Comparative analysis of goal achievement during rehabilitation for older and younger adults with spinal cord injury

Trends in the characteristics and outcomes of older patients with non-traumatic spinal cord injury treated in inpatient rehabilitation facilities: 2013-2018

OBJECTIVE

To describe the characteristics and outcomes of older (≥ 65 years of age) patients with a non-traumatic spinal cord injury (NTSCI) treated in inpatient rehabilitation facilities (IRFs) between 2013 and 2018.

DESIGN

Observational study.

SETTING

IRFs in the United States.

PARTICIPANTS

93,631 IRF Medicare stays for patients with NTSCI.

INTERVENTIONS

Not Applicable.

MAIN OUTCOME MEASURES

Length of stay, self-care and mobility function, discharge destination.

RESULTS

Between 2013 and 2018, the number of older (≥ 65 years of age) Medicare patients with a NTSCI treated in IRFs increased about 22.1 percent, from 14,149 to 17,275. In addition to the increase, patients' sociodemographic characteristics shifted to have a slightly higher percentage of patients aged 65-74 years, a slightly higher percentage of males, and slightly fewer patients who identified as Hispanic. There was also a trend of more patients in the higher acuity case-mix groups and comorbidities tiers, but the median length of stay remained 12 days across all years. The percent of patients discharged home or to a community-based setting varied from 73.7 to 75.2 without a trend, although discharge self-care and mobility function increased slightly across the years.

CONCLUSIONS

Between 2013 and 2018, the number of Medicare patients with NTSCI treated in IRFs increased by more than 22 percent. While patient complexity increased, the median length of stay remained 12 days across the years. Discharge self-care and mobility function increased slightly, and the percent of patients discharged home ranged from 73.7 to 75.2 across the years.

Building and Sustaining Inpatient-Clinician Collaboration in Spinal Cord Injury Rehabilitation: A Case Example Using the Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) and Goal Planning Programme

Goal planning is core for the delivery of the biopsychosocial model of rehabilitation and is commonly practiced in spinal cord injury (SCI) and other physical health settings. Despite a strong theoretical basis from several branches of psychology, evidence regarding specific practice, interventions and impact has yet to be established, with no universal standards in this area. Study One outlines the standards used at the National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital since the inception of the SMS-NAC and goal planning programme in 1989. The results outline the impact of a quality improvement project undertaken since 2016 and track the interventions used to improve inpatient care. Study Two reports on an international survey of rehabilitation measure usage and goal planning practice with inpatient adult and children and young people (CYP) with SCI. Respondents replied that inpatient presence at goal planning meetings only took place in 75% (adult) and 76% (CYP) of services, with more services indicating 4 or more members of the multidisciplinary team being present (85% and 90%, respectively). This paper demonstrates the gains that can be made when a structured quality improvement methodology is used and highlights the need for standards regarding goal planning in SCI rehabilitation to be developed.

Functional outcomes in geriatric patients with spinal cord injuries at a tertiary care rehabilitation hospital in Saudi Arabia

Study design

Retrospective study.

Objective

To identify demographic features, clinical characteristics, and complications associated with spinal cord injuries/disorders (SCI/D) among elderly individuals at a rehabilitation hospital and to measure the functional outcomes of rehabilitation.

Setting

Rehabilitation hospital in King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.

Methods

The study was conducted in elderly individuals (aged ≥65 years) with SCI/D, admitted to an inpatient rehabilitation program between October 2014 and 2015. Demographic and clinical data were recorded along with functional independence measure (FIM) score at admission (FIMa) and discharge (FIMd). Data were descriptively analyzed. Association of non-metric and metric variables with complications was measured using χ², and Student's t-test, respectively.

Results

Twenty-four individuals with SCI/D (95.8% were male and retired) with mean (standard deviation, SD) age of 72.3 (6.3) years were included. The most common co-morbidities were hypertension (75.0%), and diabetes mellitus (58.3%). Degenerative cervical myelopathy (33.3%) was the most common cause of SCD. Of all, nine (37.5%) individuals had clinical complications (urinary tract infection(UTI); 8/9, surgical wound infection; 1/9). Mean (SD) hospitalization period during inpatient rehabilitation was 66.0 (13.9) days. Mean (SD) FIMa scores improved from 71.7 (17.3) to 85.3 (16.8) at discharge. Co-morbidities associated with complications were peripheral vascular disease, ischemic heart disease, and stroke.

Conclusion

In Saudi Arabia, non-traumatic spinal etiologies are the most frequent cause of spinal cord dysfunction in the elderly. Male gender, hypertension, and diabetes mellitus were high-risk factors among the geriatric age group with SCI/D. Elderly individuals with SCI/D without complications can have a shorter hospitalization period and higher functional gains during rehabilitation.

Informed consent in cluster randomised trials: new and common ethical challenges

Cluster randomised trials are an increasingly important methodological tool in health research but they present challenges to the informed consent requirement. In the relatively limited literature on the ethics of cluster research there is not much clarity about the reasons for which seeking informed consent in cluster randomised trials may be morally challenging. In this paper, I distinguish between the cases where informed consent in cluster trials may be problematic due to the distinct features of 'population-based' interventions, which have not been adequately discussed in the research ethics literature, and the cases where informed consent may be problematic for reasons that investigators also encounter in other research designs. I claim that informed consent requirements in cluster trials should be adjusted to the level of risk involved, arguing for a more comprehensive notion of research risk than that currently found in the research ethics guidelines, and the amount of freedom to be sacrificed in relation to a particular research aim. I conclude that these two factors are the most important to consider when assessing whether a cluster study should proceed when informed consent is infeasible or difficult to obtain.

Targeting Adenosine Signaling in Parkinson's Disease: From Pharmacological to Non-pharmacological Approaches

Parkinson's disease (PD) is one of the most prevalent neurodegenerative disease displaying negative impacts on both the health and social ability of patients and considerable economical costs. The classical anti-parkinsonian drugs based in dopaminergic replacement are the standard treatment, but several motor side effects emerge during long-term use. This mini-review presents the rationale to several efforts from pre-clinical and clinical studies using adenosine receptor antagonists as a non-dopaminergic therapy. As several studies have indicated that the monotherapy with adenosine receptor antagonists reaches limited efficacy, the usage as a co-adjuvant appeared to be a promising strategy. The formulation of multi-targeted drugs, using adenosine receptor antagonists and other neurotransmitter systems than the dopaminergic one as targets, have been receiving attention since Parkinson's disease presents a complex biological impact. While pharmacological approaches to cure or ameliorate the conditions of PD are the leading strategy in this area, emerging positive aspects have arisen from non-pharmacological approaches and adenosine function inhibition appears to improve both strategies.

The energy expenditure of people with spinal cord injury whilst walking compared to an able-bodied population

BACKGROUND

In the field of spinal cord injury (SCI) research there is an emphasis on the ability to ambulate.

PURPOSE

To determine the ambulation energy expenditure (EE) and factors that affect ambulation EE in SCI participants compared to able-bodied participants.

METHODS

This was a cross-sectional study. Participants were recruited from seven SCI rehabilitation units within the Johannesburg area. The following were used: demographic questionnaire to capture participants' characteristics, modified Ashworth scale for spasticity; goniometer for range of movement (ROM); American Spinal Injury Association (ASIA) scale for patient classification; accelerometer for EE and the six-minute walk test (6MWT) for endurance. Characteristics of the study participants were summarised using descriptive statistics. Data were analysed as follows: two-sample t-test for comparison between the able-bodied and SCI sample and Pearson product moment correlations for relationship between identified factors and EE.

RESULTS

Participants comprised 45 in the SCI group and 21 in the able-bodied group. The mean energy expenditure per metre (EE/m) for the SCI participants was 0.33 (± 0.29) calories compared to 0.08 (± 0.02) calories for the able-bodied participants. A decrease in walking velocity resulted in an increase in EE. For SCI participants, every decrease in degree of hip flexion ROM resulted in a 0.003 increase in EE/m walked. A unit decrease in velocity resulted in an increase of 0.41 in EE/m walked. Energy expenditure per metre decreased from ASIA A to ASIA D. Crutch walking utilised 0.34 calories per metre less energy than walking frames (p = 0.03).

CONCLUSION

Based on this study's findings, factors to consider in order to maximise energy efficiency whilst walking are maintaining hip flexion ROM and optimising velocity of walking.

Concepts of aging with paralysis: implications for recovery and treatment

This chapter deals with the impact of age on the occurrence, clinical presentation, outcome, and course of a spinal cord injury (SCI). This is of importance in a society where the population of elderly people continuously increases. The chapter is focused first, on the actual problems of a SCI in elderly subjects and second, on age-specific sequelae after a SCI. The etiology and clinical presentation of a SCI differs in elderly subjects compared to young subjects. With advanced age, incomplete cervical lesions following falls or due to spondylotic degeneration of the cervical spine and non-traumatic SCI occur more frequently. Research pertaining to the comparison of different age groups is prone to bias due to survival and treatment cohort effects. There is an increased risk of complications and mortality after a complete SCI in elderly people. Surprisingly, the recovery of the neurological deficit does not depend on age. However, elderly subjects with SCI have more problems in transferring an improvement in motor score into a functional improvement in their ability to carry out the activities of daily living. With increasing age after a SCI the completeness and level of injury determine the occurrence of complications and outcome restrictions. In addition, problems in general health (e.g., in circulation, kidney function, diabetes mellitus) may affect the functional independence of elderly subjects with SCI.

Epidemiology of spinal fractures among the elderly in Chongqing, China

OBJECTIVE

To illustrate the epidemiology of spinal fractures including traumatic spinal fractures and osteoporotic spinal fracture with no specific cause, spinal fracture caused by tumour and tuberculosis among the elderly.

DESIGN

We retrospectively reviewed hospital records on all patients who was 60 years of age or older with spinal fracture at two university-affiliated hospitals between January 2001 and May 2011 (n=996). Variables assessed included age, gender, incidence of hospital admission, mechanism of spinal fracture, anatomic distribution, neurologic deficit, therapeutic method, length of hospitalisation and hospitalisation cost.

SETTING

Two university-affiliated hospitals from January 2001 to May 2011.

RESULTS

A total of 996 patients with spinal fractures were identified, of whom 34.8% were males. The annual incidence of spinal fractures among the elderly was 24 cases per 100,000 hospital admission in 2001 and then gradually increased to 130 cases per 100,000 hospital admission in 2010. The causes of spinal fractures include traumatic spinal fractures (n=714, 71.7%), osteoporotic fracture with no specific cause (n=264, 26.5%) and spinal fracture caused by tumour and tuberculosis (n=18, 1.8%). The lumbar region was the most common region of spinal fracture (n=823, 48.8%), followed by the thoracic (n=724, 43.0%) and the cervical (n=138, 8.2%) regions. Lumbar spinal fractures and thoracic spinal fractures were more commonly seen as a result of accidental falls from low heights and osteoporotic spinal fractures respectively. Thirty-five (3.5%) patients exhibited a complete motor and sensory deficit and 151 (15.2%) an incomplete neurological deficit. The greatest number of complete motor and sensory neurological deficits was associated with cervical spinal fractures and accidental falls. A total of 87 (8.7%) patients had associated non-spinal injuries, of whom 26 (29.9%) sustained a head and neck injury, 28 (32.2%) patients suffered a thoracic injury and 19 (21.8%) patients suffered a fracture of a lower extremity.

CONCLUSION

Spinal fractures usually occur outdoors causing by accidental falls from low heights, most frequently happen on the road. The number of fall-induced injuries and sports injury increased steadily with age, may indicate that there is growing concern for the consequences of falls and sports in the elderly.

Clinical Utility of the Canadian Occupational Performance Measure in Spinal Cord Injury Rehabilitation

Introduction:

Collaborative goal setting is an important part of the occupational therapy process in spinal cord injury rehabilitation. Little is known about the clinical utility of the Canadian Occupational Performance Measure (COPM) with this population, although it has potential advantages over informal methods of goal setting commonly used in a spinal injury unit (SIU). The aim of this study was to investigate the goal setting process and clinical utility of the COPM from the perspective of occupational therapists within a SIU.

Method:

A focus group was conducted with six occupational therapists working in a SIU to explore their experiences and use of goal setting and the COPM. Inductive thematic analysis identified key themes from their comments.

Findings:

Focus group themes were the impact of client adjustment and other factors, organisational and administrative factors, therapist skill level and experience requirements, benefits of the COPM and incorporating the COPM into practice.

Conclusion:

Formal goal setting was a concept that was identified as a priority by the participants; however, there were organisational, client and therapist related factors that were considered as both barriers and facilitators to formal goal setting and the use of the COPM in this setting.

Mismatch Between Investigator-Determined and Patient-Reported Independence After Spinal Cord Injury

Objective. This study investigated the course and relationship between investigator-determined and patient-reported level of independence within the first year after spinal cord injury (SCI). The authors examined variables that contributed to these scores. Methods. In this observational cohort study, 73 patients with traumatic SCI were evaluated at 1, 3, and 6 months (and 40 subjects at 1 to 12 months). The investigator-determined independence was quantified using the Spinal Cord Independence Measure (SCIM). The subjective, patient-reported independence was determined by asking how their general restrictions influenced everyday life activities. Several variables were used to explain these 2 scores. Results. The SCIM score was higher than the patient-reported independence and improved significantly more over time (up to about 70/100 at 12 months), whereas the perceived independence remained below 50/100. The correlations between the 2 measures were at most moderate ( rs ≤ 0.51), but in general somewhat higher for subjects with tetraplegia. Age and muscle strength predicted the SCIM score well. No variable predicted the patient-reported level of independence. Conclusions. Investigator-determined and patient-reported outcomes can differ considerably and evolve differently. A patient-reported outcome measure may not detect actual functional improvement. It is likely that changes in patient-reported outcomes are influenced by many factors in addition to those associated with functional recovery, including psychological factors.

Age influences rehabilitative outcomes in patients with spinal cord injury (SCI)

BACKGROUND AND AIMS

To define differences in rehabilitative outcome after Spinal Cord Injury (SCI), according to age at injury.

METHODS

This is a prospective, observational, follow-up study. Completion of a questionnaire administered by a psychologist through a telephone interview to subjects discharged about 4 years previously from 22 SCI centers in Italy, who had already participated in a prospective multicenter study. A total of 403 out of 511 patients with SCI (79%), discharged between 1997 and 1999 after comprehensive rehabilitation in SCI centers, who gave their consent to a telephone interview. Main outcome measures are: number of re-admissions and medical consultations for clinical problems during follow-up (FU) period, clinical outcome related to bowel/ bladder function, family, sentimental and personal satisfaction, mobility, three-day autonomy, subjective feelings of dependency, subjective perception of quality of life.

RESULTS

The sample population was categorized into two subgroups according to severity on the Asia Spinal Injury Association (ASIA) scale by the ROC method: 276 subjects, the younger group were aged between 0 and 49 years, mean age 32 (±8 yrs), and 127 subjects in over 50 group, mean age 63 (±8 yrs). Differences in sample characteristics were found as regards cervical/dorsal lesion distribution and incompleteness of damage, more frequent in the older group. Incidence of hospital re-admissions and medical consultations, bladder autonomy, bowel autonomy and bowel continence were similar in both groups. Variables related to personal and social life, as well as life satisfaction, showed significant differences, with worse outcomes in the older group.

CONCLUSIONS

Age at injury deserves major attention, as persons not yet in geriatric age may show greater vulnerability after SCI.

Coping strategies used by people with spinal cord injury: a qualitative study

STUDY DESIGN

Qualitative.

OBJECTIVES

Although using coping strategies have an important role in the adaptation process and quality of life following spinal cord injury (SCI), there is still trivial information about this issue in the world and especially in Iran. The purpose of this study was to explore coping strategies used by Iranian patients with spinal cord injuries.

SETTING

The Brain and Spinal injury Repair Research Center of Tehran University of Medical Sciences and the Protection Center of spinal cord disables, Iran.

METHOD

Eighteen patients with SCI were interviewed deeply. Data were concurrently analyzed, using the content analysis method.

RESULTS

During the data analysis, three coping strategies, including seeking help from religious beliefs (understanding the disease as a divine fate and as a spiritual combat), hope and making efforts towards independence/self-care appeared.

CONCLUSION

Understanding strategies that influence the patients' coping with the SCI will contribute to the nursing body of knowledge. It also helps nurses and other health-care professionals as well as the families in reinforcing the most effective coping strategies and promoting the quality of care. Such coping strategies also can help patients to achieve a greater sense of empowerment.

Difficulty of elderly SCI subjects to translate motor recovery--"body function"--into daily living activities

The objective of this retrospective analysis was to determine whether outcome of body functions and activities as well as length of stay of inpatient rehabilitation is related to age in patients with traumatic spinal cord injury (SCI). Data were collected from a European network of 17 SCI rehabilitation centers (EM-SCI); a total of 237 traumatic SCI subjects were included. Assessments were performed at 1, 6, and 12 months after SCI. The measures analyzed were motor score according to the American Spinal Injury Association, Spinal Cord Independence Measure (SCIM), gait speed, and length of stay. Correlation analysis was applied to quantify the association between age and change in the outcome measures. A positive relationship was found between age and neurological recovery in both the first and second 6-month periods of assessment. A negative relationship was found between age and change in SCIM in the second 6-month period after SCI. A negative relationship between age and gait speed was observed in the first half year. Length of stay was not associated with age. It was concluded that age is an important determining factor for functional outcome after SCI and that elderly patients have difficulties in translating an improvement in neurological outcome into functional changes. Therefore, rehabilitation approaches in elderly subjects should focus on functional training.

Perceptions of exercise mastery in persons with complete and incomplete spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To compare exercise-related self-perceptions in persons with complete and incomplete spinal cord injury (SCI) and to identify factors that explain the variance of perceived exercise mastery in the study population.

SETTING

Sunnaas Rehabilitation Hospital and the Norwegian School of Sport Sciences, Norway.

METHODS

A total of 116 respondents (47 persons with complete and 69 persons with incomplete SCI) answered a questionnaire measuring self-rated physical exercise habits and self-perceptions in exercise. Respondents with complete SCI performed a max test on an arm ergometer.

RESULTS

Exercisers with complete SCI reported a significantly higher perceived exercise mastery (P=0.002) and exercisers with incomplete SCI reported a significantly lower perceived exercise mastery (P=0.012) than nonexercisers. Exercisers in both groups reported a higher perceived fitness (complete SCI, P=0.016; incomplete SCI, P=0.004) than nonexercisers. A regression analysis showed that exercising versus nonexercising (exercise status) was the only variable that contributed to the variance in perceived exercise mastery for persons with complete SCI (P<0.001). For persons with incomplete injury, exercise status and exercise hours per week contributed to the variance in perceived exercise mastery.

CONCLUSION

Although perceived fitness is associated with exercise in the whole SCI population, perception of exercise mastery is negatively related to exercise in persons with incomplete SCI, in contrast to those with complete lesions.

Traumatic spine injuries in the geriatric population

In this paper the authors review spine trauma and spinal cord injury (SCI) in the geriatric population. The information in this study was compiled through a literature review of clinical presentation and management of SCI in the elderly population. This was done to define, identify, and specify treatment algorithms and management strategies in this unique patient population.

Influence of age and gender on rehabilitation outcomes in nontraumatic spinal cord injury

STUDY DESIGN

Retrospective, 3-year case series.

OBJECTIVE

To investigate the relationship between gender and age and a range variables in patients with nontraumatic spinal cord injury (SCI).

SETTING

Tertiary medical unit specializing in rehabilitation of patients with nontraumatic SCI.

METHOD

Participants were a consecutive series of 70 adult inpatients with nontraumatic SCI undergoing initial rehabilitation. The variables of interest were demographic characteristics, clinical features, complications, mortality, length of stay (LOS), mobility, bladder and bowel continence, and Functional Independence Measure (FIM) scores.

RESULTS

Men were younger than women, but the difference was not statistically significant (median 64 years vs 72.5 years, P= 0.2). There was no statistically significant relationship between age or gender and the following: American Spinal Injury Association grade, level of injury, many SCI complications, mortality, LOS, walking ability, bladder management, and fecal continence. The only SCI complication that was related to age was pressure ulcers (<65 years = 20% vs >65 years = 50%, P = 0.04). Patients discharged home were more likely to be younger (P = 0.01) and male (P = 0.03). There was a significant negative correlation between patients' age and the discharge Rasch-transformed FIM motor (Spearman's p = -0.30, P = 0.015) and cognitive (Spearman's p = -0.25, P = 0.04) subscores. There were no significant relationships between gender and FIM subscale scores.

CONCLUSIONS

Gender and age do not significantly influence most aspects of rehabilitation in patients with nontraumatic SCI. Age alone should not be used as a discriminator of ability to benefit from nontraumatic SCI rehabilitation.

A pilot investigation of a psychosocial activity coursefor people with spinal cord injuries

This study investigated the general benefits and impact that sports activity courses organized by Back-Up, a charitable trust, have on quality of life, mood, self-efficacy and perceived manageability. Participants were 35 community-based individuals with spinal cord injuries (SCI). Questionnaires were completed at the start and end of the course. Fourteen participants also completed the follow-up questionnaire. Questionnaires included demographic questions, the Life Satisfaction Questionnaire, the Hospital Anxiety and Depression Scale, a measure of Perceived Manageability, the Generalised Self-Efficacy Scale and four questions about what participants had gained. Results found that participants' satisfaction with leisure, generalized self-efficacy and motivation to engage in activities was significantly increased between the start and end of the courses and anxiety significantly reduced. Such results were in line with participants' responses relating to overall gains from the course. At both the start and end of the course, higher Perceived Manageability scores correlated with greater self-efficacy and higher Perceived Manageability scores and self-efficacy were correlated with lower depression and anxiety. The study provides evidence of the benefits of sports participation and teamwork for people with SCI, confirming the results of previous research.

The clinical significance of spinal cord injuries in patients older than 60 years of age

OBJECTIVES

To study the causes and the rehabilitation outcome of traumatic spinal cord injury (SCI) in patients older than 60 years at the time of injury.

MATERIAL

Forty-four patients were included.

METHODS

The American Spinal Injury Association Motor Impairment Scale on admission and at discharge and the Functional Independence Measure Motor subscale at discharge were calculated retrospectively according to the patient records. The causes of injury and treatment were obtained. The MRI-scans in patients with cervical injuries during the last 5 years were evaluated.

RESULTS

Thirty-four patients (77%) were injured after falling from a height, 24 with cervical lesions. Thirty-five patients (80%) had incomplete lesions and they had the best outcome with regard to functional level. MR images of 15 patients with cervical lesions revealed preexisting cervical stenosis in 80%.

CONCLUSIONS

A high proportion of the patients had a cervical spinal stenosis and incomplete SCI; most of them regained good function.

Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

(1) Describe the self-care, productivity and leisure problems identified by individuals with a spinal cord injury (SCI) during rehabilitation, (2) describe the perceived level of satisfaction and performance with self-care, productivity and leisure activities following an SCI, (3) quantify the relationship between the Canadian occupational performance measure (COPM), a client-centred, individualized measure of function, and the functional independence measure (FIM).

SETTING

Tertiary rehabilitation centre, spinal cord injury unit, GF Strong Rehabilitation Centre, Vancouver, Canada.

METHODS

Health records from 41 individuals with an SCI admitted between 2000 and 2002 were reviewed. Information was obtained from assessments performed on admission and discharge. Self-care, productivity and leisure problems identified by individuals with an SCI were described and their perceived level of performance and satisfaction was calculated. The relationship between the COPM and the FIM was measured by the Pearson product correlation.

RESULTS

Self-care goals were identified most frequently (79%) followed by productivity (12%) and leisure (9%) goals. The top three problems identified by individuals with an SCI were functional mobility (including transfers and wheelchair use), dressing and grooming. A fair relationship was found between the COPM and the FIM (r between 0.351 and 0.514, P<0.05).

CONCLUSIONS

The results highlight the importance of including a client-centred outcome measure in the assessment of individuals with an SCI. Initial support is provided for use of the COPM in individuals with an SCI.

A psychometric analysis of the Needs Assessment Checklist (NAC)

DESIGN

Consecutive series, psychometric validation study.

OBJECTIVE

To evaluate the psychometric reliability and validity of a clinically focused measure of rehabilitation outcome, known as the Needs Assessment Checklist (NAC).

SETTING

Tertiary care, spinal cord injury centre (National Spinal Injuries Centre), Stoke Mandeville Hospital, UK.

PARTICIPANTS

In total, 43 spinal cord injured (SCI) in-patients (38 male and five female). During this study all patients actively participated in a comprehensive, multidisciplinary Goal Planning and Needs Assessment Rehabilitation Programme.

INTERVENTION

Test-retest and concurrent assessment, conducted in one administration, within a week of routine clinical assessment. Reliability analyses were performed examining the NAC's internal consistency, test-retest reliability, and concurrent validity.

MAIN OUTCOME MEASURES

The NAC is a rehabilitation outcome measure, specifically developed for the SCI population, which is used to assess patient attainment in core rehabilitation areas at mobilisation and prior to discharge. The Spinal Cord Independence Measure (SCIM) and Hospital Anxiety and Depression Scale (HADS) were also employed as comparable benchmark assessment measures with established psychometric properties. Patient comments were gained during this administration, rating the NAC with regard to its usefulness, clarity, and personal relevance.

RESULTS

Reliability analyses yielded high internal consistency coefficients (mean alpha = 0.8587, SD = 0.918). All subscales performed above the specified level (0.7). The mean item-internal validity correlation for NAC subscales was 0.5921 (SD = 0.1411). Test-retest correlations ranged between 0.694 (Bladder Management) and 0.904 (Skin Management) (P < or = 0.01). The mean percentage of agreement between clinical and test-retest assessment over all NAC subscales was 75.5% (SD = 5.01%). Concurrent validity analyses correlating individual subscale scores with SCIM and HADS subscales produced high correlations between 0.850 (Activities of Daily Living with SCIM Self-Care, P < or = 0.01) and -0.466 (Psychological Issues with HADS-Depression, P < or = 0.01). Significant differences were identified between injury category within NAC subscales; however, this was not consistent. The NAC achieved high patient ratings, attaining mean ratings of seven (out of 10) for usefulness, and eight for its clarity and personal relevance.

CONCLUSION

The findings of this study indicate that the NAC is a psychometrically reliable and valid clinical measure of rehabilitation outcome.

The effect of a specialist seating assessment clinic on the skin management of individuals with spinal cord injury

OBJECTIVE

To evaluate the specialist seating clinic's effectiveness in improving skin management knowledge and independence, represented by the Needs Assessment Checklist (NAC).

DESIGN

Longitudinal, between subjects design, with two intervention groups and one control.

SETTING

Tertiary care, spinal cord injury centre (National Spinal Injuries Centre), Stoke Mandeville Hospital, United Kingdom.

METHOD

This study assessed the skin management ability of three groups. Group 1 consisted of individuals who had attended a specialist seating assessment (SSA) clinic before their first needs assessment, group 2 had attended SSA between their first and second needs assessment, and group 3 (control) had not attended at all. Patient skin management ability was assessed using the skin management subscale of the NAC, a measure of rehabilitation outcome, at two time points.

RESULTS

Significant differences were identified between group 3 and group 1 at both the first (t = 2.36, degrees of freedom (df) = 37, p < 0.05) and second (t = 2.84, df = 37, p < 0.01) needs assessment. Significant improvements were also observed within each group between the first and second needs assessment time points in all seating assessment categories.

CONCLUSION

Skin management achievement scores were significantly higher for patients who had attended a SSA clinic before their first NAC (group 1) at both time points, supporting the use of SSA as a proactive intervention to improve patient independence, knowledge and awareness, and potentially reduce pressure ulcer incidence.