Jeanne M. Zanca

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.

A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions.

OBJECTIVES: To determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home population.

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.

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.

Development of a theory-driven rehabilitation treatment taxonomy: conceptual issues.

Many rehabilitation treatment interventions, unlike pharmacologic treatments, are not operationally defined, and the labels given to such treatments do not specify the active ingredients that produce the intended treatment effects. This, in turn, limits the ability to study and disseminate treatments, to communicate about them clearly, or to train new clinicians to administer them appropriately. We sought to begin the development of a system of classification of rehabilitation treatments and services that is based on their active ingredients. To do this, we reviewed a range of published descriptions of rehabilitation treatments and treatments that were familiar to the authors from their clinical and research experience. These treatment examples were used to develop preliminary rules for defining discrete treatments, identifying the area of function they directly treat, and identifying their active ingredients. These preliminary rules were then tested against additional treatment examples, and problems in their application were used to revise the rules in an iterative fashion. The following concepts, which emerged from this process, are defined and discussed in relation with the development of a rehabilitation treatment taxonomy: rehabilitation treatment taxonomy; treatment and enablement theory; recipient (of treatment); essential, active, and inactive ingredients; mechanism of action; targets and aims of treatment; session; progression; dosing parameters; and social and physical environment. It is hoped that articulation of the conceptual issues encountered during this project will be useful to others attempting to promote theory-based discussion of rehabilitation effects and that multidisciplinary discussion and research will further refine these rules and definitions to advance rehabilitation treatment classification.

Toward a theory-driven classification of rehabilitation treatments.

Rehabilitation is in need of an organized system or taxonomy for classifying treatments to aid in research, practice, training, and interdisciplinary communication. In this article, we describe a work-in-progress effort to create a rehabilitation treatment taxonomy (RTT) for classifying rehabilitation interventions by the underlying treatment theories that explain their effects. In the RTT, treatments are grouped together according to their targets, or measurable aspects of functioning they are intended to change; ingredients, or measurable clinician decisions and behaviors responsible for effecting changes; and the hypothesized mechanisms of action by which ingredients are transformed into changes in the target. Four treatment groupings are proposed: structural tissue properties, organ functions, skilled performances, and cognitive/affective representations, which are similar in the types of targets addressed, ingredients used, and mechanisms of action that account for change. The typical ingredients and examples of clinical treatments associated with each of these groupings are explored, and the challenges of further subdivision are discussed. Although a Linnaean hierarchical tree structure was envisioned at the outset of work on the RTT, further development may necessitate a model with less rigid boundaries between classification groups, and/or a matrix-like structure for organizing active ingredients along selected continua, to allow for both qualitative and quantitative variations of importance to treatment effects.

Spinal cord injury-functional index: item banks to measure physical functioning in individuals with spinal cord injury.

OBJECTIVES To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning. DESIGN Cross-sectional. SETTING Inpatient and community. PARTICIPANTS Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury. INTERVENTIONS None. MAIN OUTCOME MEASURE Spinal Cord Injury-Functional Index (SCI-FI) measurement system. RESULTS Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models. CONCLUSIONS Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning.

Development and initial evaluation of the spinal cord injury-functional index.

OBJECTIVES To describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain. DESIGN Cross-sectional survey followed by calibration data simulations. SETTING Inpatient and community settings. PARTICIPANTS A sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury. INTERVENTIONS None. MAIN OUTCOME MEASURE SCI-FI instrument. RESULTS Item response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks. CONCLUSIONS Initial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI.

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.

Pressure ulcer research funding in America: creation and analysis of an on-line database.

OBJECTIVETo systematically collect information on active research grants to characterize pressure ulcer research funding in the United States and to identify potential targets for future research and funding initiatives. DESIGNA descriptive study MAIN RESULTSThe investigators identified 32 grants, representing