Deborah Backus

United States (US) multi-center study to assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III)

Study design:Multi-center, prospective, cohort study.Objectives:To assess the validity and reliability of the Spinal Cord Independence Measure (SCIM III) in measuring functional ability in persons with spinal cord injury (SCI).Setting:Inpatient rehabilitation hospitals in the United States (US).Methods:Functional ability was measured with the SCIM III during the first week of admittance into inpatient acute rehabilitation and within one week of discharge from the same rehabilitation program. Motor and sensory neurologic impairment was measured with the American Spinal Injury Association Impairment Scale. The Functional Independence Measure (FIM), the default functional measure currently used in most US hospitals, was used as a comparison standard for the SCIM III. Statistical analyses were used to test the validity and reliability of the SCIM III.Results:Total agreement between raters was above 70% on most SCIM III tasks and all κ-coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.81 and intraclass correlation coefficients were above 0.81. Cronbach’s-α was above 0.7, with the exception of the respiration task. The coefficient of Pearson correlation between the FIM and SCIM III was 0.8 (P<0.001). For the respiration and sphincter management subscale, the SCIM III was more responsive to change, than the FIM (P<0.0001).Conclusion:Overall, the SCIM III is a reliable and valid measure of functional change in SCI. However, improved scoring instructions and a few modifications to the scoring categories may reduce variability between raters and enhance clinical utility.

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.

Inpatient treatment time across disciplines in spinal cord injury rehabilitation

Abstract Background/objective Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs. Methods Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patients stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline. Results Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patients stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics. Conclusions Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.

Physical therapy treatment time during inpatient spinal cord injury rehabilitation

Abstract Background/objective To describe the nature and distribution of activities during physical therapy (PT) delivered in inpatient spinal cord injury (SCI) rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities. Methods Six hundred patients from six inpatient SCI centers were enrolled in the SCIRehab study. Physical therapists documented details, including time spent, of treatment provided during 37 306 PT sessions that occurred during inpatient SCI rehabilitation. Ordinary least squares regression models associated patient and injury characteristics with time spent in specific PT activities. Results SCIRehab patients received a mean total of 55.3 hours of PT over the course of their rehabilitation stay. Significant differences among four neurologic groups were seen in the amount of time spent on most activities, including the most common PT activities of strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training. Most PT work (77%) was provided in individual therapy sessions; the remaining 23% was done in group settings. Patient and injury characteristics explained only some of the variations seen in time spent on wheelchair mobility, transfer and bed mobility training, and range of motion/stretching. Conclusion Analysis yielded both expected and unexpected trends in SCI rehabilitation. Significant variation was seen in time spent on PT activities within and among injury groups. Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings. Details about services provided, including time spent, will serve as a starting point in detailing the optimal treatment delivery for maximal outcomes.Background: Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams. Objective: To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI. Methods: Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models. Results: Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent. Conclusions: Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.

SCIRehab Project Series: The Physical Therapy Taxonomy

Abstract Background/Objective: Outcomes research is in need of a classification system of physical therapy (PT) interventions for acute traumatic spinal cord injury (SCI) rehabilitation in the United States. The objective of this study was to describe a taxonomy (system to categorize and classify interventions) to examine the effects of PT interventions on rehabilitation outcomes. Methods: The SCIRehab study uses the rigorous observational practice-based evidence methodology to examine current treatment processes without changing existing practice. PT clinicians and researchers from 6 centers developed a taxonomy to describe details of each PT session. Results: The PT taxonomy consists of 19 treatment activities (eg, bed mobility, transfers, wheelchair mobility, strengthening and stretching exercises) and supplementary information to describe the associated therapeutic interventions. Details that focus on patient assistance needs and family involvement are included as additional descriptors to help to describe and justify PT activity selection. Time spent on each activity is used as the measure of intensity. Conclusion: The detailed PT taxonomy documentation process, which offers efficiency in data collection, is being used for all PT sessions with 1,500 patients with acute traumatic SCI at the 6 participating centers. It might be the first attempt to document the many details of the PT rehabilitation process for patients with SCI in the United States.

SCIRehab Project Series: The Occupational Therapy Taxonomy

Abstract Background/Objective: Lack of a classification system for occupational therapy (OT) rehabilitation interventions for traumatic spinal cord injury (SCI) rehabilitation in the United States makes conducting outcomes research difficult. This article describes an OT SCI rehabilitation taxonomy (system to categorize and classify treatments). Methods: OT clinicians and researchers from 6 SCI rehabilitation centers developed a taxonomy to describe details of each OT session. This effort is part of the SCIRehab study, which uses the practice-based evidence, observational research methodology to examine current treatment processes without changing existing practice. Results: The OT taxonomy consists of 26 OT activities (eg, training on activities of daily living, communication, home management skills, wheelchair mobility, bed mobility, transfers, balance, strength-ening, stretching, equipment evaluation, and community reintegration). Time spent on each activity is documented along with therapeutic interventions used to facilitate the activity. Treatment descriptions are enhanced further with identification of assistance needs, patient direction of care, and family involvement, which help to describe and guide OT activity selection. The OT taxonomy documentation process includes all OT rehabilitation interventions for patients with SCI while maintaining efficiency in data collection. Conclusion: The electronic documentation system is being used at 6 centers for all OT sessions with 1,500 patients with acute traumatic SCI. It is the largest known attempt to document details of the comprehensive OT rehabilitation process for patients with SCI in the United States.

Misdirection of Regenerating Axons and Functional Recovery Following Sciatic Nerve Injury in Rats

Poor functional recovery found after peripheral nerve injury has been attributed to the misdirection of regenerating axons to reinnervate functionally inappropriate muscles. We applied brief electrical stimulation (ES) to the common fibular (CF) but not the tibial (Tib) nerve just prior to transection and repair of the entire rat sciatic nerve, to attempt to influence the misdirection of its regenerating axons. The specificity with which regenerating axons reinnervated appropriate targets was evaluated physiologically using compound muscle action potentials (M responses) evoked from stimulation of the two nerve branches above the injury site. Functional recovery was assayed using the timing of electromyography (EMG) activity recorded from the tibialis anterior (TA) and soleus (Sol) muscles during treadmill locomotion and kinematic analysis of hindlimb locomotor movements. Selective ES of the CF nerve resulted in restored M‐responses at earlier times than in unstimulated controls in both TA and Sol muscles. Stimulated CF axons reinnervated inappropriate targets to a greater extent than unstimulated Tib axons. During locomotion, functional antagonist muscles, TA and Sol, were coactivated both in stimulated rats and in unstimulated but injured rats. Hindlimb kinematics in stimulated rats were comparable to untreated rats, but significantly different from intact controls. Selective ES promotes enhanced axon regeneration but does so with decreased fidelity of muscle reinnervation. Functional recovery is neither improved nor degraded, suggesting that compensatory changes in the outputs of the spinal circuits driving locomotion may occur irrespective of the extent of misdirection of regenerating axons in the periphery. J. Comp. Neurol. 519:21‐33, 2011.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Abstract Background/objective Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury. Methods Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia. Results PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of “walk” or “both (walk and wheelchair)” on the discharge motor FIM for patients with AIS D injuries. Conclusion Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note This is the second of nine articles in the SCIRehab series.

Target-, limb-, and context-dependent neural activity in the cingulate and supplementary motor areas of the monkey

Very little is known about the role of the cingulate motor area (CMA) in visually guided reaching compared to other cortical motor areas. To investigate the hierarchical role of the caudal CMA (CMAc) during reaching we recorded the activity of neurons in CMAc in comparison to the supplementary motor area proper (SMA) while a monkey performed an instructed delay task that required it to position a cursor over visual targets on a computer screen using two-dimensional (2D) joystick movements. The direction of the monkey’s arm movement was dissociated from the direction of the visual target by periodically reversing the relationship between the direction of movement of the joystick and that of the cursor. Neurons that responded maximally with a particular limb movement direction regardless of target location were classified as limb-dependent, whereas neurons that responded maximally to a particular target direction regardless of the direction of limb movement were classified as target-dependent. Neurons whose activity was directional in one of the two visuomotor mapping conditions and non-directional or inactive in the other were categorized as context-dependent. Limb-dependent activity was observed more frequently than target-dependent activity in both CMAc and SMA proper during both the delay period (preparatory activity; CMAc, 17%; SMA, 31%) and during movement execution (CMAc, 49%, SMA, 48%). A modest percentage of neurons with preparatory activity were target-dependent in both CMAc (11%) and SMA proper (8%) and a similar percentage of neurons in both areas demonstrated target-dependent, movement activity (CMAc, 8%; SMA, 10%). The surprising finding was that a very large percentage of neurons in both areas displayed context-dependent activity either during the preparatory (CMAc, 72%; SMA, 61%) or movement (CMAc, 43%, SMA 42%) epochs of the task. These results show that neural activity in both CMAc and SMA can directly represent movement direction in either limb-centered or target-centered coordinates. The presence of target-dependent activity in CMAc, as well as SMA, suggests that both are involved in the transformation of visual target information into appropriate motor commands. Target-dependent activity has been found in the putamen, SMA, CMAc, dorsal and ventral premotor cortex, as well as primary motor cortex. This indicates that the visuomotor transformations required for visually guided reaching are carried out by a distributed network of interconnected motor areas. The large proportion of neurons with context-dependent activity suggests, however, that while both CMAc and SMA may play a role in the visuomotor transformation of target information into movement parameters, their activity is not solely coding parameters of movement, since their involvement in this process is highly condition-dependent.

Inpatient and Postdischarge Rehabilitation Services Provided in the First Year After Spinal Cord Injury: Findings From the SCIRehab Study

OBJECTIVE To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI). DESIGN Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview. SETTING Inpatient and postdischarge rehabilitation programs. PARTICIPANTS Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews. RESULTS Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services. CONCLUSIONS SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes.