurological outcomes.

RESULTS

30.1% (N = 59) of patients presented early spasms. These patients had several distinguishing characteristics including higher odds of tetraplegia (vs. paraplegia) and more severe injuries. At the bivariate level, patients with early spasms had higher odds of improving at least 1 AIS grade between baseline and follow-up. However, this was not significant at the multivariate level.

CONCLUSIONS

Early spasms are not significantly associated with poorer neurological outcomes, contrasting with the unwritten consensus that early spasticity translates maladaptive neuroplasticity.

Spinal cord injury: Current trends in acute management

Introduction

Traumatic spinal cord injury (tSCI) is a profoundly debilitating condition necessitating prompt intervention. However, the optimal acute treatment strategy remains a subject of debate.

Research question

The aim of this overview is to elucidate prevailing trends in the acute tSCI management.

Material and Methods

We provided an overview using peer-reviewed studies.

Results

Early surgical treatment (<24h after trauma) appears beneficial compared to delayed surgery. Nonetheless, there is insufficient evidence supporting a positive influence of ultra-early surgery on neurological outcome in tSCI. Furthermore, the optimal surgical approach to decompress the spinal cord remains unclear. These uncertainties extend to a growing aging population suffering from central cord syndrome (CCS). Additionally, there is a paucity of evidence supporting the beneficial effects of strict hemodynamic management.

Discussion and Conclusion

This overview highlights the current literature on surgical timing, surgical techniques and hemodynamic management during the acute phase of tSCI. It also delves into considerations specific to the elderly population experiencing CCS.

Predicting inpatient rehabilitation length of stay for adults with traumatic spinal cord injury

INTRODUCTION

Most post-injury traumatic spinal cord injury (TSCI) care occurs in the inpatient rehabilitation setting. The inpatient rehabilitation length of stay (R-LOS) has been shown to be a significant predictor of motor function restoration in persons with TSCI. Due to the complexity, and heterogeneity of individuals with TSCI, the R-LOS is challenging to predict at admission.

PURPOSE

To identify the main predictors of R-LOS and derive an equation to estimate R-LOS in persons with TSCI.

METHODS

This is a retrospective analysis of data from adults with TSCI from The Rick Hansen Spinal Cord Injury Registry in Alberta, Canada, who received rehabilitation care between May 10, 2005, and January 28, 2020. Multiple linear regression analysis was used to determine significant relationships between R-LOS and measures of participant demographics, length of stay, impairment and injury classification, and comorbidities.

RESULTS

The analysis included 736 adults with TSCI from an eligible cohort of 1365. The median R-LOS was 65 days (IQR 39-99 days), ranging from 1 to 469 days. Multivariate linear regression analysis identified two significant predictors of R-LOS, total FIM score and the injury classification. This model was used to derive a R-LOS prediction equation, which explained 34% of the variance in R-LOS.

CONCLUSION

We developed a simple equation to predict R-LOS based on the level of impairment and total FIM scores in persons with TSCI. These data have implications for health system planning, improvement, and innovation, and provide insights to support further research into the predictors of R-LOS, identification of higher-risk individuals.

Decision Tree Analysis Accurately Predicts Discharge Destination After Spinal Cord Injury Rehabilitation

OBJECTIVES

To predict discharge destination after spinal cord injury (SCI) rehabilitation.

STUDY DESIGN

A retrospective, single-center study. We collected the following data from medical charts: age, sex, living arrangement before injury, acute length of stay (LOS), level of injury on admission, American Spinal Injury Association Impairment Scale (AIS) on admission, Upper Extremity Motor Score (UEMS) on admission, Lower Extremity Motor Score on admission (LEMS), Spinal Cord Independence Measure (SCIM) scores on admission and discharge, and discharge destination. A decision tree algorithm was used to establish prediction models in a train-test split manner using features on admission or discharge.

SETTING

A spinal center in Tokyo, Japan.

PARTICIPANTS

Participants were individuals with SCI admitted to our hospital from March 2016 to October 2021 for the first rehabilitation after the injury. The study included 210 participants divided into 2 groups: training (n=140) and testing (n=70). Random sampling without replacement was used.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prediction accuracy was evaluated with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating curve (AUC).

RESULTS

AIS was significantly different between the groups. The prediction model using total SCIM scores on discharge (D-Classification and Regression Tree [CART]) revealed that a cut-off value of 40 accurately predicted the discharge destination. In contrast, the prediction model using features on admission (A-CART) revealed that subtotal SCIM mobility scores of 5, age of 74 years, and UEMS of 23 were significant predictors. Sensitivity, specificity, PPV, NPV, and AUC of D-CART and A-CART were 0.837, 0.810, 0.911, 0.680, and 0.832 and 0.857, 0.810, 0.913, 0.708, and 0.869, respectively.

CONCLUSIONS

D-CART and A-CART showed comparable prediction accuracies. This suggests that, even during the early stages of rehabilitation, it is possible to predict the discharge destination.

Factors Affecting Home Discharge of Older Adults with Cervical Spinal Cord Injury in Japan Regional Population

Introduction

Older adults with cervical spinal cord injury (CSCI) often have a poor prognosis due to the high number of complications, decreased motivation to rehabilitation, and poor response to treatment. This study aimed to investigate the characteristics of CSCI in Japanese older adults and examined the factors influencing their discharge home.

Methods

In this retrospective cohort study, we extracted data on consecutive cases with CSCI between 2005 and 2020 from the study hospital's database. Patients over 65 years old who were admitted to the hospital within 14 days of injury were selected. A univariate analysis was performed between the home discharge and out-of-home discharge groups. In addition, binary logistic regression analysis of admission findings and patient background was performed to examine independent factors influencing home discharge.

Results

Of the 219 patients included, 90 (41.1%) were eventually discharged to home. Comparing home discharge and out-of-home discharge groups revealed significant differences in age at injury, length of hospital stay, neurological level of injury (NLI), percentage of American Spinal Injury Association (ASIA) Impairment Scale (AIS: A), percentage of living alone, ASIA motor score (AMS), and Spinal Cord Independence Measure (SCIM) at initial visit and discharge. Binary logistic regression analysis revealed that old age (over 75 years old) at injury (odds ratio [OR]: 0.31, 95% CI: 0.16-0.60, P<.001), living alone (OR: 0.22, 95% CI: 0.03-0.42, P<.01), high level of injury (i.e., NLI: C1-4; OR: 0.22, 95% CI: 0.09-0.53, P<.0001), and percentage of AIS: A at admission (OR: 0.09, 95% CI: 0.04-0.24, P<.001) were independent factors that influenced home discharge.

Conclusions

More than 50% older adults with CSCI were discharged to a place other than their own home. Age, percentage of AIS: A, living alone, and high level of injury at admission were independent factors that influenced home discharge.

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.