Relation Between Inpatient and Postdischarge Services and Outcomes 1 Year Postinjury in People With Traumatic Spinal Cord Injury

doi:10.1016/j.apmr.2013.01.012

Archives of Physical Medicine and Rehabilitation

Volume 94, Issue 4, Supplement, April 2013, Pages S165-S174

A portion of this work has been presented previously (Whiteneck et al. Arch Phys Med Rehabil 2011;92:361-8).

https://doi.org/10.1016/j.apmr.2013.01.012 Get rights and content

Abstract

Objective

To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI).

Design

Prospective, observational.

Setting

Six rehabilitation facilities.

Participants

Patients with SCI (N=1376).

Interventions

None.

Main Outcome Measures

Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI.

Results

Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied.

Conclusions

Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most effective use of therapy services after SCI.

Section snippets

Methods

Data were collected under the aegis of the 5-year, prospective, observational cohort, multicenter SCIRehab study. SCIRehab collected detailed information regarding patient characteristics, interventions, and services during inpatient rehabilitation and after discharge, as well as outcomes 1 year after SCI. Study details are reported elsewhere.10, 18

Participant and injury characteristics

The analysis sample consisted of 1032 individuals with traumatic SCI (see table 1). The validation dataset of 344 participants was essentially the same for all key participant characteristics. The majority of participants were men, white, had a high school diploma, were covered by private health plans, and were not obese (ie, body mass index <30). Only about one third were married. Nearly half were injured as a result of motor vehicle events. The average admission mFIM scores were low,

Discussion

Type and intensity of inpatient rehabilitation services have been reported to be associated with a variety of outcomes at 1 year postinjury.¹⁰ This analysis expands on these findings and demonstrates that some discipline-specific postdischarge services are associated with life satisfaction, participation, and function 1 year after SCI. In some cases, these associations are positive and in other cases negative. The direction of associations may indicate service benefits, patient need, or a

Conclusions

Rehabilitation services during and after inpatient rehabilitation are weakly associated with 1-year, postdischarge SCI outcomes, such as functional status, as well as distal outcomes, such as life satisfaction and societal participation. Although relatively few patients received postdischarge TR and VOC services, both appeared to have a positive relation to outcomes at 1 year postdischarge from SCI rehabilitation. Further, a high proportion of PT and OT services were received after inpatient

References (40)

G.G. Whiteneck et al.
Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study
Arch Phys Med Rehabil
(2011)
S.A. van Langeveld et al.
Feasibility of a classification system for physical therapy, occupational therapy, and sports therapy interventions for mobility and self-care in spinal cord injury rehabilitation
Arch Phys Med Rehabil
(2008)
G. Scivoletto et al.
Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study
Arch Phys Med Rehabil
(2005)
M. Sumida et al.
Early rehabilitation effect for traumatic spinal cord injury
Arch Phys Med Rehabil
(2001)
D.K. Ryser et al.
Measuring medical complexity during inpatient rehabilitation after traumatic brain injury
Arch Phys Med Rehabil
(2005)
E.J. Lenze et al.
The Pittsburgh Rehabilitation Participation Scale: reliability and validity of a clinician-rated measure of participation in acute rehabilitation
Arch Phys Med Rehabil
(2004)
S.C. Kogos et al.
Recent trends in spinal cord injury rehabilitation practices and outcomes
Top Spinal Cord Inj Rehabil
(2004)
R. Brougham et al.
SCIRehab: speech language pathology therapy treatment time during inpatient spinal cord injury rehabilitation
J Spinal Cord Med
(2011)
T. Foy et al.
The SCIRehab project: treatment time spent in SCI rehabilitation. Occupational therapy treatment time during inpatient spinal cord injury rehabilitation
J Spinal Cord Med
(2011)
J. Gassaway et al.
SCIRehab: therapeutic recreation treatment time during inpatient spinal cord injury rehabilitation
J Spinal Cord Med
(2011)

Cited by (16)

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy
2022, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
Over the past half century, inpatient rehabilitation for spinal cord injury (SCI) has been characterized by an increase in medical and rehabilitation sophistication coupled with a decrease in length of stay while aiming to maximize function, mobility, and independence.1,2 Outpatient services and wellness programs have helped to fill the gap in rehabilitation resulting from decreasing inpatient length of stay and the need to enhance function in the community.3,4 Whiteneck et al5,6 investigated outpatient rehabilitation characteristics using a practice-based evidence framework and reported that 44% of all rehabilitation services provided in the first year after SCI occur after inpatient discharge.
To characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy.
Observational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services.
Rehabilitation and community wellness facilities at 4 SCI Model Systems centers.
Eligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training.
Outpatient physical therapy or community wellness services for locomotor/gait training.
SCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference.
After controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group.
Locomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants’ preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.
Physical Function Recovery Trajectories After Spinal Cord Injury
2022, Archives of Physical Medicine and Rehabilitation
To explore trajectories of functional recovery that occur during the first 2 years after spinal cord injury (SCI).
Observational cohort study.
Eight SCI Model System sites.
A total of 479 adults with SCI completed 4 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 after baseline assessment (N=479).
None.
SCI-FI Basic Mobility/Capacity (C), Fine Motor Function/C, Self-care/C, and Wheelchair Mobility/Assistive Technology (AT) item banks.
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 6 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 6 months. Finally, for individuals with tetraplegia, trajectories of Fine Motor Function/C scores followed 2 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 regarding rates of recovery.
Trajectories of functional recovery followed a small number of change patterns, although variation around these patterns emerged. During the first 2 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 2 years and beyond.
Using individual growth curve models to predict recovery and activities of daily living after spinal cord injury: An SCIRehab project study
2013, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
While IGC models can accommodate time-varying characteristics, our models are not sufficiently sophisticated to examine such variations in treatment characteristics because of the lack of time points between admission and discharge and the lack of specificity of the variation of treatment hours by discipline across the intervention. Our results were consistent with associations reported in other SCIRehab studies for PT and OT total treatment hours and discharge motor FIM scores2 and with admission motor FIM scores and hours of OT therapeutic activities per week.5 Although our results appear contrary to the association between admission motor FIM scores and hours of PT transfer training per week,4 our models included PT hours per week for all activities, which may be distributed according to patient need and ability.
To evaluate change in functional outcomes over 1 year after spinal cord injury (SCI).
Observational longitudinal secondary analysis.
Six rehabilitation facilities participating in the SCIRehab project.
Patients (N=1146) with SCI enrolled from 2007 to 2010.
Not applicable.
FIM instrument 13-item and 11-item motor, 3-item transfer, 6-item self-care, 3-item self-care upper-extremity, and 3-item self-care lower-extremity subscores modeled as trajectories of change.
Patients were on average 37 years old, non-Hispanic white, with high school or higher education, a body mass index of 25, and a Comprehensive Severity Index score of 20. Most were men with paraplegia (37%) or high tetraplegia (27%). Median time frames were 22 days from injury to admission, 46 days from admission to discharge, 407 days from admission to follow-up, and 44 days for rehabilitation length of stay. The motor subscores were higher on admission for paraplegia and American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade D groups, and recovered faster for the AIS grade D group. Lower function at admission was associated with older age, higher Comprehensive Severity Index score, longer length of stay, fewer physical therapy and therapeutic recreation hours, and more occupational therapy hours. Slower recovery rates were associated with older age, more days from injury to admission, and fewer physical therapy hours per week.
Longitudinal outcomes modeled as individual trajectories of change are clinically meaningful. Individual growth curve models could facilitate recovery prediction and outcome evaluation at individual and group levels. However, assessment of the effects of treatment on outcome trajectories will require the addition of outcome measures at time points during intervention and may require the use of outcome measures specific to aspects of rehabilitation, such as mobility and self-care.
CER, PBE, SCIRehab, NIDRR, and other important abbreviations
2013, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
They report that white non-Hispanic patients who were admitted promptly after injury and received fewer PT hours per week have slower functional recovery rates. Backus et al21 note that rehabilitation services during and after inpatient rehabilitation are associated with life satisfaction, societal participation, and functional outcomes in the first year after SCI, but explain only a small part of the variance in these outcomes. They suggest that further study of the type and intensity of postdischarge services is needed to ascertain the most effective and economically sound use of therapy services after SCI.
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.
Environmental and systems experiences of persons with spinal cord injury and their caregivers when transitioning from acute care to community living during the COVID-19 pandemic: a comparative case study
2023, Spinal Cord Series and Cases
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
2023, Journal of Spinal Cord Medicine

View all citing articles on Scopus

: Supported in part by the National Institute on Disability and Rehabilitation Research, U.S. Department of Education (grant nos. H133A060103, H133N060005, H133N060009, H133N060028, and H133N060014).

: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

View full text

Original articleRelation Between Inpatient and Postdischarge Services and Outcomes 1 Year Postinjury in People With Traumatic Spinal Cord Injury

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Participant and injury characteristics

Discussion

Conclusions

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Recent trends in spinal cord injury rehabilitation practices and outcomes

Top Spinal Cord Inj Rehabil

SCIRehab: speech language pathology therapy treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

The SCIRehab project: treatment time spent in SCI rehabilitation. Occupational therapy treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

SCIRehab: therapeutic recreation treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

The SCIRehab project: social work and case management. Social work and case management treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

SCIRehab: psychology treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

SCIRehab: nursing bedside education and care management time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

The SCIRehab project: treatment time spent in SCI rehabilitation. Physical therapy treatment time during inpatient spinal cord injury rehabilitation

J Spinal Cord Med

The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation

J Spinal Cord Med

Trends in spinal cord injury demographics and treatment outcomes between 1973 and 1986

Arch Phys Med Rehabil

Enhancing community re-integration following spinal cord injury

NeuroRehabilitation

Vocational perspectives after spinal cord injury

Clin Rehabil

Participation following traumatic spinal cord injury: an evidence-based review for research: Report on the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures Meeting

J Spinal Cord Med

New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project

J Spinal Cord Med

Original article
Relation Between Inpatient and Postdischarge Services and Outcomes 1 Year Postinjury in People With Traumatic Spinal Cord Injury