Sander L. Hitzig

The Spinal Cord Independence Measure (SCIM) version III: Reliability and validity in a multi-center international study

Purpose. To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. Method. Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. Results. Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P < 0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbachs α was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P < 0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. Conclusions. The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

A multicenter international study on the spinal cord independence measure, version III: Rasch psychometric validation

Background:A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version.Objective:To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis.Design:Multicenter cohort study.Setting:Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East.Subjects:425 patients with spinal cord lesions (SCL).Interventions:SCIM III assessments by professional staff members. Rasch analysis of admission scores.Main outcome measures:SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries.Results:Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79–1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found.Conclusions:The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Secondary Health Complications in an Aging Canadian Spinal Cord Injury Sample

Hitzig SL, Tonack M, Campbell KA, McGillivray CF, Boschen KA, Richards K, Craven BC: Secondary health complications in an aging Canadian spinal cord injury sample. Am J Phys Med Rehabil 2008;87:545–555. Objectives:This study describes self-reported incidence of secondary health complications (SHCs) and their associations with age, years postinjury (YPI), and impairment among a Canadian spinal cord-injured (SCI) cohort. Design:Cross-sectional telephone survey methods were used to collect data on (1) sociodemographics, (2) impairment, (3) health status, and (4) self-reported SHCs on 781 adults ≥1 yr post-SCI living in Ontario, Canada. Results:Logistic regression analyses were used to determine associations between self-reported incidences of SHCs with the following covariates: (1) age, (2) YPI, and (3) impairment. The odds ratios for cardiac complications, high blood pressure (HBP), and respiratory complications increased per year with age, whereas autonomic dysreflexia (AD), bladder infections, heterotopic ossification, psychological distress, and drug addiction decreased. The odds ratios for pressure ulcers, AD, and heterotopic ossification increased per YPI, whereas HBP, bowel problems, psychological distress, and depression decreased. Complete injuries were associated with bladder infections, pressure ulcers, and AD. Paraplegia was associated with HBP and bowel problems, and tetraplegia was associated with AD. Conclusions:The findings provide some clarification on factors associated with the occurrence of SHCs after SCI and are useful for informing health-promotion planners, clinicians, and stakeholders regarding the odds of SHCs with aging or among specific impairment groups.

Influence of Sport Participation on Community Integration and Quality of Life: A Comparison Between Sport Participants and Non-Sport Participants With Spinal Cord Injury

Abstract Background/Objective: To determine whether community integration and/or quality of life (QoL) among people living with chronic spinal cord injury (SCI) are superior among sport participants vs non-sport participants. Study Design: Cross-sectional study. Participants/Methods: Persons (n = 90) living in the community with SCI (ASIA Impairment Scale A-D), level C5 or below, > 15 years of age, ≥ 12 months postinjury, and requiring a wheelchair for > 1 hours/day were divided into 2 groups based on their self-reported sport participation at interview: sport participants (n = 45) and non-sport participants (n = 45). Results: Independent-sample t tests revealed that both Community Integration Questionnaire (CIQ) and Reintegration to Normal Living Index (RNL) total mean scores were higher among sport participants vs nonsport participants (P < 0.05). Significant correlation between CIQ and RNL total scores was found for all participants (Pearson correlation coefficients, P < 0.01). Logistic regression analysis revealed that the unadjusted odds ratio of a high CIQ mean score was 4.75 (95% Cl 1.7, 13.5) among current sport participants. Similarly, the unadjusted odds ratio of a high RNL score was 7.00 (95% Cl 2.3, 21.0) among current sport participants. Regression-adjusted odds ratios of high CIQ and high RNL scores were 1.36 (95% Cl 0.09, 1.45) and 0.15 (95% Cl 0.04, 0.55), respectively. The odds ratio for pre-SCI sport participation predicting post-SCI sport participation was 3.06 (95% Cl 1.23, 7.65). Conclusions: CIQ and QoL scores were higher among sport participants compared to non-sport participants. There was an association between mean CIQ and RNL scores for both groups. Sport participants were 4.75 and 7.00 times as likely to have high CIQ and QoL scores. Both groups had a similar likelihood of high CIQ and RNL scores after adjusting for important confounders. Individuals who participated in sports prior to SCI were more likely to participate in sports post-SCI.

Predicting life satisfaction after spinal cord injury in a Canadian sample

Study design:Cross-sectional, survey.Objectives:To extend current theoretical models predicting life satisfaction post-spinal cord injury (SCI). Our primary model predicting life satisfaction as measured by the Satisfaction with Life Scale (SWLS) examined demographic characteristics, elements of the International Classification of Functioning and subjective and objective measures of health. A second model was developed to examine factors that are associated with successful community participation as measured by the Reintegration to Normal Living Index (RNL). In addition, the effects of psychological distress and chronic pain on life satisfaction and community participation were examined.Setting:Toronto Rehabilitation Institute, Spinal Cord Rehabilitation Program, Lyndhurst Centre.Methods:Prospective data collection via semi-structured telephone interview on an established SCI Canadian sample.Results:In predicting life satisfaction, our model accounted for 35.3% of the variance with demographic characteristics, objective and subjective health, and community participation significantly contributing to the model. In particular, psychological complications, current health rating and community participation were the only variables that made significant contributions in predicting life satisfaction. With regards to community participation, the presence of psychological complications and number of medical complications were associated with decreased reintegration. Increased time since injury onset, higher health ratings and being employed were positively related to RNL.Conclusion:It would appear that factors involving functional decline and aging are associated with lower participation but not life satisfaction. Further, models predicting quality of life should incorporate measures of psychological functioning.Sponsorship:Toronto Rehabilitation Institute

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions

Study design:A multi-center international cohort study.Objective:To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs).Setting:A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East.Methods:SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity.Results:In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearsons coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ⩾0.95. Cronbachs α values for the entire SCIM III scale were 0.833–0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02).Conclusion:The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Traumatic Brain Injury in Patients With Traumatic Spinal Cord Injury: Clinical and Economic Consequences

OBJECTIVE To evaluate the clinical and economic burden of traumatic brain injury (TBI) in people with traumatic spinal cord injury (SCI). DESIGN Prospective, case-matched control study. SETTING Inpatient spinal cord rehabilitation program. PARTICIPANTS Patients (n=10) diagnosed with traumatic SCI and concomitant TBI matched to an SCI only control group. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Inpatient rehabilitation length of stay, health care costs (patient care hours), clinician resource allocation, behavioral and critical incidents, FIM, Personality Assessment Inventory, and neuropsychological assessment findings. RESULTS Prolonged loss of consciousness, increased rehabilitation costs, and greater demands on clinician recourses (trend) were found in the SCI with TBI group relative to the SCI-only group. Neuropsychological test performance was significantly worse in the SCI with TBI group, while the FIM cognition score did not discriminate because of ceiling effects. Greater evidence of psychopathology was observed in the SCI with TBI group. CONCLUSIONS The presence of TBI in SCI has a range of clinical and economic consequences. This dual diagnosis has the potential to affect SCI rehabilitation negatively, as well as quality of life and reintegration in the community. Specialized care appears to be needed to improve outcomes and to minimize clinical and economic burden, but further research is required.

Understanding age effects associated with changes in secondary health conditions in a Canadian spinal cord injury cohort

Study design:Longitudinal cohort.Objectives:To determine whether changes in secondary health conditions (SHC) associated with spinal cord injury (SCI) were effectively modeled from a longitudinal or cross-sectional perspective, and whether the changes in SHCs were attributable to age or years post-injury (YPI).Setting:Toronto Rehabilitation Institute, Lyndhurst Centre.Methods:Telephone survey methods were used to collect data on (1) demographics, (2) impairment, (3) health status, and (4) self-reported SHCs at two time intervals (1995–1997; 2003–2004) from 344 adults with SCI. Generalized estimating equations were applied to model the longitudinal and cross-sectional effects.Results:Health status decreased over time (P<0.0005), whereas the number of SHCs increased (P<0.0001). Regardless of age or YPI, the longitudinal component of aging better predicted SHC occurrence and was associated with spasticity [odds ratio, OR=1.055 (95% confidence interval, CI, 1.018 to 1.093, P<0.01)], kidney problems [OR=1.154 (95% CI, 1.084 to 1.229, P<0.0001)], cardiac problems [OR=1.168 (95% CI, 1.060 to 1.286, P<0.01)], high blood pressure [OR=1.121 (95% CI, 1.058 to 1.188, P<0.0001)], chronic pain [OR=1.058 (95% CI, 1.021 to 1.096, P<0.01)], and arthritis/joint pain [OR=1.113 (95% CI, 1.075 to 1.152, P<0.0001)].Conclusion:Within a relatively short period of time, persons with SCI experienced substantive declines in health. The findings suggest that a longitudinal perspective is more sensitive for predicting the risk of self-reported SHCs than a cross-sectional one.

A randomized trial of functional electrical stimulation for walking in incomplete spinal cord injury: Effects on body composition

Abstract Objective To evaluate the effects of functional electrical stimulation (FES)-assisted walking on body composition, compared to a non-FES exercise program in individuals with a spinal cord injury (SCI). Design Parallel-group randomized controlled trial. Methods Individuals with chronic (≥18 months) incomplete SCI (level C2 to T12, AIS C or D) were recruited and randomized to FES-assisted walking (intervention), or aerobic and resistance training (control) sessions thrice-weekly for 16 weeks. Whole body and leg lean mass and whole body fat mass, measured with dual-energy X-ray absorptiometry, and lower-limb muscle cross-sectional area (CSA) and fat CSA, measured with peripheral computed tomography were assessed at baseline, 4 months, and 12 months. Intention-to-treat analyses using repeated measures general linear models were used to assess between-group differences. Results Thirty-four individuals were randomized (17 per group); 27 remained at 12 months. There were no significant main effects of FES-assisted walking on body composition variables in intention-to-treat analyses with group means. There was a significant group-by-time interaction for muscle area from baseline to 12 months (P = 0.04). Intention-to-treat analysis of muscle area change scores between baseline and 12 months revealed a significant difference between groups (mean (SD) muscle area change score 212 (517) mms for FES, −136 (268) mms for control, P = 0.026). There were 13 side effects or adverse events deemed related to study participation (7 intervention, 5 control); most were resolved with modifications to the protocol. One fainting episode resulted in a hospital visit and study withdrawal. Conclusions Thrice-weekly FES-assisted walking exercise over 4 months did not result in a change in body composition in individuals with chronic, motor incomplete C2 to T12 SCI (AIS classification C and D). However, longer-term follow-up revealed that it might maintain muscle area.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

Study design:Multicenter international cohort study.Objective:The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels.Setting:In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken.Methods:Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation.Results:Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001).Conclusions:Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.