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Janice Eng, PhD, Robert Teasell, MD, William Miller, PhD, Dalton Wolfe, PhD,

Andrea Townson, MD, Jo-Anne Aubut, BA, Caroline Abramson, MA,


Jane Hsieh, MSc, Sandra Connolly, BHScOT, and the SCIRE Research Team
Editors:

Janice J. Eng, PhD, BSc (PT/OT), Robert Teasell, MD, FRCPC,


William C. Miller, PhD, OT, Dalton Wolfe, PhD,
Andrea F. Townson, MD, FRCPC, Jo-Anne Aubut, BA,
Caroline Abramson, MA, Jane Hsieh, MSc,
Sandra Connolly, BHScOT(C), OTReg. (Ont.)

This review has been prepared based on the scientific and professional
information available in 2005. The SCIRE information (print, CD or web site
www.icord.org/scire) is provided for informational and educational purposes only.
Please feel free to use this information, as seen fit, without alteration. If you have
or suspect you have a health problem, you should consult your health care
provider. The SCIRE editors, contributors and supporting partners shall not be
liable for any damages, claims, liabilities, costs or obligations arising from the use
or misuse of this material.
Table of Contents

Start End
Page Page

Forward ....................................................................................................................i i

Acknowledgements ................................................................................................ii ii

Executive Summary ................................................................................................iii viii

Editors ......................................................................................................................ix ix

Contributors ............................................................................................................x xi

Chapter 1 Rehabilitation: From Bedside to Community Following


Spinal Cord Injury (SCI) .................................................................... 1-1 1-11

Chapter 2 Methods of the Systematic Reviews ................................................ 2-1 2-11

Chapter 3 Rehabilitation Practice and Associated Outcomes Following


Spinal Cord Injury ............................................................................. 3-1 3-44

Chapter 4 Community Reintegration Following Spinal Cord Injury .................... 4-1 4-37

Chapter 5 Upper Limb Rehabilitation Following Spinal Cord Injury ................... 5-1 5-58

Chapter 6 Lower Limb Rehabilitation Following Spinal Cord Injury ................... 6-1 6-34

Chapter 7 Cardiovascular Health and Exercise Following Spinal Cord Injury.... 7-1 7-28

Chapter 8 Respiratory Management Following Spinal Cord Injury .................... 8-1 8-30

Chapter 9 Bone Health Following Spinal Cord Injury ......................................... 9-1 9-18

Chapter 10 Depression Following Spinal Cord Injury .......................................... 10-1 10-19

Chapter 11 Sexual Health Following Spinal Cord Injury ...................................... 11-1 11-40

Chapter 12 Neurogenic Bowel Following Spinal Cord Injury ............................... 12-1 12-17

Chapter 13 Bladder Health and Function Following Spinal Cord Injury .............. 13-1 13-77

Chapter 14 Pain Following Spinal Cord Injury .................................................... 14-1 14-32

Chapter 15 Venous Thromboembolism Following Spinal Cord Injury ................. 15-1 15-25

Chapter 16 Orthostatic Hypotension Following Spinal Cord Injury ...................... 16-1 16-17
Table of Contents (Cont.)
Start End
Page Page

Chapter 17 Autonomic Dysreflexia Following Spinal Cord Injury ......................... 17-1 17-27

Chapter 18 Heterotopic Ossification Following Spinal Cord ................................ 18-1 18-8

Chapter 19 Nutrition Issues Following Spinal Cord Injury .................................... 19-1 19-13

Chapter 20 Pressure Ulcers Following Spinal Cord Injury ................................... 20-1 20-26

Chapter 21 Spasticity Following Spinal Cord Injury ............................................. 21-1 21-56

Chapter 22 Outcome Measures .......................................................................... 22- 1 22-89

Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S, editors.
Spinal Cord Injury Rehabilitation Evidence. 2006: Vancouver.

www.icord.org/scire
FORWARD

Over the past few years, the volume of publications encompassing a broad definition of
rehabilitation after spinal cord injury (SCI) has expanded exponentially. As in all rapidly
expanding research fields, it is helpful, from time to time, to review what has been published and
assess the quality of the data and conclusions of these reports. Thus was born the SCIRE
project.

This manual represents the first comprehensive synthesis of the published evidence on
rehabilitation strategies and community-based programs designed to improve the functional
outcomes and quality of life for people living with a SCI. It is primarily intended as a guide for
professionals in the areas of SCI health care and community care. It should also prove useful to
SCI researchers, public policy makers, and people with SCI and their families. The goal is to
provide everyone with the necessary objective information to make better-informed decisions as
to the strength and validity of current rehabilitation programs and emerging strategies, as well
as to identify gaps in our knowledge and possible research priorities.

A knowledge translation project as large as SCIRE requires clearly identified validation criteria
and the coordinated efforts of a large number of individuals. The more than 40 invited reviewers
from across Canada have long-standing expertise on the topics they reviewed. Drs. Janice
Eng, Robert Teasell and William Miller provided the vision, framework and critical leadership for
SCIRE and the ensuing team work between the Vancouver and London sites. Their tireless
efforts ensured the timely release of this first version. Version 1 is just the beginning of SCIRE
activities. In the years to come, we can anticipate revised versions of SCIRE, as new SCI
research evidence comes to light and future best practices in SCI rehabilitation are validated. In
addition, this compilation can form a basis for activities such as the development of clinical
practice guidelines and identification of disparities between current practice and best practice.

On behalf of ICORD, The Ontario Neurotrauma Foundation, and The Rick Hansen Foundation,
we offer thanks and congratulations to everyone who contributed to the successful launch of
SCIRE.

John D. Steeves
John and Penny Ryan BC Leadership Professor
Director of ICORD
Vancouver, Canada

September 2006

i
ACKNOWLEDGEMENTS

This large-scale project represents the collaborations and tremendous efforts of so many
dedicated people.

We would like to thank the funding agencies that provided financial support – the Rick Hansen
Man in Motion Foundation and the Ontario Neurotrauma Foundation.

The SCIRE Advisory Committee met regularly to provide feedback on the process and
translation methods for the SCIRE project and their input was invaluable.

The SCIRE Advisory Committee members:


Caroline Abramson, Research Coordinator, GF Strong Rehab Centre/University of BC
Jo-Anne Aubut, Research Coordinator (Parkwood, London)
Karen Anzai, Rehab Consultant, SCI Program, GF Strong Rehab Centre
Sandra Connolly, OT, Spinal Cord Program (Parkwood, London)
Armin Curt, MD, Research Chair, ICORD
Chris Fraser, Reg. Dietician, SCI & ABI Programs, SCI consumer (Parkwood, London)
Chris McBride, PhD, Managing Director, ICORD
Dave Metcalf, Vocational Counselor, SCI consumer (GF Strong Rehab Centre)
Kelly Moore, Educator, SCI Program, GF Strong Rehab Centre
Steve Orenczuk, PsyD, SCI program (Parkwood, London)
Andrea Townson, MD, FRCPC, GF Strong Rehab Centre, Co-PI, SCIRE Project
Dalton Wolfe, PhD, SCI (Parkwood, London)
Daryl Rock, Associate Director, Knowledge Exchange Canadian Council on Learning

In addition to the editors and contributors already recognized, several individuals made
significant contributions to assessing and extracting data from Vancouver: Jennifer Cumal,
Nicole Elfring, Marcia Fukunaga, Chihya Hung, Emily Procter, and Jeff Tan and from London:
Joan Conlon and Dr. Jeff Jutai.

We are grateful to the GF Strong Rehab Centre (Vancouver Coastal Health), Parkwood Hospital
(St. Joseph’s Health Care) and Lawson Health Research Institute which provided the space and
infrastructure support for undertaking the project.

We’d also like to recognize the support from ICORD, in particular, Cheryl Niamath for her
graphic designs and endless patience, Dave Pataky for his web and CD development and Dr.
John Steeves for his guidance.

Lastly, we’d like to express our gratitude to the many SCI rehabilitation scientists and clinicians
who spent endless hours putting the chapters together and made this project possible.

ii
EXECUTIVE SUMMARY

1. SCIRE Project overview

The Spinal Cord Injury Rehabilitation Evidence (SCIRE) is a synthesis of the research evidence
underlying rehabilitation interventions to improve the health of people living with SCI. SCIRE
covers a comprehensive set of topics relevant to SCI rehabilitation and community re-integration.
This project is intended to translate existing knowledge to health professionals to inform them of
best practice. This research synthesis will also enable relevant decision-making in public policy
and practice settings applicable to SCI rehabilitation. In addition, transparent evidence-based
reviews can guide the research community and funding organizations to strategically focus their
time and resources on the gaps in knowledge and identify research priorities. People with SCI
and their families may also find the information useful to understanding their health care.

The Spinal Cord Injury Rehabilitation Evidence developed from a research collaboration
between Vancouver and London (Ontario) and involved their respective health centres (GF
Strong Rehab Centre, St. Joseph’s Health Care), research institutions (International
Collaboration on Repair Discoveries, Lawson Health Research Institute) and universities
(University of BC, University of Western Ontario).

2. Methods

Systematic Review

An exhaustive search (keyword literature search, previous practice guidelines and systematic
reviews, review articles) was used to identify published literature evaluating the effectiveness of
any treatment or therapy related to SCI rehabilitation. Topics relevant to rehabilitation were
selected with input from scientists and clinicians in the field of SCI rehabilitation, in addition to
the SCIRE Advisory Committee (which included consumers with SCI and policy-makers).

This search involved the review of over 17,000 titles and 8400 abstracts, and a final extraction
and synthesis of almost 700 articles. A variety of study designs were included (from
randomized controlled trials to case reports), however, controlled trials were given priority in
generating conclusions. In order to provide transparent and unbiased evidence-based reviews,
the rigor and quality of each study was scored on standardized scales by two independent
reviewers (Physiotherapy Evidence Database Scale for randomized controlled trials and the
Downs and Black Tool for all other studies). Following this individual study assessment,
conclusions were drawn about the accumulated studies for each topic of interest (e.g., pressure
ulcers) using a modified version of Sackett’s description of levels of evidence. In this 5 point
scale, the strongest evidence, level 1, was assigned if the intervention was supported by at least
one randomized controlled trial, while a level 5 was assigned if no critical appraisal existed, but
perhaps was supported by clinical consensus. Conclusions were based on the levels, quality
and concurring evidence. When conflicting data was present, an explanation was provided as
to how the conclusions were derived.

Outcome measure assessment


Outcome measures used in spinal cord injury evaluation were identified by keyword search of
the major electronic databases and through hand searches of noted spinal cord journals. Only
measures with published studies of the psychometric (reliability and validity) properties within
the spinal cord population were identified for review. The measures were categorized into the

iii
domains of the World Health Organization’s International Classification of Functioning, Disability
and Health (body function/structure, activity and participation). A fourth category was created for
quality of life measures. Approximately 160 measures were identified of which 63 were selected
for review based on clinician interest. The measures were evaluated using elements of the
Health Technology Assessment to assess the psychometric properties, interpretability,
acceptability, and feasibility. Summary tables identifying the rigor and quality of the
psychometric properties were constructed. A clinical conclusion is offered based on the
synthesis of the review.

3. Findings from the Systematic Review of SCI Rehabilitation

Given that the SCIRE consists of over 800 pages of evidence, we cannot represent all the
findings here. What follows are selected findings which demonstrate the scope of the research
and the value of the results.

Rehabilitation Practice
Earlier admission to specialized, interdisciplinary SCI care is associated with reduced length of
total hospital stay and greater and faster rehabilitation gains with fewer medical secondary
complications (especially pressure sores).

Community Re-integration
The average level of quality of life after SCI is slightly lower than in people without disability but
a substantial number of people with SCI report good or excellent levels of quality of life. The
severity of injury and other diagnostic factors do not significantly impact quality of life. Their
influence may become significant through restrictions in community integration or social
participation.

Upper Limb Rehabilitation


Upper limb muscle strength is identified as an important contributor to functional independence.
Neuromuscular stimulation-assisted exercise (e.g., during arm ergometry) following a spinal
cord injury is effective in improving muscle strength, preventing injury and increasing
independence in all phases of rehabilitation. Practice of repetitive movements in conjunction
with low intensity peripheral nerve stimulation may induce beneficial brain cortical changes, in
addition to improved arm and hand function.

Lower Limb Rehabilitation


Body-weight supported treadmill exercise using a suspended harness is a relatively new
treatment of interest. For patients less than 6 months post-SCI, body weight supported treadmill
training has equivalent effects on gait outcomes to conventional rehabilitation consisting of
overground mobility practice. Body weight-support gait training strategies can improve gait
outcomes in chronic, incomplete SCI, but no single specific body weight-support strategy
(overground, treadmill, with functional electrical stimulation) is more effective.

Cardiovascular Health and Exercise


There appears to be an earlier onset and increased prevalence of cardiovascular disease in
individuals with SCI in comparison to the general population. Tetraplegics and paraplegics can
improve their cardiovascular fitness and physical work capacity through aerobic exercise
training (e.g., arm cycle or wheelchair ergometry), which are of moderate intensity, performed
20-60 min day, at least three times per week for a minimum of six to eight weeks.

iv
Respiratory Management
Respiratory complications continue to be one of the leading causes of morbidity and mortality in
people with spinal cord injury, especially among cervical and higher thoracic injuries. Unlike the
cardiovascular system, the lungs and airways do not change appreciably in response to
exercise training. For exercise training to improve respiratory function, the training intensity must
be relatively high (70-80% of maximum heart rate) performed three times per week for six
weeks.

Bone Health
There is a significant risk for lower extremity fragility fractures after SCI. Early assessment and
ongoing monitoring of bone health is an essential element of SCI care. There is strong evidence
from randomized controlled trials that support the use of medications for the prevention and
treatment of bone loss following SCI. Non-pharmacological treatments have not been found to
prevent bone loss in the first year, however, electrical stimulation can increase bone density
over the area stimulated in people with SCI more than 1 year post-injury.

Depression
Depression is a common consequence of SCI. Cognitive behavioural interventions provided in
a group setting appear helpful in reducing post-SCI depression. The benefits of drug treatment
(including selective serotonin reuptake inhibitors and tricyclic antidepressants) in combination
with psychotherapy may alleviate depression. However, pharmacological management for post-
SCI depression is largely extrapolated from studies in non-SCI populations. Programs to
encourage regular exercise, reduce stress, and improve or maintain health are beneficial in
reducing reports of depressive symptoms in persons with SCI.

Sexual Health
In men with SCI, erections are often not reliable or adequate for sexual intercourse since there
may be difficulties with maintenance of the erection. The pharmacological agent,
Phosphodiesterase Type 5 Inhibitors (PDE5i, Viagra®) can be used safely and effectively for
treatment of erectile dysfunction in men with SCI and are recommended as first line treatment
for erectile dysfunction after SCI.

Bowel Management
Multifaceted programs incorporating intereventions such as, nutrition, fluid consumption, routine
bowel evacuation, may improve movement of substances through the colon as well as decrease
the incidences of difficult bowel evacuations. Pharmacological agents such as cisapride,
prucalopride, and metoclopramide are effective for the treatment of chronic constipation in
persons with SCI.

Bladder Management
Disruption of the signals from the brain resulting from a SCI prevents normal voluntary voiding
without assistance. Intermittent catheterization and spontaneous triggered voiding are
associated with the lower complications compared to indwelling catheters. Intermittent
catheterization may be difficult to continue at home for those with tetraplegia and complete
injuries. Assistive devices may enhance compliance with intermittent catheterization for those
with impaired hand function.

Pain Management
Pain following a SCI is common, often severe and has a significant effect on quality of life. A
shoulder exercise protocol (consisting of shoulder stretching and strengthening) reduces the
intensity of shoulder pain post-SCI. Reduce pain may be achieved from massage, heat,

v
acupuncture or hypnosis. A number of pharmacological agents can provide pain relief,
including the anticonvulsant Gabapentin, Intrathecal Baclofen, and Lidocaine through a
subarachnoid lumbar catheter. Tricyclic antidepressants and Intrathecal Clonidine have not
been shown to reduce post-SCI pain.

Venous Thromboembolism
Venous thromboembolism (blood clot) is very common in untreated spinal cord-injured patients.
The pharmacological agent low molecular weight heparin is more effective than standard
heparin in reducing the risk of venous thromboembolism post-SCI with less bleeding
complications. Physical interventions such as pneumatic compression or pressure stockings
may have some additional benefits when used in combination with pharmacological agents.

Orthostatic Hypotension
Orthostatic hypotension is an excessive reduction in blood pressure with changes in body
position and can result in lightheadedness or dizziness. It is commonly experienced following
SCI due to the loss of muscle activation. Although a wide array of physical and pharmacological
measures are recommended for the general management of orthostatic hypotension, very few
have been evaluated for use in SCI. Of the pharmacological interventions, only midodrine was
found to be effective, while functional electrical stimulation is one of the only non-
pharmacological interventions which demonstrates some evidence to support its use.

Autonomic Dysreflexia
Autonomic dysreflexia is a potentially life-threatening acute elevation of blood pressure
commonly experienced post-SCI. The identification of the possible trigger and decrease of
sensory stimulation to the spinal cord is the most effective prevention strategy. Urinary bladder
irritation is one of the major triggers of autonomic dysreflexia following SCI. The
pharmacological agents, nifedipine or captopril are commonly used and can prevent or control
autonomic dysreflexia in SCI individuals.

Heterotopic Ossification
Heterotopic ossification, the formation of pathological bone in muscle or soft tissue, occurs
frequently in the first two months following SCI. Anti-inflammatory medications or warfarin (anti-
coagulant) can reduce the risk of heterotopic ossification post-SCI. Once ossification is
identified, the pharmacological agent, etidronate or radiation therapy can reduce the
progression of heterotopic ossification.

Nutrition
There is an increased risk for obesity, abnormal lipid metabolism, cardiovascular disease,
impaired glucose regulation and diabetes mellitus post-SCI. Standard dietary counseling (daily
total fat <30% of total daily calories, saturated fat <10% of total daily calories, cholesterol <300
mg, carbohydrates equal to 60% of total daily calories) can reduce total cholesterol. A holistic
wellness program can help people adopt healthy nutritional behaviours following a SCI. Vitamin
deficiency is common post-SCI, therefore individuals should be screened and if needed,
replacement therapy should be initiated.

Pressure Ulcers
Pressure ulcers are a serious, lifelong secondary complication of SCI. A number of prevention
strategies exist to reduce the risk of pressure ulcers and appropriate seating is one important
consideration. No one cushion is suitable for all individuals with SCI. Cushion selection should
be based on a combination of pressure mapping results, individual characteristics and
preference. Adding lumbar support to the wheelchairs of individuals with chronic SCI is unlikely

vi
to have a role in pressure ulcer prevention post-SCI. A forward leaning position or the
wheelchair tilted back position (> 65º) are effective methods of pressure relief.

Spasticity
Spasticity is the excessive involuntary motor activity of a muscle or muscle group reacting to
external stimuli. It is a major obstacle for community and workplace integration following SC.
Oral baclofen or intrathecal baclofen reduces muscle spasticity following SCI. A number of non-
pharmacological interventions (transcutanous electrical stimulation, massage, assisted standing,
ice) have short term effects on spasticity lasting several minutes to hours.

Outcome measures
Numerous outcome measures are available for use in SCI practice and research. Many SCI
specific measures are gaining acclaim such as the Spinal Cord Independence Measure which is
slowly replacing the Functional Independence Measure as the outcome of choice for assessing
personal activities of daily living. Several new generic measures of participation in higher order
social activities and life habits are available. These tools are conceptually well developed and
support for psychometric properties is accumulating.

4. Limitations in SCI Rehabilitation Literature

The task of compiling this vast amount of literature provided the SCIRE team a unique
opportunity to appraise the body of SCI rehabilitation literature as a whole. There is a
substantial amount of literature available in SCI rehabilitation as highlighted in the previous
section. However, the SCIRE team noted several gaps and recurring methodological issues
across different topics in SCI rehabilitation and highlight these limitations here.

Our topics were selected by clinicians, researchers and consumers with SCI and not necessarily
by the abundance of research papers in a particular area. Little or no information was available
in several areas. Despite the inherent value we place on integrating an individual in their
community, we do not know the best methods to facilitate successful re-entry into community
life and literature was either absent or based on observational studies for this topic. There was
also a dearth of literature concerning sexual and reproductive health of women with SCI that
would potentially guide selection of contraception, enhancement of sexual adjustment and
response or access to routine gynecological procedures. Women make up a significant
proportion of the SCI population (one-quarter to one-third) and were underrepresented across
all areas of SCI rehabilitation literature.

For many areas, we rely on information based primarily on other medical conditions. Although
guidelines exist for SCI related conditions such as depression, autonomic dysreflexia, and deep
vein thrombosis, many of the recommendations are based on other patient populations (not
SCI). SCI is a complex condition with effects and interactions on multiple systems and
responses that are not always predictable. For example, a simple dietary intervention such as
increased fibre, had a response in SCI (worsened constipation) which was opposite to what
would be expected in able-bodied individuals (reduced constipation).

The SCI rehabilitation literature suffers from several methodological shortcomings, including
small, heterogeneous samples, few controlled trials, and a lack of consensus as to common
outcome measures. Study samples consisted of people who had sustained different injuries:
paraplegia and tetraplegia, complete and incomplete injuries, and acute and chronic injuries.
This was prevalent throughout the current literature, despite the knowledge that physiological
responses from interventions are different in these subgroups. As a result, a heterogeneous

vii
sample can also wash out what might have been important effects for a subsample of the
population. For example, bone health interventions depend on the stage of injury; preventing
bone loss during the rapid bone mineral loss in the first 4-6 months compared with maintaining
or improving bone during the relative stabilization after 1-2 years after SCI. However, some of
the bone health studies included participants within a few months to several years post-injury
representing physiologically different phases.

Pharmacological interventions were supported by the largest proportion of randomized


controlled trials (level 1 evidence) while other rehabilitation interventions were primarily
supported by single group, pre-test/post-test studies (level 4 evidence). Without a comparable
control group, one cannot determine if improvements are attributed to the intervention or other
factors such as increased familiarity with the outcome measures, time post-injury or attention
from the clinician. Furthermore, randomizing the subjects into the treatment and control group
reduces the biases associated with patient selection. It was not surprising to see a number of
interventions where the weaker evidence demonstrated positive effects, but the more rigorous
controlled trials did not. For example, lower levels of study design (pre-test/post-test study or
non-randomized trial) suggested that body-weight support treadmill training in sub-acute SCI
resulted in better outcomes than conventional rehabilitation; however, stronger evidence from a
single-blinded RCT suggested that no differences between body weight support treadmill
training and conventional rehabilitation.

Rigorous randomized trials with homogeneous groups require a large available source of
patients. The number of new spinal cord injuries is relatively small compared to conditions like
arthritis or heart disease. There is no doubt that multi-site trials are required if we strive to
increase the certainty as to whether a treatment is effective or not in SCI rehabilitation.

There is a lack of standardization when selecting the outcome measures for an intervention.
For example, the chapter authors (Hsieh et al. 2006) noted that the spasticity interventions
included 66 different outcome measures. No single outcome measure can capture the multi-
dimensional nature of spasticity and its effects and studies should include effective outcome
measures that meet minimum standards and that encompass the range of health outcomes
relevant to the treatment and the patients. In addition, consensus on some common measures
would assist the interpretation of results across studies.

5. Conclusions

The SCIRE combined the efforts of expert scientists, clinicians, consumers and stakeholders to
increase the accessibility of quality information in SCI rehabilitation. A broad range of topics are
evaluated, and future editions will continue to update, improve and add new topics for people
seeking information relevant to SCI rehabilitation from bed side to community. The pre-
appraised, synthesized research from SCIRE can translate into improved health for Canadians
by keeping health care professionals, scientists, policy-makers and consumers with SCI
informed of the latest evidence.

viii
EDITORS

Janice J Eng, PhD, BSc (PT/OT), is Professor, School of Rehabilitation Sciences,


University of BC, GF Strong Rehab Centre and ICORD (Vancouver, Canada). Her
program in neurological rehabilitation spans mechanistic research, clinical trials to
knowledge translation. She is a Canadian Institutes of Health Research Scholar and
Michael Smith Scholar.

Robert Teasell, MD, FRCPC is Professor/Chair/Chief of the Department of Physical


Medicine and Rehabilitation at the University of Western Ontario and Parkwood Hospital
(SJHC). Dr. Teasell’s research interests are in evidence-based applications to clinical
rehabilitation practice with a specific interest in neurorehabilitation, and chronic pain,
particularly the role of personality in coping with pain.

William C Miller, PhD, OT, is Associate Professor, School of Rehabilitation Sciences,


University of BC and ICORD faculty. An epidemiologist by background, his expertise is
in the area of measurement and examination of mobility limitations and daily occupations
across diagnoses in older adults. He is a Canadian Institutes of Health Research
Scholar.

Dalton Wolfe, PhD is an Associate Scientist in the Program of Aging, Rehabilitation and
Geriatric Care in the Lawson Health Research Institute, London, ON, Canada. Dr. Wolfe
has a background in clinical neurophysiology and research methods. His current
research interests are in the areas of health promotion and FES-assisted exercise for
people with SCI.

Andrea F Townson, MD, FRCPC is Clinical Assistant Professor in the Division of


Physical Medicine and Rehabilitation, University of British Columbia and ICORD. She is
Medical Manager, SCI Rehab Program at GF Strong Rehab Centre. Research interests
include high lesion spinal cord injuries, ventilator dependency, fatigue and outcome
measures.

Jo-Anne Aubut, BA is a research assistant in the Department of Physical Medicine &


Rehabilitation located at Parkwood Hospital. She has worked on a variety of research
projects through the University of Western Ontario and the Lawson Health Research
Institute in London, ON.

Caroline Abramson, MA, is the Clinical Research Coordinator for the Division of
Physical Medicine and Rehabilitation. She works with physiatrists and residents on a
variety of research projects through the University of British Columbia and GF Strong
Rehab Centre.

Jane Hsieh, MSc, has over 15 years in clinical research in both the academic and
biotechnology industry settings. Previously as the senior director of Clinical Program at
AcordaTherapeutics, she oversaw a variety of phase 1, 2 & 3 studies mainly in SCI and
MS populations. Her current activities inlcude consultation to both academic and
industrial research groups.

Sandra Connolly, BHScOT(C), OTReg. (Ont.) is an occupational therapist in the Spinal


Cord Injury Rehabilitation Program at Parkwood Hospital, St. Joseph's Health Care
London.

ix
CONTRIBUTORS

Maureen Ashe, PhD, PT Chris Fraser, HBSc, RD


School of Rehabilitation Sciences Rehabilitation Program
University of BC Parkwood Hospital
Vancouver, BC London, ON

Najib Ayas, MD, MPH, FRCPC Tal Jarus, PhD, OT


Faculty of Medicine School of Rehabilitation Sciences
University of BC University of BC
Vancouver, BC Vancouver, BC

Jeff Blackmer, MD, FRCPC Lyn Jongbloed, PhD, OT(C)


Physical Medicine and Rehab School of Rehabilitation Sciences
University of Ottawa University of BC
Ottawa, ON Vancouver,BC

Sally Breen, RN, BSN, CRRN David Keast, MD, FRCPC


Sexual Health Outpatient Chronic Wound Management
GF Strong Rehab Centre Parkwood Hospital
Vancouver, BC London, ON

Geri Claxton, RN Andrei Krassioukov, MD, PhD


Outpatient Nursing Department of Medicine
GF Strong Rehab Centre University of BC, ICORD
Vancouver, BC Vancouver, BC

B. Cathy Craven, MD FRCPC Tania Lam, PhD, PT


Bone Density Lab School of Human Kinetics
Toronto Rehabilitation Institute University of BC, ICORD
Toronto, ON Vancouver, BC

Armin Curt, MD, FRCPC Kate McBride, RN


Faculty of Graduate Studies Sexual Health
University of BC, ICORD GF Strong Rehab Centre
Vancouver, BC Vancouver, BC

Stacy Elliot, MD William B Mortensen, BScOT, MSc


Department of Psychiatry School of Rehabilitation Sciences
University of BC, ICORD University of BC
Vancouver, BC Vancouver, BC

Susan J Forwell, PhD, OT(C) Stephanie Muir-Derbyshire, MSc, SLP(C),


School of Rehabilitation Sciences Reg CASLPA
University of BC, ICORD Parkwood Hospital
Vancouver, BC London, ON

x
Vanessa Noonan, BScPT, MSc A William Sheel, PhD
Dept of Orthopaedic Surgery School of Human Kinetics
University of BC University of BC, ICORD
Vancouver, BC Vancouver, BC

Luc Noreau, PhD Jim Slivinski, MA


Department of Rehabilitation Psychology Intern
Laval University Parkwood Hospital
Quebec City, QC London, ON

Steven Orenczuk, PsyD Shannon Sproule, PT


Rehabilitation Program GF Strong Rehab Centre
Parkwood Hospital Vancouver, BC
London, ON

Emily Procter, BSc John Steeves, PhD


GF Strong Rehab Centre John and Penny Ryan BC Leadership
Vancouver, BC Chair, ICORD, UBC/VCHRI
Vancouver, BC
MaryAnn Regan, RN, BScN Linh Tu, BHSc
Spinal Cord Injury Rehabilitation Program Physical Medicine and Rehabilitation
Parkwood Hospital Parkwood Hospital, SJHC
London, ON London, ON

W Darlene Reid, PhD, PT Darren Warburton, PhD


School of Rehabilitation Sciences School of Human Kinetics
University of BC University of BC, ICORD
Vancouver, BC Vancouver, BC

Candice Rideout, PhD (Candidate) Maura Whittaker, PT


Human Nutrition GF Strong Rehab Centre
University of BC Vancouver, BC
Vancouver, BC

Bonita Sawatzky, PhD Shannon Wilkinson, BScOT


Dept of Orthopaedic Surgery Spinal Cord Unit
University of BC GF Strong Rehab Centre
Vancouver, BC Vancouver, BC

Keith Sequeira, MD, FRCPC


Physical Medicine & Rehab
University of Western Ontario, Parkwood
Hospital, London, ON

xi
CHAPTER ONE

Rehabilitation: From Bedside To Community


Following Spinal Cord Injury (SCI)
Janice J Eng, PhD, BSc (PT/OT)
William C Miller, PhD, OT
Table of Contents

1.1 Background ......................................................................................................................1-1

1.2 Epidmiology .....................................................................................................................1-2


1.2.1 Traumatic SCI .................................................................................................................1-2
1.2.2 Non-traumatic SCI ..........................................................................................................1-3

1.3 Recovery...........................................................................................................................1-3
1.3.1 Neuroplasticity ................................................................................................................1-4
1.3.2 Measures of Recovery ....................................................................................................1-4

1.4 Rehabilitation ...................................................................................................................1-6

1.5 Community Re-integration..............................................................................................1-7

References................................................................................................................................1-9

This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising
from the use or misuse of this material.

Eng JJ, Miller WC (2006). Rehabilitation: From Bedside To Community Following Spinal Cord Injury. In: Eng JJ,
Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S, editors. Spinal Cord
Injury Rehabilitation Evidence. Vancouver, p 1.1-1.11.

www.icord.org/scire
Rehabilitation: From Bedside To Community
Following Spinal Cord Injury (SCI)

1.1 Background

The spinal cord extends from the foramen magnum (opening at the base of the skull) to the
conus medullaris (most distal bulbous part of the cord) at the level of the first and second
lumbar vertebrae. It consists of 31 segments associated with 31 pairs of spinal nerves (8
cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal). The ascending sensory nerves within
the spinal cord receive and transmit sensory information to the brain. The descending motor
nerves transmit information from the higher brain structures to various parts of the body to
initiate motor functions such as movement and to regulate autonomic functions such as
respiration and blood pressure. The spinal cord is also critical for transmitting and integrating
information within the spinal cord.

Figure 1.1

C2-3 Sternomastoid
Cervical C3-5 Diaphragm
C5 Elbow Flexors
C6 Wrist Extensors
C7 Elbow Extensors
C8 Long Fingers Flexors
T1 Small Finger Abductors

Thoracic T1-11 Intercostals


T7-L1 Abdominals Muscle

T11-L2 Ejaculation
L2 Hip Flexors
Conus medullaris
L3 Knee Extensors
Cauda Equina L4 Ankle Dorsiflexors
Lumbar
L5 Long Toe Extensor
S1 Ankle Plantarflexors
S2-3 Bowel / Bladder
Sacral S2-4 Penile Erection

Coccygeal

Spinal cord injury (SCI) which results in disruption of the nervous transmission can have
considerable physical and emotion consequences to an individual’s life. Paralysis, altered
sensation, or weakness in the parts of the body innervated by areas below the injured region
almost always occur. In addition to a loss of sensation, muscle functioning and movement,
individuals with SCI also experience many other changes which may affect bowel and bladder,
presence of pain, sexual functioning, gastrointestinal function, swallowing ability, blood
pressure, temperature regulation and breathing ability. Numerous secondary complications

1-1
may arise from SCI including deep vein thrombosis, heterotopic ossification, pressure ulcers
and spasticity.

The recovery can be long from the acute hospital admission to the return of full participation in
the individual’s community. Even those individuals who make significant gains in rehabilitation
may experience difficulty when returning to pre-injury activities. Thus, SCI has a severe effect
on quality of life. It also has an enormous cost on the health care system. Dryden et al. (2005)
examined the health care costs following a SCI in Canada. The acute and rehabilitation care
represented 68.2% of the total health care costs incurred over the first 6 years for an individual
following an injury to the spinal cord. The direct costs of a spinal cord injury were estimated at
$146,000 Canadian in the first year for a person with a complete traumatic injury and $42,000
for an incomplete injury. Annual costs in the subsequent 5 years post-injury were reported to be
$5400 Canadian per person with a complete injury and $2800 for an incomplete injury (Dryden
et al. 2005). Compared to age and gender-matched controls, individuals with SCI discharged
from hospital are more likely to be re-hospitalized, have physician contact and use more hours
of home care services (Dryden et al. 2004). The need for evidence-based SCI rehabilitation
programs has never been greater given the enormous cost of SCI rehabilitation, the growing
demands on the Canadian health care system and the devastating impact that an SCI has on
the quality of lives of individuals.

1.2 Epidemiology

Injuries to the spinal cord have been classified as either traumatic in cause (e.g., motor vehicle
accidents, falls, violent incidences, diving) or non-traumatic (e.g., tumors, spinal stenosis,
vascular). Traumatic SCI accounts for the larger proportion of SCI injuries, however, the exact
proportion compared to non-traumatic SCI is difficult to ascertain because reporting of non-
traumatic SCI has been inconsistent. The percent of traumatic SCI to overall SCI injury has
been reported to range from 75% in Germany (Exner & Meinecke 1997), 61% in the United
States (McKinley et al. 1999a) and 48% in the Netherlands (Schonherr et al. 1996).

1.2.1 Traumatic SCI

Much of the following epidemiology data on traumatic spinal cord injury in Canada has been
extracted from the 2006 Canadian Institute of Health Information Report on Traumatic SCI (CIHI
2006a) using 2003-2004 data from the Canadian National Trauma Registry (NTR). Over 950
traumatic spinal cord injuries occurred in 2003-2004 (CIHI 2006a). Reports of the annual
incidence vary in part due to differing methods of identifying and tracking injuries, and due to
regional differences. The annual incidence has been estimated at 52.5 per million population in
Alberta (Dryden et al. 2003) and 46.2 to 37.1 per million population over the 1994 to 1999
period in Ontario (Pickett et al. 2003). The global incidence of SCI estimated primarily from
developed countries ranges between 10.4 to 83 per million population per year when including
only patients who survived before hospital admission (Wyndaele & Wyndaele 2006).

In Canada, males comprise over three-quarters of these traumatic injuries with the majority
occurring in those under 35 years of age. Motor vehicle accidents are the leading cause of SCI
injury (43%), while falls are the second leading cause (36%) (NTR 1999). The number of spinal
cord injuries resulting from falls are increasing due to the growing older adult segment of the
population. This has contributed to the increase in age of a person with traumatic SCI (from
average age 46 in 1994 to average 49 in 1998). In fact, we are now seeing a bimodal
distribution of SCI in the population with one mode centralizing at approximately 30 years of age
and another mode centralizing at 60 years of age. Interestingly, falls are the primary cause of

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spinal cord injury admissions in seniors (64%), while motor vehicle accidents are the leading
cause in young adults (NRT 1999). Fractures of the vertebral column, in addition to spinal cord
injury represent 71% of all SCI hospital admissions (NTR 1999). Of the SCI admissions, 44%
result in paraplegia and 56% tetraplegia (NTR 1999).

Traumatic SCI can be complex as motor vehicle accidents or other violent incidents often result
in more than injury to the spinal cord. In particular, patients with the dual diagnosis of traumatic
brain injury and spinal cord injury present a challenge to the rehabilitation professional as they
are often agitated and have poor concentration. The percentage of SCI injuries which are
accompanied by a traumatic brain injury are substantial, for example, Lida et al. (1999) reported
that 35% of SCI had a traumatic brain injury.

There appears to be a trend towards more severe injuries in Canada. In the 1970s, the
Canadian Paraplegic Association (CPA) reported that about 25% of injuries resulted in
tetraplegia and 75% paraplegia. Of the new injuries reported to CPA during 1999, 47% resulted
in tetraplegia and 53% resulted in paraplegia. This increase in tetraplegic injuries concurs with
a slight significant increase from 53.5% tetraplegia in the 1970s to 56.5% in 2000 at the facilities
with the Model Spinal Cord Systems in the US (Jackson et al. 2004). A survey of the
epidemiology literature (Wyndaele and Wyndaele 2006) suggests increasing proportions of
tetraplegia with a global proportion of approximately two-thirds tetraplegia.

There have been some suggestions that there are increasing numbers of incomplete lesions in
some regions (Calancie et al. 2005). However, these finding are not consistent. The Model
Spinal Cord Systems in the US (Jackson et al. 2004) reported an increase in complete injuries
in the 1990s which has since dropped back to pre-1990 levels with just less than half of the
injuries being complete. The Australian Spinal Cord Injury Registry reported increasing rates in
elderly males, fall-related injury and incomplete tetraplegia and complete paraplegia over an
eleven year period (O’Connor 2006).

1.2.2 Non-traumatic SCI

There are many different causes of non-traumatic SCI, the more common conditions include
spinal stenosis (narrowing of the spinal canal), tumor compression and vascular ischemia.
Individuals with a non-traumatic SCI do not necessarily enter major trauma or rehabilitation
centres and thus are not easily tracked in SCI registries or databases. Non-traumatic SCI has
different demographics than traumatic SCI as spinal stenosis and spinal tumors are more
common in adults over 50 years of age. In addition, specific diseases such as multiple
sclerosis, paediatric spina bifida or poliomyelitis can also contribute to non-traumatic spinal cord
injury and each has demographics specific to the condition.

Overall, compared to traumatic SCI, individuals with non-traumatic SCI tend to be older with
less severe injuries, more likely to be female, married, retired, and have an incomplete
paraplegic injury (McKinley et al. 1999, 2002a, 2002b). Differences in demographics, clinical
presentation and rehabilitation outcomes have important implications for management of non-
traumatic SCI.

1.3 Recovery

The majority of individuals experience some neurological recovery (changes in motor or sensory
status) following a SCI, in addition to functional recovery. Given that all patients receive some

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treatment (e.g., pharmacological, self-care and mobility training), it is difficult to separate the
contributions of spontaneous recovery with those from active rehabilitation in humans.

1.3.1 Neuroplasticity

Spontaneous neuronal plasticity occurs through various mechanisms and has been
demonstrated primarily in animal models. Recovery mechanisms following complete injuries
may include recovery of nerve roots beside the lesion level, changes in the gray matter of the
spinal cord at the lesion level, reorganization of existing spinal circuits and peripheral changes
(Bradbury & McMahon 2006; Kern et al. 2005; Ding et al. 2005; Hagg & Oudega 2006; Ramer
et al. 2005). The evidence for spontaneous axonal regeneration is limited as a small proportion
of fibres regenerate and over a modest distance (Bradbury & McMahon 2006). However,
cortical re-organization can occur, for example, Lotze et al. (2006) showed that cortical
representation of elbow movements following a complete thoracic injury in humans was moved
toward cortical areas which represented the injured thoracic regions. There is evidence that a
pattern-generating spinal circuitry (also known as a central pattern generator) is retained
following a complete injury which can produce stepping-like movements and activation patterns
with epidural lumbar cord stimulation (Kern et al. 2005) or treadmill stimulation (Dietz et al.
2002). However, the functional consequences of these observations are yet to be determined.

Incomplete injuries may have a greater extent of axonal sprouting and axonal growth (Ding et al.
2005; Hagg & Oudega 2006). In incomplete spinal cord injury in rats, transected hindlimb
corticospinal tract axons sprouted into the cervical gray matter to contact short and long
propriospinal neurons (Bareyre et al. 2004). Following cervical lesions of the rat dorsal
corticospinal motor pathway which contains more than 95% of all corticospinal axons, there was
spontaneous sprouting from the ventral corticospinal tract onto medial motoneuron pools
(Weidner et al. 2001). This sprouting was paralleled by functional recovery. Ramer et al.
(2005) suggested that if axonal regeneration occurs or if synaptic spaces become occupied with
different axons, functional recovery will require retraining to optimize these new circuits. The
neuroplastic changes which underlie spontaneous recovery may be enhanced by physical
interventions (e.g., exercise, electrical stimulation) and pharmacological agents (Ramer et al.
2005).

1.3.2 Measures of Recovery

Changes in the American Spinal Injury Association (ASIA) International Classification of Spinal
Cord Injury, neurological level of injury and completeness of injury are often used to indicate
human neurological recovery.

ASIA International Standards for Neurological Classification of Spinal Cord Injury consists of 1)
5 category ASIA Impairment Scale (A-E), 2) motor score and 3) sensory score (ASIA 2002).
Twenty-eight dermatomes are assessed bilaterally using pinprick and light touch sensation for
the sensory score (maximum of 112 for pinprick and 112 for light touch sensation). Ten key
muscles are assessed bilaterally with manual muscle testing for the motor score (maximum of
50 for lower limbs and 50 for upper limbs). The results are used in combination with evaluation
of anal sensory and motor function as a basis for the determination of the ASIA Impairment
Scale and the 5 categories are summarized below (ASIA 2002).

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Table 1.1 Descriptions of Categories from ASIA Impairment Scale

ASIA A: Complete injury where no sensory or motor function is preserved in sacral segments S4-S5.
ASIA B: Incomplete injury where sensory, but not motor, function is preserved below the neurologic level and
extends through sacral segments S4-S5.
ASIA C: Incomplete injury where motor function is preserved below the neurologic level, and most key muscles
below the neurologic level have muscle grade less than 3 (active full-range movement against gravity).
ASIA D: Incomplete injury where motor function is preserved below the neurologic level, and most key muscles
below the neurologic level have muscle grade greater than or equal to 3.
ASIA E: Normal sensory and motor functions.

Neurological level of injury is the most caudal level at which both motor and sensory levels are
intact and has been shown to change in some individuals over recovery.

Completeness of injury are based on the ASIA standards where the absence of sensory and
motor functions in the lowest sacral segments indicates a complete injury and preservation of
sensory or motor function below the level of injury, including the lowest sacral segments
indicates an incomplete injury. Sacral-sparing is an important indicator of motor recovery and
provides evidence of the physiologic continuity of spinal cord long tract fibers with the sacral
fibers at the end of the cord. The requirement of sacral sparing to identify an incomplete injury
provides a more rigorous definition and less patients will convert from incomplete to complete
injury over time when using this definition.

Stauffer (1976) proposed that individuals with tetraplegia would recover one neurological level,
although this has been revised in recent years to qualify that recovery of one neurologic level in
subjects with tetraplegia depends on severity, initial level of the injury and the strength of
muscles below the level of injury (Dittuno et al. 2005). Dittuno et al. (1992) reported that 70 to
80% of motor-complete tetraplegia subjects with some motor strength at the injury level would
recover to the next neurologic level within 3 to 6 months. Although those with complete lesions
are generally limited to improvements of one or two levels, subjects with incomplete lesions may
exhibit recovery at multiple levels below the injury site (Dittuno et al. 2005). Triceps elbow
extension (C7) is a significant determinant for functional independence in self-care for
community-living individuals with tetraplegia (Welch et al. 1986).

For those with complete paraplegia, Waters et al. (1992) reported that 73% of 108 patients (T2-
L2) did not change in neurological level at one year post-injury compared to the rehabilitation
admission assessment. 18% recovered to the next neurological level, while 7% had 2 levels of
recovery. For incomplete paraplegia, 78% of 45 cases (T1-L3) had no changes in neurological
level between the first and 12th month but there was substantial improvement in motor function
particularly within the first 3 months (Waters et al. 1994). 70% of this sample were able to
ambulate within 1 or 2 years post-injury (27% without any devices). Patients with initial grade 2
hip flexor and knee extensor motor strength achieved community ambulation. In terms of
function, individuals with a T2-T9 injury have some trunk control and may be able to stand using
braces and an assistive device such as a walker. Although injuries below T11 have increased
potential for ambulation with bracing, successful community ambulation often involves
individuals with an injury at the L3 level or below.

Marino et al. (1999) assessed data from 21 Model System SCI systems with 3585 individuals
with SCI over the first year of recovery. They found that 10 to 15% of those with initial complete

1-5
ASIA A injuries converted to incomplete injuries. For ASIA B injuries, 1/3 converted to ASIA C
and 1/3 to ASIA D or E. For ASIA C injuries, over 2/3 converted to ASIA D. However, the
accurate prediction of ASIA conversion can be fraught with problems. Burns et al. (2003) found
that individuals with cognitive factors (e.g., traumatic brain injury, alcohol intoxication, analgesic
administration, psychological disorders) and communication barriers (e.g., language barriers,
ventilatory dependency) had a higher percent of ASIA conversion over the first year likely due to
an inaccurate initial assessment.

1.4 Rehabilitation

Rehabilitation has been defined by the World Health Organization as a progressive, dynamic,
goal-oriented and often time-limited process, which enables an individual with an impairment to
identify and reach his/her optimal mental, physical, cognitive and social functional level.
Enhancing quality of life is regarded as an inherent goal of rehabilitation services and programs
given their focus on interventions to minimize the impact of pain and physical and cognitive
impairment, and on enhancing participation in work and everyday activities. SCI rehabilitation
involves a multitude of services and health professionals and is initiated in the acute phase and
continues with extensive and specialized inpatient services during the sub-acute phase.
Inpatient rehabilitation is an important stepping stone towards regaining and learning new skills
for independent living. Here patients engage in an intensive full day program with services
which may include nursing, physical therapy, occupational therapy, respiratory management,
medical management, recreation and leisure, psychology, vocational counseling, driver training,
nutritional services, speech pathology, social worker, sexual health counseling, assistive device
prescription and pharmaceutical services. Rehabilitation continues with planning for discharge
back to the community and finally, re-integration into former or new roles and activities within
the community. Family and peers have important roles throughout the rehabilitation process.

In Canada, the median length of inpatient rehabilitation stay for traumatic SCI is 59 days with
longer stays for those with complete injuries or tetraplegic injuries ranging from 49 days for
those with incomplete paraplegia to 101 days to those with complete tetraplegia (CIHI 2006a).
SCI has the longest inpatient rehab length of stay over all other rehabilitation patient groups
except for burns (CIHI 2006b).

Functional recovery is often measured by the Functional Independence Measure (FIM), an 18


item scale that is intended to measure caregiver burden and includes tasks related to cognition,
mobility, bowel and bladder management and self-care. During inpatient rehabilitation, patients
with complete tetraplegia have the lowest FIM admission score and make less change
compared to those with incomplete or paraplegic injuries (CIHI 2006a). Persons with the dual
diagnosis of spinal cord injury and traumatic brain injury achieve smaller functional gains in
rehabilitation (Macciocchi et al. 2004).

Compared to traumatic SCI, the non-traumatic SCI rehabilitation length of stay is shorter, with a
lower FIM change and fewer medical complications including deep venous thrombosis,
orthostatic hypotension, pressure ulcers, wound infections, spasticity, autonomic dysrelfexia
were less likely (McKinley et al. 2002a, 2002b). The shorter length of stay may be a result of
the less severe injury. However, the earlier discharge in metastatic tumors may reflect the
terminal nature of the disease and patients and family may wish for the remaining time to be
spent at home.

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1.5 Community Re-integration

There is a fundamental belief among consumers with SCI that there needs to be a paradigm
shift in the approach to rehabilitation from an institutionally based physical restoration model to
a community-based independent living model (Rick Hansen SCI Network 2005). Going home is
a frequent goal established by patients newly admitted to hospital and 79% of individuals with
traumatic SCI injuries return home. Only 62% of individuals with complete tetraplegia return
home with 15% discharged back to acute care and 18% to long term care (CIHI 2006a). In a
study of high lesion SCI (C1-C4), it was found that 40% of these clients were discharged to
extended care units post rehabilitation, while the majority of these respiratory dependent
patients returned to the community (Anzai et al. 2006).

Life expectancy is less than normal, particularly for people with tetraplegia and who are
ventilator-dependent (NSCISC 2004). The life expectancy of a 40 year old paraplegic who has
survived at least 1 year post-injury is 10 years less than a person without a SCI (NSCISC 2004).
Although the mortality rate during the first 2 years after SCI has been reduced over the past 30
years, Strauss et al. (2006) noted that there has not been a substantial change in life
expectancy following the second year post-injury. In contrast, there has been an increase in life
expectancy over the last 2 decades in the general population.

Given that the majority of traumatic SCI occur in young adults, return to work or school is of high
importance, but often necessitates a change in vocation. Less than 18% of those employed at
the time of injury were able to return to the same job (CPA 1997). Within 3-6 months post
inpatient rehabilitation, 14% of people with SCI are employed, while 64% were employed prior
to injury. Approximately 9% are students (roughly double the pre-injury status). The majority
are unemployed (26%) or on disability status (35%) at 3-6 months follow-up (CIHI 2006a).
Canadians living with SCI tend to have a higher level of education than the general Canadian
population (CPA 1997). In a survey of Canadians who had been injured at least 5 years, 62%
were unemployed while 38% are employed (CPA 1997). Education is key to employment –
higher education or increasing education following injury result in more success with
employment. Of those who find employment, 44% do so within 2 years of injury while 77% find
employment within 5 years.

Accessible infrastructure and disability support are two major areas which people with SCI feel
would improve quality of life (RHMIMF 2004). When considering priorities for research,
individuals living with SCI rank finding a cure for SCI similarly to developing advances in
rehabilitation/therapy (RHMIMF 2004). Regaining arm and hand function has been cited as one
of the most important priorities to tetraplegics, while regaining sexual function has been cited as
the highest priority for paraplegics (Anderson 2004). Improving bladder and bowel function was
important to both injury groups (Anderson 2004). Although the majority of participants indicated
that exercise was important to functional recovery, more than half did not have access to
exercise (Anderson 2004). Anderson (2004) emphasized the need for researchers to be aware
of the needs of SCI consumers in their quest for discovery.

The continuum of health care in the community includes mechanisms for people to access
information resources about living with a SCI. However, it appears that people with SCI do not
approach traditional health care sources for their information (e.g., physician, hospital). For
people living with SCI, the internet was by far the number one source for information about SCI
(48%), while support groups and media ranked higher than hospitals, books, rehab centres,

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physicians and peers (RHMIMF 2004). It appears that the internet can be an ideal medium for
promoting health-related education. To facilitate accessibility of information, the SCIRE
information is available on CD, print version, as well as through web-access
(www.icord.org/scire).

In a recent survey, the majority (70%) of individuals with SCI rated the quality of life of people
with SCI as good or very good while 23% rated it as poor or very poor (RHMIMF 2004). It is
encouraging that 65% of individuals with SCI felt that the quality of life of people with SCI has
improved over the past 5 years (RHMIMF 2004). As enhancing quality of life is an inherent goal
of rehabilitation, there is a continual challenge to close the gap between treatment activities and
functional competence in the individual’s actual environment.

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CHAPTER TWO

Methods of Systematic Reviews


Table of Contents

2.1 Introduction ......................................................................................................................2-1

2.2 Article Assessment..........................................................................................................2-2


2.2.1 Literature Search Strategy ..............................................................................................2-2
2.2.2 Quality Assessment Tool and Data Extraction................................................................2-2

2.3 Determining Levels of Evidence and Formulating Conclusions .................................2-3

Appendix 1. Specific Search Terms .....................................................................................2-5

Appendix 2. The PEDro Scale...............................................................................................2-8

Appendix 3. Downs and Black tool (Downs and Black 1998) ..........................................2-10

References..............................................................................................................................2-11

This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising
from the use or misuse of this material.

Methods of the Systematic Reviews. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson
C, Hsieh JTC, Connolly S, editors. Spinal Cord Injury Rehabilitation Evidence. 2006: Vancouver, p 2.1-2.11.

www.icord.org/scire
Methods of the Systematic Reviews

2.1 Introduction

Providing a framework for evidence-base practice was championed in the early 1990s, although
it was practiced and discussed in medical circles long before this. In 1992, the Evidence-Based
Practice Working Group (EBPWG) described a new framework of using research to guide and
augment the practice of medicine (Evidence-based Medicine Working Group 1992). Dr. David
Sackett, a pioneer in the field and also a member of the original working group described
evidence-based practice as:

“Evidence based medicine is the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients. The practice of evidence
based medicine means integrating individual clinical expertise with the best available external
clinical evidence from systematic research.” (Sackett et al. 1996)

Although the original definitions were framed for the practice of medicine, the practice has
spread to all fields of health care with the more generic term “evidence-based practice”.
Evidence-based practice does not ignore clinical experience and patient preferences, but
weights these against a background of the highest quality scientific evidence that is available.
The importance of clinical judgement was emphasized by Dr. Sackett in his original editorial:
“Because it [evidence-based medicine] requires a bottom up approach that integrates the best
external evidence with individual clinical expertise and patients' choice, it cannot result in
slavish, cookbook approaches to individual patient care. External clinical evidence can inform,
but can never replace, individual clinical expertise, and it is this expertise that decides whether
the external evidence applies to the individual patient at all and, if so, how it should be
integrated into a clinical decision.” Sackett et al. (1996)

Acquiring and interpreting the evidence from the research literature can be daunting. Not only is
there a wealth of ever changing information from multiple sources, but it is often difficult for a
front-line clinician not intimately familiar with the research methods to interpret the results of a
study. In addition, the interpretation is further complicated by the presence of multiple studies
on an intervention, often with what appears to be conflicting messages. The Spinal Cord Injury
Rehabilitation Evidence (SCIRE) is dedicated to providing up-to-date, accurate information
about the effect of rehabilitation health-care for people with SCI. The SCIRE used a systematic
and transparent procedure to assess and synthesize the evidence of the effects of rehabilitation
healthcare interventions in SCI and is designed for health professionals inform them of best
practice. Consumers with SCI and their families may also find the synthesis useful to better
understand their health care. In addition, such a research synthesis will enable relevant
decision-making in public policy and practice settings applicable to SCI rehabilitation. Lastly,
transparent and unbiased evidence-based reviews will guide the research community and
funding organizations to strategically focus their time and resources on the gaps in knowledge
and identify research priorities.

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2.2 Article Assessment

2.2.1 Literature Search Strategy

A systematic review was undertaken using multiple databases (MEDLINE/PubMed, CINAHL®,


EMBASE, PsycINFO) to identify and synthesize all relevant literature published from 1980-
2005. An initial broad search was performed with five types of SCI therapies searched: drug
therapy, radiotherapy, diet therapy, rehabilitation therapy and therapy. To further refine the
search, the search was limited to human subjects and articles published in English.

Based on the above search criteria, the total number of references from all databases was
8007. Two investigators reviewed both the title of the citation and the abstract (of all 8007
references) to determine its suitability for inclusion. Articles’ suitability was based on the above
inclusion criteria as well as the following exclusion criteria: less than half the reported population
had a spinal cord injury; no measurable outcome associated with treatment; animal studies.
Unless there were no other supporting literature, studies with less than 3 subjects were
excluded.

Meta-analyses, systematic reviews and review articles were identified at this point and studies
cited with these works that were not identified in the original literature search, were also sought,
through hand searching. The review was restricted to published works.

MeSH headings were used with the keywords. Key words were paired with spinal cord injury,
tetraplegia, quadriplegia or paraplegia

Specific SCI rehabilitation topics (e.g., pressure ulcers) were identified by a multi-disciplinary
team of expert scientists, clinicians, consumers with SCI and policy-makers. These specific
topics were searched with additional keywords generated from expert scientists and clinicians in
SCI rehabilitation familiar with the topic and more titles and abstracts were reviewed. The
reference lists of previous review articles, key articles, systematic reviews and clinical practice
guidelines were hand searched. It is known that hand searching may provide higher rates of
return than electronic searching within a particular subject area (Hopewell et al. 2002). The
number of titles and abstracts reviewed is approximately 8400. Additional keywords used for
each specific topic are outlined in Appendix 1.

2.2.2 Quality Assessment Tool and Data Extraction

Methodological quality of individual RCTs was assessed using the Physiotherapy Evidence
Database (PEDro) tool (http://www.pedro.fhs.usyd.edu.au/scale_item.html). PEDro was
developed for the purpose of accessing bibliographic details and abstracts of randomized-
controlled trials (RCT), quasi-randomized studies and systematic reviews in physiotherapy.
PEDro has been used to assess both pharmacological and non-pharmacological studies with
good agreement between raters at an individual item level and in total PEDro scores (Foley et
al. 2006). Maher et al. (2003) found the reliability of PEDro scale item ratings varied from "fair"
to "substantial," while the reliability of the total PEDro score was "fair" to "good. Studies
included in this review using a non-experimental or uncontrolled design (non-randomized
comparative trials, cohort studies or retrospective studies) could not be assigned a PEDro score
and were given a not applicable (n/a) designation.

The PEDro is an 11-item scale, in which the first item relates to external validity and the other
ten items assess the internal validity of a clinical trial. One point was given for each satisfied

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criterion (except for the first item, which was given a YES or NO), yielding a maximum score of
ten. The higher the score, the better the quality of the study and the following cut-points were
used where 9-10: excellent; 6-8: good; 4-5: fair; <4: poor. A point for a particular criterion was
awarded only if the article explicitly reported that the criterion was met. The scoring system is
detailed in Appendix 2. Two independent raters reviewed each article. Scoring discrepancies
were resolved through discussion.

All other studies with an intervention were assessed with the Downs and Black Tool (Downs and
Black 1998) for methodological quality. This tool consists of 27 questions in the following sub-
sections: Reporting, External Validity, Internal Validity – bias and Internal Validity – confounding
(selection bias). The original tool range from 0 to 32. However, we modified the last question
form a scale of 0 to 5 to a scale of 0 to 1 where 1 was scored if a power calculation or sample
size calculation was present while 0 was scored if there was no power calculation, sample size
calculation or explanation whether the number of subjects was appropriate. Thus, our modified
version ranged from 0 to 28, with a higher score indicating higher methodological quality. The
Downs and Black tool is attached in Appendix 3.

Data were extracted to form tables. Sample subject characteristics (Population), nature of the
treatment (Intervention), measurements (Outcome Measures) and key results are presented in
the tables. In cases, where a single study overlapped into multiple chapters (e.g., treadmill
training has effects on the cardiorespiratory, lower extremity and bone health), the results focus
on the outcomes relevant to that chapter.

2.3 Determining Levels of Evidence and Formulating Conclusions

Table 2.1 Five levels of evidence


Level Research Design Description
Randomized controlled trial, PEDro score ≥ 6. Includes within
Level 1 Randomized controlled trial (RCT) subjects comparison with randomized conditions and cross-
over designs
RCT Randomized controlled trial, PEDro score < 6.
Prospective controlled trial Prospective controlled trial (not randomized)
Level 2
Prospective longitudinal study using at least 2 similar groups
Cohort
with one exposed to a particular condition.
A retrospective study comparing conditions, including
Level 3 Case control
historical controls
A prospective trial with a baseline measure, intervention, and
Pre-post
a post-test using a single group of subjects.
A prospective post-test with two or more groups – intervention,
Level 4 Post-test then post-test (no pre-test or baseline measurement) using a
single group of subjects.
A retrospective study usually collecting variables from a chart
Case Series
review.
Observational Study using cross-sectional analysis to interpret relations.
Expert opinion without explicit critical appraisal, or based on
Level 5 Clinical Consensus
physiology, biomechanics or "first principles"
Case Report Pre-post or case series involving one subject

The levels of evidence used to summarize the findings are based on the levels of evidence
developed by Sackett et al. (2000). The levels proposed by Sackett et al. (2000) were modified
to collapse the subcategories within a level (e.g., level 1a, 1b, 1c) into a single level. This was
performed to reduce the 10 categories from Sackett et al. (2000) to a less complex system from
level 1 to level 5. We provided additional descriptions specific to the types of research designs
encountered in SCI rehabilitation to facilitate the decision-making process. Sackett et al. (2000)

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distinguishes high and low quality randomized controlled trials (RCTs) into level 1b and level 2b,
respectively. To provide a more reliable decision-making process, we required that a level 1
RCT had a PEDro score of greater than or equal to 6 (good to excellent quality), while a level 2
RCT had a PEDro score of 5 or less. The appropriateness of the control group was assessed
per study. In some studies, an able-bodied group may not have been an adequate control for
the particular intervention used, but simply provided “normative’ values for comparison. In those
studies, the study was considered “not controlled” and the level of evidence reduced (e.g., level
4 pre-post).

RCTs received priority when formulating conclusions. Conclusions were not difficult to form
when the results of multiple studies were in agreement. However, interpretation became difficult
when the study results conflicted. In cases where studies differed in terms of quality, the results
of the study (or studies) with the higher quality score were more heavily weighted to arrive at the
final conclusions. Sometimes, interpretation was difficult, for example, the authors needed to
make a judgment when the results of a single study of higher quality conflicted with those of
several studies of inferior quality. In these cases we attempted to provide a rationale for our
decision and to make the process as transparent as possible.

As emphasized by Sackett et al. (1996), the evidence from systematic research should be
integrated with clinical expertise and patients' choice to form best practice.

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Appendix 1. Specific Search Terms

Specific SCI rehabilitation topics were identified by a multi-disciplinary team of expert scientists,
clinicians, consumers with SCI and policy-makers. These specific topics were searched with
additional keywords generated from expert scientists and clinicians in SCI rehabilitation familiar
with the topic and more titles and abstracts are reviewed. MeSH headings were used with the
keywords. Key words were paired with spinal cord injury, tetraplegia, quadriplegia or
paraplegia. The reference lists of previous review articles, systematic reviews and clinical
practice guidelines were hand searched. It is known that hand searching may provide higher
rates of return than electronic searching within a particular subject area (Hopewell et al. 2002).

Chapter 3: Rehabilitation Practice: ("rehabilitation"[Subheading] OR "Rehabilitation"[MeSH])


AND "Spinal Cord Injuries"[MeSH] AND "Treatment Outcome"[MeSH]

Chapter 4: Community Reintegration: accessibility, attendant care, attitudes, community +


leisure + recreation, community involvement, community Involvement, community living,
community participation, community reintegration, community reintegration, daily functioning,
domestic life, employment, empowerment, environment + functioning, environment +
reintegration, environment + social, environment + social + home, environmental policy, family
involvement, HRQOL, intervention – trial, control group, treatment group; income support,
independent living, interpersonal relations, leisure – intervention, control group, treatment,
clinical trials, leisure + use of time, life happiness, life satisfaction, living independent,
occupations, personal assistance, personal satisfaction, productivity, psychosocial rehabilitation,
QOL – intervention, trial, control group, treatment group, recreation therapy, school education,
self care, social environment, social interactions, social network, social policy, social roles,
social support, socializing, use of technology, volunteer

Chapter 5: Upper Limb: upper limb, FES and upper limb, exercise programs, upper limb
injuries, splinting, specific researchers [Popovic…]

Chapter 6: Lower Limb: 4-AP, 4-AP + ambulation, assisted walking device, walking, assisted
rehabilitation device, biofeedback, body weight support, body weight supported treadmill training
(BWSTT), brace, bracing, Clonidine, Cyproheptadine, EMG + feedback, epidural stimulation /
epidural lumbar stimulation, FES + muscle, flexibility, gait, gait + bracing, gait + orthotics, gait
devices, GM-1 ganglioside, knee-ankle-foot, leg + bracing, leg + FES, locomotion, locomotor
training, lower extremity spasticity, orthotics, orthotics + lower limb, parawalker, robotics,
salbutamol, scott-craig knee ankle foot orthosis, spasticity management, stepping, stretching,
treadmill, trendelenburg gait, Vannini-rizzoli stabilizing orthosis, virtual reality, walking,
weakness

Chapter 7: Cardiovascular Exercise: cardiac output, cardiovascular disease, cardiovascular


fitness, coronary heart disease, endothelium, epoetin alfa, FES + blood pressure,
fludrocortisone, glucose intolerance, glucose sensitivity, hydralazine, lipid, lipid + metabolism,
neuromuscular + blood, nifedipine, orthostatic hypotension, oxygen consumption,
phenazopyridine, physiotherapy + blood, stroke volume, thromboembolism, ventilation,
ventilatory threshold, VO2

Chapter 8: Respiratory: abdominal binder, acapello, assisted cough, asthma – incidence,


prevalence, atelectasis, autogenic drainage, barotraumas, BiPAP, breathing exercises,
bronchial lavage, bronchitis, bronchoscopy, cardiopulmonary function, chest physiotherapy,
COPD – incidence, prevalence, CPAP, diaphragmatic pacemaker, dysphagia, exsufflation,

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flutter, flutter device, flutter valve, forced expiratory technique, Garshick, glossopharyngeal
breathing, incentive spirometry, insufflation, intermittent positive pressure breathing,
intrapulmonary percussive ventilation, IPPB stretch, manual percussion, manual vibration,
mechanical vibration, paripep , PEP / PEEP, percussion, phrenic pacemaker, pneumonia -
incidence, prevalence, positive pressure breathing, postural drainage, progressive ventilatory
free breathing, pulmonary capacity, pulmonary complications – incidence, prevalence,
pulmonary embolism, pulmonary health, pulmonary secretions, respiratory complications –
incidence, prevalence, secretion removal, sleep apnea, smoking – incidence, prevalence,
spirometry, synchronous intermittent mandatory ventilation, TheraPep, tidal volume,
tracheostomy, ventilator weaning, ventilatory capacity, ventilatory failure – incidence,
prevalence

Chapter 9 Bone Health alendronate, Amino-bisphosphonates, bone + fracture, bone health,


cyclic etidonate, exercise therapy, FES, heterotopic ossification, incidence + fracture,
osteoporosis, pamidronate, skeletal + fracture, vibration

Chapter 10 Depression: alcohol abuse, drug abuse, depression, anxiety, gender differences,
sexuality, [specific researches: Krause, Noreau…], aging, sexual health, male and female,
spinal cord, vocational issues, sexual issues, psychosocial

Chapter 11 Sexual Health: autonomic dysreflexia, birth control, birthing, bladder + sex, bladder
management + body image, bladder management + mitrofanoff, bladder management + sexual
life, bladder management + suprapubic, body image, bowel + sex, Cesarean section,
contraception, dysparunia, dyspareunia + infertility, ejaculation, ejaculatory disorder,
electroejaculation, erection, female fertility, hypogonadism, ICSI, infertility + pregnancy,
intercavernosal injection, intraurethral palette, intraurethro palette, urethra palette, IVF, labour,
labour + delivery, marital, marital status + sexuality, menopause, menstruation, penile injection,
post-partum, pregnancy, premature labour, semen quality, seminal emissions, sex, sex +
depression, sex/sexual + foley catheter, sex/sexual + intermittent catheter, sexual adjustment,
sexual changes, sexual function + medications, sexual functioning + foley catheter, sexual
position, sexual relationships, sexual self-esteem, sexual self-views, sexuality, sexuality +
depression, sperm/semen quality, sperm/semen retrieval, vacuum device, vaginal lubrication,
Viagra, vibrator, vibrostimulation

Chapter 12 Bowel Management: bowel management, cisapride, colonic, colostomy,


constipation, dietary fibre, hemorrhoids, incontinence, irregular, laxative, neurogenic bowel,
suppositories

Chapter 13 Bladder: Bladder, Neurogenic"[MeSH] AND "Spinal Cord Injuries"[MeSH]

Chapter 14 Pain: pain treatment, pharmacology, pain, surgical intervention, pain management
Secondary complications

Chapter 15 Venous Thromboembolism: Deep venous thrombosis, thrombosis, emboli, DVT,


thromboembolism, heparin, vena cava filtration

Chapter 16 Orthostatic hypotension: orthostatic hypotension, dysreflexia, autonomic,


hyperreflexia, midodrine, postural hypotension, orthostatic intolerance, orthostatic tolerance,
orthostatic stress, blood flow, blood flow + exercise, blood pressure, blood vessel health

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Chatper 17 Autonomic dysreflexia: AD, autonomic, dyreflexia, hyperreflexia, midodrine,
fludrocortisone, beta-blockers, Viagra, nifedipine, phenazopyridine

Chapter 18 Heterotopic Ossification: heterotopic ossification, excision surgery, etidronate

Chapter 19 Nutrition: diabetes, energy requirements, energy needs, caloric intake, weight
gain, obesity, overweight, prevention, body composition, cardiovasular disease risk, nutrient,
supplementation, supplements, dietary, nutrition intervention, folate, vitamin B6, vitamin B12,
omega 3 fatty acids, essential fatty acids, pressure ulcers, vitamin supplementation, mineral
supplementation, vitamin C, vitamin A, zinc, iron, protein, diabetes risk, hydration/optimal
hydration, cranberry juice, neurogenic bowel, dietary fibre, soluble fibre, insoluble fibre, fibre
supplements, peristalsis, osteoporosis, osteopenia, bone mineral density, calcium, vitamin D,
magnesium, renal stone/kidney stone and calcium intake/supplementation, urinary tract,
hypercalcemia

Chapter 20 Pressure Sores: pressure sores, ulcers

Chapter 21 Spasticity: botox, baclofen, spasticity

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Appendix 2. The PEDro Scale (www.pedro.fhs.usyd.edu.au/scale_item.html)

1. “Subjects were randomly allocated to groups.” (in a crossover study, subjects were randomly
allocated an order in which treatments were received). A point for random allocation was
awarded if random allocation of patients was stated in its methods. The precise method of
randomization need not be specified. Procedures such as coin-tossing and dice-rolling were
considered random. Quasi-randomization allocation procedures such as allocation by bed
availability did not satisfy this criterion.
2. “Allocation was concealed.” A point was awarded for concealed allocation if this was explicitly
stated in the methods section or if there was reference that allocation was by sealed opaque
envelopes or that allocation involved contacting the holder of the allocation schedule who
was "off-site."
3. “The groups were similar at baseline regarding the most important prognostic indicators.” A
trial was awarded a point for baseline comparability if at least one key outcome measure at
baseline was reported for the study and control groups. This criterion was satisfied even if
only baseline data of study completed-only subjects were presented.
4. “There was blinding of all subjects.” The person in question (subject, therapist or assessor)
was considered blinded if he/she did not know which group the subject had been allocated
to. In addition, subjects and therapists were only considered to be "blind" if it could be
expected that they would have been unable to distinguish between the treatments applied to
different groups. In drug therapy trials, the administrator of the drug was considered the
therapist and was considered blinded if he/she did not prepare the drug and was unaware of
the drug being administered.
5. “There was blinding of all therapists who administered the therapy.” (criteria 4.)
6. “There was blinding of all assessors who measured at least one key outcome” (criteria 4).
7. “Adequacy of follow-up.” For the purposes of this review, follow-up was considered adequate
if all of the subjects that had been originally randomized could be accounted for at the end of
the study. The interpretation of this criterion differs from that described by PEDro, where
adequacy is defined as the measurement of the main outcome in more than 85% of
subjects.
8. “Intention to treat.” All subjects for whom outcome measures were available received the
treatment or control condition as allocated or, where this was not the case, data for at least
one key outcome was analyzed by "intention to treat". For purpose of the present evidence-
based review, a trial was awarded a point for intention-to-treat if the trial explicitly stated that
an intention-to-treat analysis was performed.
9. “The results of between-group statistical comparisons are reported for at least one key
outcome.” Scoring of this criterion was design dependent. As such, between groups
comparison may have involved comparison of two or more treatments, or comparison of
treatment with a control condition. The analysis was considered a between-group analysis if
either a simple comparison of outcomes measured after the treatment was administered
was made, or a comparison of the change in one group with the change in another was
made. The comparison may be in the form of hypothesis testing (e.g. p-value) or in the form
of an estimate (e.g. the mean, median difference, difference in proportion, number needed
to treat, relative risk or hazard ratio) and its confidence interval. A trial was awarded a point
for this criterion if between group comparison on at least one outcome measure was made
and its analysis of comparison was provided.
10. “The study provides both point measures and measures of variability for at least one key
outcome.” A point measure was referred as to the measure of the size of the treatment
effect. The treatment effect was described as being either a difference in group outcomes,
or as the outcome in (each of) all groups. Measures of variability included standard
deviations, standard errors, confidence intervals, interquartile ranges (or other quartile

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ranges), and ranges. Point measures and/or measures of variability that were provided
graphically (for example, SDs may be given as error bars in a Figure) were awarded a point
as long as it was clear what was being graphed (e.g. whether error bars represent SDs or
SEs). For those outcomes that were categorical, this criterion was considered to have been
met if the number of subjects in each category was given for each group.

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Appendix 3. Downs and Black tool (Downs and Black 1998)

Reporting
1) Is the hypothesis/aim/objective of the study clearly described?
2) Are the main outcomes to be measured clearly described in the Introduction or Methods
section?
3) Are the characteristics of the patients included in the study clearly described ? I4) Are the
interventions of interest clearly described?
5) Are the distributions of principal confounders in each group of subjects to be compared
clearly described?
6) Are the main findings of the study clearly described?
7) Does the study provide estimates of the random variability in the data for the main
outcomes?
8) Have all important adverse events that may be a consequence of the intervention been
reported?
9) Have the characteristics of patients lost to follow-up been described?
10) Have actual probability values been reported (e.g. 0.035 rather than <0.05) for the main
outcomes except where the probability value is less than 0.001?

External validity
11) Were the subjects asked to participate in the study representative of the entire population
from which they were recruited?
12) Were those subjects who were prepared to participate representative of the entire
population from which they were recruited?
13) Were the staff, places, and facilities where the patients were treated, representative of the
treatment the majority of patients receive?

Internal validity - bias


14) Was an attempt made to blind study subjects to the intervention they have received?
15) Was an attempt made to blind those measuring the main outcomes of the intervention?
16) If any of the results of the study were based on “data dredging”, was this made clear?
17) In trials and cohort studies, do the analyses adjust for different lengths of follow-up of
patients, or in case-control studies, is the time period between the intervention and
outcome the same for cases and controls ?
18) Were the statistical tests used to assess the main outcomes appropriate?
19) Was compliance with the intervention/s reliable?
20) Were the main outcome measures used accurate (valid and reliable)?

Internal validity – confounding (selection bias)


21) Were the patients in different intervention groups (trials and cohort studies) or were the
cases and controls (case-control studies) recruited from the same population?
22) Were study subjects in different intervention groups (trials and cohort studies) or were the
cases and controls (case-control studies) recruited over the same period of time?
23) Were study subjects randomised to intervention groups?
24) Was the randomised intervention assignment concealed from both patients and health
care staff until recruitment was complete and irrevocable?
25) Was there adequate adjustment for confounding in the analyses from which the main
findings were drawn?
26) Were losses of patients to follow-up taken into account?
27) Did the study have sufficient power to detect a clinically important effect where the
probability value for a difference being due to chance is less than 5%?

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References

Downs SH and Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-randomised studies of health care
interventions. J Epidemiol Community Health (1998); 52:377-384.
Evidence-Based Medicine Working Group (1992): A new approach to teaching the practice of
medicine. JAMA: The Journal of the American Medical Association 268: 2420-2425.
Fitzpatrick R, Davey C, Buxton MJ, Jones DR. Evaluation of patient-based outcome measures
for use in clinical trials. Health Technology Assessment 1998;2:1 – 74.
Foley NC, Bhogal SK, Teasell RW, Bureau Y, Speechley MR. Estimates of quality and reliability
with the physiotherapy evidence-based database scale to assess the methodology of
randomized controlled trials of pharmacological and nonpharmacological interventions. Phys
Ther. 2006;86:817-24.
Hopewell S, Clarke M, Lefebvre C, Scherer R. Handsearching versus electronic searching to
identify reports of randomized trials. The Cochrane Database of Methodology Reviews
2002, Issue 4. Art. No. MR000001.
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for
rating quality of randomized controlled trials. Phys Ther. 2003;83:713-21.
PEDro: http://www.pedro.fhs.usyd.edu.au/scale_item.html
Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine:
how to practice and teach EBM. Toronto, Ontario: Churchill Livingstone, 2000.
Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic
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Sackett DL, Rosenberg WM, et al. Evidence based medicine: what it is and what it isn't. BMJ
1996;312:71-72. 52.

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CHAPTER THREE

Rehabilitation Practice And Associated Outcomes


Following Spinal Cord Injury

Dalton L. Wolfe, PhD


Jane TC Hsieh, MSc
Key Points

Those with higher level and more severe injuries have longer rehabilitation LoS
(Length of Stay.

Rehabilitation LoS in the US has become progressively shorter up to the mid-


1990s.

Most individuals make significant functional gains during inpatient rehabilitation.

A significant proportion of people improve 1 AIS (ASIA Impairment Scale) grade in


the first few months post-injury particularly those initially assessed AIS B and C.

Increased therapeutic intensity may not necessarily lead to functional benefits, but
data is scarce.

Younger individuals with paraplegia are more likely to have shorter rehabilitation
LoS than older individuals.

Younger individuals are more likely to make greater functional gains during
rehabilitation than older individuals.

Younger individuals with tetraplegia (or in a mixed traumatic, non-traumatic


sample) are more likely to make gains in neurological status during rehabilitation
than older individuals.

Individuals with non-traumatic SCI have reduced LoS and less functional
improvement with rehabilitation as compared to those with traumatic SCI although
controlled comparisons are limited to data from the US Model Systems.

Neither gender nor race effects have been demonstrated for discharge destination,
rehabilitation LoS and neurological or functional status in US Model Systems data.

More specialized, interdisciplinary acute SCI care is associated with faster


transfers to rehabilitation and may result in fewer medical secondary
complications, more efficient functional gains and reductions in overall mortality.

Earlier admission to specialized, interdisciplinary SCI care is associated with


reduced length of total hospital stay and greater and faster rehabilitation gains
with fewer medical secondary complications.

Prospective studies with stronger designs are needed to strengthen the evidence
and provide more direction as to the optimal model of care.

Routine, comprehensive, specialist follow-up services may result in improved


health.
Table of Contents

3.1 Introduction ......................................................................................................................3-1

3.2 Common Abbreviations Used In SCI Rehabilitation.....................................................3-1

3.3 Description of SCI Rehabilitation Outcomes ................................................................3-2


3.3.1 Describing SCI Rehabilitation Outcomes ........................................................................3-2
3.3.1.1 Health Delivery Indicators ............................................................................................3-3
3.3.1.1.1 Rehabilitation Length of Stay ....................................................................................3-3
3.3.1.2 Neurological and Functional Status .............................................................................3-6

3.4 Factors for Optimal Outcomes .......................................................................................3-9


3.4.1 Effect of Intensity on Rehabilitation Outcomes ...............................................................3-9
3.4.2 Effect of Age on Rehabilitation Outcomes ....................................................................3-10
3.4.3 Differences in Traumatic vs Non-Traumatic SCI Rehabilitation Outcomes...................3-14
3.4.4 Effect of Gender and Race on Rehabilitation Outcomes ..............................................3-18

3.5 Specialized vs General SCI Units (Acute Care)...........................................................3-21

3.6 Early vs Delayed Admission to Specialized SCI Units ...............................................3-24

3.7 Outpatient and Follow-up Care.....................................................................................3-30

3.8 Summary.........................................................................................................................3-31

Appendix – Studies Describing Rehabilitation Outcomes.................................................3-34

References..............................................................................................................................3-41

This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
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Wolfe DL, Hsieh, JTC (2006). Rehabilitation Practices and Associated Outcomes Following Spinal Cord Injury.
In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S, editors.
Spinal Cord Injury Rehabilitation Evidence. Vancouver, p 3.1-3.44.
www.icord.org/scire
Rehabilitation Practice And
Associated Outcomes
Following Spinal Cord Injury
3.1 Introduction
The SCI rehabilitation practices of today were influenced greatly by the pioneering efforts of Sir
Ludwig Guttman who was instrumental in the creation of specialized spinal units to care for
injured soldiers returning to England during and after WWII (Guttmann 1967). Eventual adoption
of this more specialized and integrated approach followed in many additional jurisdictions (Bors
1967; Bedbrook 1979), bolstered by reports of reduced mortality and enhanced long-term
survival which was attributed in part to more effective management of secondary conditions
associated with SCI (e.g., UTI’s, pressure sores, respiratory conditions) (Richardson & Meyer
Jr. 1981; Le & Price 1982;. Geisler et al.1983).
At present, the “ideal” scenario for modern SCI care is purported to be treatment in specialized,
integrated centres with an interdisciplinary team of health care professional providing care as
early as possible following injury and throughout the rehabilitation process with appropriate
discharge to the community characterized by ongoing outpatient care and follow-up (Donovan et
al. 1984; Tator et al. 1995). This is best facilitated under one roof or within an organized
“system” which is distinguished by seamless transitions as patients proceed from acute care
through rehabilitation to outpatient care. While it is generally accepted that this “ideal” more
specialized, integrated approach should result in better outcomes, there is very little robust
evidence that supports this directly. This is understandable, given the relatively low incidence of
SCI, limitations in designing trials with adequate controls and the inherent difficulty in ascribing
potential outcomes to such a multi-faceted process as rehabilitation. For these reasons, we
have adopted a more lenient approach within the present chapter with respect to the reviewed
articles as compared to most other chapters. Many of the articles presented in the current
chapter do not investigate a specific intervention although they do describe rehabilitation
outcomes and the various factors that are associated with producing optimal outcomes.
Accordingly, when no specific intervention is assessed experimentally, a PEDro or Downs and
Black (Downs & Black 1998) score is not provided. These articles were separated into five
categories: Description of Rehabilitation Outcomes, Factors for Optimal Outcomes, Specialized
vs. General SCI Units, Early vs. Delayed Admission to Specialized Units and Outpatient and
Follow-up Care.
In addition, in some studies the distinction between acute vs. rehabilitative care is somewhat
blurred as studies may have been conducted in centers or systems where these services are
more integrated. The present chapter is focused on issues associated with rehabilitation care
and we have attempted to clearly identify when acute care practice may have been merged
within the reporting of rehabilitation research results.

3.2 Common Abbreviations Used In SCI Rehabilitation

AIS – ASIA Impairment Scale


ASIA – American Spinal Injury Association (and associated International Guidelines for
Neurological Classification)
BI – Barthel Index

3-1
FIM – Functional Independence Measure
LoS – Length of Stay
MBI – Modified Barthel Index
OT – Occupational Therapy
SLT – Speech & Language Therapy
PT – Physical Therapy (Physiotherapy)
UTI – Urinary Tract Infection

3.3 Description of SCI Rehabilitation Outcomes

Much research has been directed at describing outcomes following SCI rehabilitation and
examining various factors that might be associated with good (or poor) outcomes. Ethical and
practical considerations limit the application of randomized controlled designs or other
experimental designs in investigating methods for enhancing patient outcomes. Typically,
investigators employ case series, case control or pre-post trial designs and often utilize
correlational or predictive analyses (e.g., univariate or multivariate regression) of large single or
multi-centre patient databases to determine specific associations or factors that are associated
with optimal rehabilitation outcomes. Often these studies are quite large in scope as
investigators explore relationships among a variety of socio-demographic and injury-related
variables as they endeavour to determine optimal rehabilitation practice. Given the inherent
breadth of findings present in individual studies in this area in which large databases are mined
for relationships among large arrays of variables, it is difficult to follow the same pattern of
brevity and topic focus found in most chapters of the present review. In the present section we
have taken a slightly different approach. First, a comprehensive table can be found in Section
3.9 Appendix 3.1 that lists specific studies in more detail and which outlines various findings
directed at describing outcomes associated with comprehensive inpatient SCI rehabilitation.
This is intended as an overall resource for those interested in the specific findings relating to
outcomes associated with rehabilitation practice. In the text are more focused tables
summarizing specific data culled from the more comprehensive table, thereby permitting an
assessment of similar types of rehabilitation outcomes. This is intended for those interested in
more specific information about particular issues pertaining to rehabilitation outcomes. The
subsequent section then describes more focused investigations that examine the effect of the
various factors in producing optimal outcomes. These include studies that assess the effect of
the intensity of rehabilitation, age, gender and race on rehabilitation outcomes.

3.3.1 Describing SCI Rehabilitation Outcomes

There are many types of outcomes that have been associated with SCI rehabilitation. In the
present review, we will focus on the most commonly employed measures and have outlined
these along with a few typical examples of outcome measurement tools in Table 3.1. In
particular, these include measures that examine the effectiveness of health delivery as well as
measures that assess functional, neurological and general health status of patients. As noted
earlier, each of these measurement types will form the basis of separate summary tables
following the overall more comprehensive table. It should be noted that other measures of
obvious importance to SCI rehabilitation care providers and people with SCI such as measures
of health-related quality of life and those that assess different facets of community integration
(e.g., employment status, Reintegration to Normal Living Index) have not been included in the
present chapter as they are considered in the chapter entitled “Community Reintegration Issues

3-2
Post Spinal Cord Injury”. In addition, studies examining health status have not been addressed
in the present chapter as these typically report the incidence of specific secondary conditions
(most notably, pressure sores and UTIs) and these will be described more fully in the specific
chapters devoted to these issues.

Table 3.1 Outcome Measure Types and Examples Relevant to SCI Rehabilitation
Outcome Measure Type Specific Outcome Measures

Health Delivery Indicators LoS, Hospital Charges, Discharge Destination

Functional Status FIM, MBI

Neurological Status AIS, ASIA motor scores, Frankel Index

Health Status Incidence of secondary complications

It should also be noted that specific outcome measurement tools can combine 2 of these
outcome measure types such as in measures of efficiency. Most commonly, change scores for
functional (e.g., FIM) or neurological (e.g., ASIA motor scores) measures are divided by LoS to
get an average change for that particular measure, thereby providing an indication of the
efficiency of the rehabilitation process in effecting change. Measures of this nature will be
profiled in the sub-section for which the numerator is related. For example, ASIA motor score
efficiency would be addressed under findings associated with neurological status. However,
before these specific summary tables are presented, see Section 3.9 Appendix 3.1 for a more
comprehensive table summarizing studies describing various SCI rehabilitation outcomes.

3.3.1.1 Health Delivery Indicators

3.3.1.1.1 Rehabilitation Length of Stay

Several authors have made comparisons of rehabilitation length of stay (LoS) between
countries or across other jurisdictions (Burke et al. 1985; Muslumanoglu et al. 1997; Pagliacci et
al. 2003; Chan & Chan 2005). Additionally, others have noted the trend for progressively shorter
LoS over the past several decades, especially in the US (De Vivo et al. 1991; Morrison &
Stanwyck 1999; Eastwood et al. 1999). Stover noted that reductions in the 1970s and early
1980s were likely due to increased efficiency of rehabilitation teams (Stover 1995). More recent
reductions in the US have been attributed to restrictions imposed by payers (Morrison &
Stanwyck 1999). Table 3.2 summarizes various reports in the literature for LoS organized by
jurisdiction and also by the time period for which the data was collected. Data were only
included in this table if the underlying sample was deemed representative of an overall
heterogeneous population of individuals with SCI (i.e., unselected sample of a single or multi-
centre study). Some data grouped for evaluating specific hypotheses has been included and
this has been appropriately indicated. In addition, data from studies for which it was not clear
that the purpose of admission was for comprehensive inpatient rehabilitation (and may have
involved acute care) were not included.

Table 3.2 Rehabilitation Length of Stay (by Country and Sample Period)
Population Sample
Study Jurisdiction Length of Stay Result
(N, Trauma &/or Nontrauma) Period

Australia 167,
Tooth et al. 2003 1993-1998 83.0 (Median)
(single centre) Trauma

3-3
Population Sample
Study Jurisdiction Length of Stay Result
(N, Trauma &/or Nontrauma) Period

Scivoletto et al. Italy 150,


1997-2001 112.4±69.3
2005 (single centre) Trauma & Nontrauma

Scivoletto et al. Italy 150,


1997-2001 98.7±68.13
2003 (single centre) Trauma & Nontrauma

Pagliacci et al. Italy 684,


1997-1999 135.5
2005 (multi-centre) Trauma
1
185.6±130.4 (N=60)
Sumida et al. Japan 123,
1994-1997 267.8±171.6 (N=63)2
2001 (multi-centre) Trauma 1
Early vs 2delayed admission

1997 60.8±38.7
1996 54.3±34.9
1995 60.1±37.1
Eastwood et al. USA 3,904, 1994 57.6±35.5
1999 (multi-centre) Trauma 1993 70.1±44.0
1992 80.9±46.9
1991 77.3±42.0
1990 74.0±41.1

1995 95.8 (N=66)


Morrison & USA 127,
Stanwyck 1999 (single centre) Trauma
1991 54.2 (N=61)

Yarkony et al. USA 1382,


1972-1986 68.1 (1986 data only)
1990 (single centre) Trauma

84.9 (N=185)1
Heinemann et al. USA 338, 87.7 (N=153)2
1981-1985 1
1989 (single centre) unknown Specialist vs 2more general
care

84.9 (N=185)1
2
Yarkony et al. USA 711, 87.7 (N=153)
1973-1980 1 2
1987 (single centre) Trauma Specialist vs more general
care

Rehabilitation LoS is also known to vary according to neurological status and data from studies
reporting LoS organized by level of injury (i.e., paraplegia vs. tetraplegia) or completeness are
shown in Table 3.3. Again this is organized by jurisdiction (country) and the time period over
which the sample was analyzed.

Table 3.3 Rehabilitation Length of Stay (by Neurological Status


Length of Stay Result
Population Sample
Study Jurisdiction (Mean – in days)
(N, Trauma &/or Nontrauma) Period
(±SD if available)

Incomplete paraplegia – 43.0


(All Medians)
Australia 167,
Tooth et al. 2003 1993-1998 Complete paraplegia – 96.5
(single centre) Trauma
Incomplete tetraplegia – 64.5
Complete tetraplegia – 206.0

3-4
Length of Stay Result
Population Sample
Study Jurisdiction (Mean – in days)
(N, Trauma &/or Nontrauma) Period
(±SD if available)

AIS D paraplegia –
79.42±20.07 (N=3)
AIS ABC low paraplegia –
52.00±1.41 (N=2)
AIS ABC high paraplegia –
China (Hong
Chan & Chan 33, 55.8±43.0 (N=2)
Kong) 2002
2005 Trauma AIS D tetraplegia –
(single centre)
143.75±69.25 (N=4)
AIS ABC low tetraplegia –
215.9±56.1 (N=7)
AIS ABC high tetraplegia –
146.5±75.4 (N=6)

Paraplegia - 46.7
1995
Morrison & USA 127, Tetraplegia – 61.9
Stanwyck 1999 (single centre) Trauma Paraplegia - 82.2
1991
Tetraplegia – 110.9

Paraplegia – 54.3 (1986 data


Yarkony et al. USA 1382,
1972-1986 only)
1990 (single centre) Trauma
Tetraplegia – 82.8

Paraplegia – 68.71, 70.72


Heinemann et al. USA Tetraplegia – 98.0, 103.4
338, unknown 1981-1985 1
1989 (single centre) Specialist (N=185) vs 2more
general (N=153) care.

Incomplete paraplegia –
1 2
46.3 , 50.6
Complete paraplegia – 62.2,
62.9
DeVivo et al. USA 661, Incomplete tetraplegia – 59.7,
1973-1985
1990 (single centre) Trauma 71.3
Complete tetraplegia – 90.4,
83.8
1 2
( Early (N=284) vs later
(N=377) admitted patients)

Woolsey et al. USA 100, Unknown Paraplegia – ~105


1985 (single centre) Trauma (pre 1985) Tetraplegia – ~165

Incomplete paraplegia – 78.2


Complete paraplegia – 83.4
Yarkony et al. USA 711,
1973-1980 Incomplete tetraplegia –
1987 (single centre) Trauma
107.6
Complete tetraplegia – 135.3

Discussion

As seen in Tables 3.2 and 3.3, rehabilitation LoS varies widely from country to country. While no
investigators have systematically analyzed country-by-country variation it is apparent that the
US has typically shorter rehabilitation LoS times than other countries reporting data. Most data
has originated in the US, bolstered by the development of the US model systems database, with
reports from other countries for the most part limited to a handful of descriptions of single-centre
experience.

3-5
Within the US, it is clear that the trend for progressively shorter rehabilitation LoS has continued
to at least the mid 1990’s. In 2 separate investigations, Morrison and Stanwyck (1999) and
Eastwood et al. (1990) described reduced LoS from the period between the early 1990’s to the
mid 1990’s. Eastwood et al. (1990) examined the large US Model systems database of
individuals with traumatic SCI (N=3,904) and reported annual mean LoS values from 1990
to1997. For these years, the highest value was 80.9 days in 1992 and the lowest was 54.3 days
in 1996. Mean LoS values for 1990-1992 seemed fairly stable at higher values, with 1994-1997
values lower and 1993 at an intermediate value. Morrison and Stanwyck (1999) performed a
direct comparison of 1991 vs 1995 mean LoS values in the largest SCI rehabilitation in the US
in order to assess the effect of shorter rehabilitation LoS on functional outcomes. These authors
confirmed an even more striking difference between these 2 years given an average LoS of
95.8 days in 1991 as compared to 54.2 days in 1995 (p<0.001). Other reports have described
reductions over earlier periods, most notably multi-centre investigations associated with the US
Model Systems databases (De Vivo et al. 1991). It is uncertain if these trends have continued or
if the same patterns have been seen in other countries.
Also apparent from Table 10.5 is the relationship of longer LoS associated with higher level of
injury and greater severity of injury. Similar patterns were seen in all studies describing
rehabilitation LoS for individuals with varying injuries. That is, the greatest mean rehabilitation
LoS values were seen for those with complete tetraplegia (especially high level) whereas the
shortest mean values occurred for those with incomplete paraplegia (DeVivo et al. 1990; Tooth
et al. 2003; Chan & Chan 2005).

Conclusions

There is Level 3 evidence (with US data only) that rehabilitation LoS has become
progressively shorter up to the mid-1990s. No other jurisdiction has published data that
supports this contention.

There is Level 3 evidence that those with higher level and more severe injuries have
longer rehabilitation LoS.

Those with higher level and more severe injuries have longer rehabilitation LoS. (Length of Stay)
Rehabilitation LoS in the US has become progressively shorter up to the mid-1990s.

3.3.1.2 Neurological and Functional StatusError! Bookmark not defined.

Several studies have identified patterns of neurological and/or functional improvement over the
first few months post-injury. The majority of these studies examine neurological and/or
functional status and associated changes between rehabilitation admission and discharge. In
addition, the Consortium for Spinal Cord Medicine (1999) has published a review of expected
neurological and functional outcomes following SCI. This Clinical Practice Guideline refers to
the work of Bracken et al. (1993, 1997), Geisler et al. (1991) and Waters et al. (1994a, 1994b) in
noting that over half of the expected recovery occurs in the first 2 months following injury and
recovery may continue but slows noticeably after 3-6 months. This change in neurological status
may represent the natural course of recovery, however, it is uncertain as to the extent that
rehabilitation practices play in enhancing this recovery.

3-6
In addition, the reader is directed to the Consortium for Spinal Cord Medicine (1999) Clinical
Practice Guideline for a comprehensive consensus review itemizing expected functional
achievements for individuals at every level of SCI. Table 3.4 summarizes various reports in the
literature for neurological and/or functional status organized by jurisdiction and also by the time
period for which the data was collected. As above, data were only included in this table if the
underlying sample was deemed representative of an overall heterogeneous population of
individuals with SCI (i.e., unselected sample of a single or multi-centre study).

Table 3.4 Neurological and/or Functional Status (by Country and Sample Period)
Jurisdiction Population
Neurological and/or Functional
and (N, Outcome
Study Change with Rehabilitation
Sample Trauma &/or Measure
Period Nontrauma)

• ↑ from 68.7 (admission) to 102.2


(discharge) due almost entirely to
gains in motor FIM scores.
Australia • Total FIM scores were lowest for
167,
Tooth et al. 2003 (single centre) FIM those with complete tetraplegia
Trauma
1993-1998 and highest for those with
incomplete paraplegia. Those with
complete tetraplegia had the least
change in FIM scores.

• 31% of people improved, 66%


remained unchanged, and 3%
Australia 262, deteriorated. 23% initially
Burke et al. 1985 Frankel
(single centre) Trauma complete became incomplete and
40% of those initially incomplete
improved.

• All groups showed ↑ in FIM motor


scores from admission to
discharge but these were only
China (Hong
significant for tetraplegia ASIA D.
Chan & Chan Kong) 33,
FIM • All patient groups (i.e., levels and
2005 (single centre) Trauma
severity of injury) had similar FIM
2002
motor scores at discharge as
noted by American Consortium for
Spinal Cord Medicine (1999).

• ↑ was associated with ASIA B and


Italy
Pagliacci et al. 684, C, shorter LoS, earlier admission
(multi-centre) AIS
2003 Trauma and no complications (especially
1997-1999
pressure sores).

• ↑ in ASIA motor scores and light


touch scores for those with
incomplete injuries but not
Turkey
Mϋslϋman-oğlu 52, ASIA complete injuries.
(single centre)
et al. 1997 Trauma & Nontrauma FIM • FIM showed ↑ f for those with
1992-1995
incomplete injuries and those with
complete paraplegia but not
complete tetraplegia.

3-7
Jurisdiction Population
Neurological and/or Functional
and (N, Outcome
Study Change with Rehabilitation
Sample Trauma &/or Measure
Period Nontrauma)

• Proportion showing ↑ were 10.3%


(A), 45.2% (B), 55.9% (C), 7.3%
(D) vs no change 89% (A), 50.3%
(B), 41.5% (C), 90.5% (D) vs
declined 4.5% (B), 2.6% (C), 2.0%
(D)
USA
DeVivo et al. 13,763, AIS • From 1973-1990 the proportion of
(multi-centre)
1991 Trauma FIM incomplete patients increased
1973-1990
from 40% to 55.2%.
• Average FIM gain was 37
(incomplete paraplegia, 36
(complete paraplegia), 34
(incomplete tetraplegia and 15
(complete tetraplegia).

• ↑ in total scores & self-care and


USA mobility subscores.
Yarkony et al. 711,
(single centre) MBI • greater ↑ for incomplete vs
1987 Trauma
1973-1980 complete and for those with
paraplegia vs tetraplegia.

Discussion

The AIS represents an internationally recognized system for the classification of individuals with
SCI, and as such, has been employed to characterize overall improvement in the neurological
status of people with SCI (ASIA 2002). The AIS is an ordinal 5 grade scale classifying
individuals from “A” to “E” with “A” designating those with complete SCI and “E” designating
individuals with normal sensory and motor function. Most notably, Pagliacci et al. (2003) and
DeVivo et al. (1991) employed large multi-centre databases and found that individuals with
incomplete injuries (especially AIS B or C) were more likely to improve at least 1 grade over the
course of rehabilitation. In particular, DeVivo et al. (1991) reported that 45.2% and 55.9% of
those initially admitted as AIS B and C respectively improved at least 1 AIS grade as compared
to only 10.3% and 7.3% of individuals initially classified as AIS A or D respectively.
Similarly, many individuals also make significant functional gains during comprehensive
inpatient rehabilitation. Most often functional status has been assessed at admission and
discharge from rehabilitation using the FIM (Vivo et al. 1991; Muslumanoglu et al. 1997; Tooth
et al. 2003; De Chan & Chan 2005) or MBI (Yarkony et al. 1987). Typically, functional gains are
greater with rehabilitation for those with incomplete injuries as compared to complete injuries
and for those with paraplegia as compared to those with tetraplegia (De Vivo et al. 1991;
Muslumanoglu et al. 1997;Tooth et al. 2003; Chan & Chan 2005). In particular, DeVivo et al.
(1991) reported similar average FIM gains for those with incomplete and complete paraplegia
and incomplete tetraplegia (i.e., 37, 36 and 34 respectively) but much reduced gains for those
with complete tetraplegia (i.e., 15). For the most part increases seen in the FIM have been
attributed to motor FIM changes with little change in cognitive FIM scores at least partly due to
an apparent ceiling effect (Chan & Chan 2005).

Conclusions

There is Level 4 evidence that a significant proportion of people (~50%) initially assessed
as AIS B and C will improve by at least 1 AIS grade in the first few months post-injury

3-8
concomitant with inpatient rehabilitation. Fewer individuals (~10%) initially assessed as
AIS A and D will improve by 1 AIS grade.

There is Level 4 evidence that individuals make significant functional gains during
inpatient rehabilitation, more so for those with complete and incomplete paraplegia and
incomplete tetraplegia.

Most individuals make significant functional gains during inpatient rehabilitation.


A significant proportion of people improve 1 AIS (ASIA Impairment Scale) grade in the first few
months post-injury particularly those initially assessed AIS B and C.

3.4 Factors for Optimal Outcomes

3.4.1 Effect of Intensity on Rehabilitation Outcomes

Although it is commonly assumed that the therapies delivered during inpatient rehabilitation are
effective, there is generally little direct evidence that demonstrates a clear relationship between
typical therapeutic practice and enhanced functional outcomes (Heinemann et al. 1995).
Moreover, there is no evidence that establishes a recommended intensity or amount of therapy
that should be delivered to produce a desired result. In SCI rehabilitation, there exists a paucity
of studies that examine this issue.

Table 3.5 Individual Studies - Intensity of Rehabilitation


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size

Population: SCI and ABI, SCI subjects (SCI findings only)


had a mean of 38.9 years old and were 1. When analysed together, none of the
79% male. individual therapy intensities were
Treatment: Variation in therapy intensity predictive of improved outcomes.
(OT, PT, SLT, Psych). Also examined When analysed individually, very little
effect of various other factors including was significant in the prediction with
LoS, Interruptions, Onset days, Admission only greater LoS associated with
scores and age. greater achievement of potential motor
Outcome Measures: FIM (motor, gains (p<.05) and interrupted rehab
cognitive, total), FIM Efficiency (motor or associated with less achievement of
Heinemann et al. 1995;
cognitive) all collected at Discharge. potential motor gains (p<.05).
USA
2. Patients with > intervals between
Downs & Black score=18
onset and admission had less motor
Case Series
function at discharge, achieved less of
Initial N=264;
their potential motor gains and made
Final N=246
less efficient motor gains (all p<.05).
3. Therapy intensity was predicted to a
small degree by the various functional,
demographic and medical variables
(psychology intensity had highest
explained variance with 26.3% ; SLT
17.2%, All therapies combined 16.6%,
OT 7.3%, PT 6.5%).
4. People with lower cognitive and motor
function at admission receive more

3-9
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size

intense therapy (psychology and all -


p<.001, speech & OT - p<.01, PT -
p<.05);

Discussion

Heinemann et al. (1995) employed a case series design to examine the effect of increased
therapeutic intensity on functional rehabilitation outcomes as indicated by motor, cognitive and
total FIM scores as well as FIM efficiencies. These investigators performed a comprehensive
chart review of patients with SCI (N=106) and traumatic brain injury (N=140) to determine the
number of 15-minute therapy units delivered in the provision of PT, OT, SLT and Psychology
services. They then performed multiple regression analyses to determine if the amount of
therapy was associated with positive outcomes. For the most part, there was little evidence that
increased therapeutic intensity had any effect on improving outcomes for the SCI sub-sample
although the paucity of well-controlled studies in this area limits the strength of the conclusions
that can be drawn.

Conclusions

There is Level 4 evidence based on a single case series that increased therapeutic
intensity may not be associated with any functional benefit as measured by the FIM.

Increased therapeutic intensity may not necessarily lead to functional benefits,


but data is scarce.

3.4.2 Effect of Age on Rehabilitation Outcomes

Historically, traumatic SCI has been viewed as a young, male concern although there have
been recent shifts in the demographics of SCI such that an increasing proportion of recently
injured individuals are older (both male and female). In fact, recent epidemiological evidence
from Ontario, Canada found that the highest rates of SCI-related hospital admission following
trauma in this jurisdiction was for those over 70 years of age although the frequency of specific
etiologies (e.g., falls vs motor vehicle crashes) varied with age (Pickett et al. 2003). In the US
the average age at injury has increased steadily over the last 30 years with the US Model
Systems National SCI Statistical Center (2006) reporting an average age of injury of 38.0 years
for the period from 2000-2006 as compared to 28.7 years for the period from 1973-1979. In
addition, many centers in various jurisdictions around the world also provide rehabilitation
services to individuals with spinal cord damage as the result of a variety of non-traumatic
etiologies and often these people are much older than those injured due to trauma (McKinley et
al. 2001; McKinley et al. 2002; Scivoletto et al. 2003; New 2005).
Given these trends for increasing age in those undergoing rehabilitation it is important to
understand the effects of age on rehabilitation outcomes. Several investigators have employed
retrospective assessments of single or multi-centre patient databases to examine this issue
(Cifu et al. 1999a; Cifu et al. 1999b; Seel et al. 2001; Scivoletto et al. 2003; Kennedy et al.
2003).

3 - 10
Table 3.6 Individual Studies – The Effect of Age on Rehabilitation Outcomes
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Traumatic and non-traumatic 1. Improvements were noted in ↓


SCI, 147 males, 45 females, Mean “percentage to be achieved" scores for
age=40.7±16.5 years, (152 aged 16-54, 40 all 9 areas of need (p<0.0001). No
aged 55-85), incomplete tetraplegia (23%), significant differences were seen
complete tetraplegia (21%), complete between age groups.
paraplegia (34%) and incomplete 2. Those with complete lesions showed
paraplegia (22%), Mean time post-injury to greater improvement in bowel
admission=28.8 days. management than those with
Treatment: No treatment per se, but incomplete lesions (p<0.005) and
various outcomes associated with inpatient those with tetraplegia showed greater
rehabilitation focusing on goal attainment improvement in the area of skin care
Kennedy et al. 2003;UK
in younger vs. older patients. than those with paraplegia group
Case Control
Outcome Measures: Needs Assessment (p<0.005) Otherwise no other
(Inadequate control)
Checklist (NAC) collected within 2 weeks differences.
Initial N=200;
of mobilization and within 6 weeks of 3. Mobility needs of older subjects were
Final N=192
discharge. significantly higher compared to the
younger subjects (p<0.005) initially,
but lower for the community score
(p=0.01). Higher scores (i.e., more
unmet need) assessed close to
discharge were noted for older vs
younger for the areas of skin
management (p<0.01), bladder
management (p<0.01), bowel
management (p<0.05) and mobility
(p<0.01).
Population: Traumatic (105) and non- 1. Although LoS was longer for younger
traumatic (179) SCI, 184 males, 100 patients (111.3±63.88 vs 89±69.9,
females, Mean age=50.4±19.3 (12-86) p<0.008) which was related to a
years, cervical (81), thoracic (148), lumbo- higher incidence of incomplete lesions
sacral (55), ASIA A-D, and etiology, a matched-block sub-
Mean time post-lesion to admission was analysis (N=130) showed differences
56.9±43.9 days. were not significant.
Treatment: No treatment per se, but 2. Neurological recovery was more
various outcomes associated with inpatient frequent with younger group (p=0.006)
rehabilitation focusing on younger (<50) vs and for those at ASIA C. Matched
older (>50) patients. Mean LoS was group sub-analysis showed more
98.7±68.1 days. ASIA grade (p=0.027) and motor
Scivoletto et al. 2003; Outcome Measures: LoS, ASIA score improvements in younger group.
Italy Impairment Scale, ASIA Motor Index, 3. Gains for independence of daily living
Case Control Barthel Index (BI), Rivermead Mobility measures (BI and RMI) were
Initial N=284; Index (RMI), Walking Index for SCI significantly greater for younger group
Final N=284 (WISCI), Discharge Destination. All (p<0.001).
collected at admission and discharge. 4. Younger age group had more people
reach independent walking levels on
WISCI than in older group (p<0.004).
Similar findings for related subscales
in BI and RMI.
5. Younger age group had more people
reach autonomous bladder (p=0.005)
and bowel control (p=0.014) than in
older group. Similar findings for
bladder subscales in BI.

3 - 11
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Traumatic SCI from US Model 1. FIM improvement was less for people
Systems database, 83% male, Mean ≥ 60 than those younger.
age=31.72±12.68 (18-92) years, 2. There were no significant differences
paraplegia, ASIA A-D. in ASIA motor index scores, change
Treatment: No treatment per se, but scores or efficiency scores across
various outcomes associated with inpatient different ages.
acute and rehabilitation care focusing on 3. No systematic significant differences
age effects by comparing results between were noted for acute care LoS or
Cifu et al.1999; USA
11 age categories. Mean acute LoS was hospital charges.
Case Control
13.2±16.92 days. Mean rehabilitation LoS 4. Rehabilitation LoS was longer and
(Inadequate control)
was 56.76±34.28 days. associated hospital charges greater
Initial N=2,169;
Outcome Measures: LoS, Charges, ASIA for older individuals (trend beginning
Final N=2,169
motor index score, Functional for those > 54 and peaking in the 60-
Independence Measure (FIM), change 64 age group).
scores and efficiencies for FIM and ASIA 5. Younger age groups were more likely
motor index. All collected at admission to injured as a result of vehicular crashes
acute care and admission to rehabilitation or violence while older groups were
care and discharge. more likely injured as a result of falls
or other events including being struck
by falling objects, pedestrian accidents
and medical/surgical complications.
Population: Traumatic SCI from US Model 1. The younger the age group, the
Systems database, male and female, 3 greater the FIM motor score
equal (N=125) age groups (18-34, 35-64, improvement and greater FIM motor
>64) matched for neurological level and efficiency.
completeness, tetraplegia, ASIA A-D, 85% 2. The younger and middle age groups
admitted within 21 days post-injury. had significantly greater ASIA motor
Treatment: No treatment per se, but index score increases and efficiency
Cifu et al. 1999; USA various outcomes associated with inpatient than the older age group.
Case Control acute and rehabilitation care focusing on 3. No systematic significant differences
Initial N=375; age effects by comparing results between related to age were noted for acute
Final N=375 3 age categories. care or rehabilitation Length of Stay or
Outcome Measures: LoS, Charges, ASIA hospital charges.
motor index score, Functional 4. The older the age group, the more
Independence Measure (FIM), change likely individuals would be discharged
scores and efficiencies for FIM and ASIA to an institutional setting.
motor index, Discharge destination. All
collected at admission to acute care and
admission to rehabilitation care and
discharge.
Population: Traumatic SCI from US Model 1. FIM improvement was greater for the
Systems database, male, female, 3 equal younger and middle group that for the
(N=60) age groups (18-39, 40-59, >59) older group (p<0.001). FIM efficiency
matched for neurological level and ASIA was greater for the young group as
classification, paraplegia, ASIA A-D, 84% compared to the 2 older groups
admitted within 21 days post-injury. (p<0.001).
Seel et al. 2001; USA
Treatment: No treatment per se, but 2. There were no significant differences
Case Control
various outcomes associated with inpatient in ASIA motor index scores at any of
Initial N=180;
acute and rehabilitation care focusing on the time points across the different
Final N=180
age effects by comparing results between ages.
3 age categories. 3. No systematic significant differences
Outcome Measures: LoS, Charges, ASIA were noted between the 3 age groups
motor index score, Functional for acute care LoS or hospital charges.
Independence Measure (FIM), change 4. Rehabilitation LoS was significantly
scores and efficiencies for FIM. All shorter for younger than middle or
collected at admission to acute care and older groups. There was no difference

3 - 12
Author Year; Country
Research Design Methods Outcome
Total Sample Size

admission to rehabilitation care and in associated hospital charges for the


discharge. 3 groups.
5. All age groups were equally likely to
be discharged to a private residence
(≥92%).

Discussion

Similar approaches involving case control study designs have been employed by various
investigators to examine the effect of age on rehabilitation outcomes. However, in the present
review, studies employing some form of matching across different age groups were assessed
as representing a higher level of evidence (i.e., Level 3) (Cifu et al. 1999b; Seel et al. 2001;
Scivoletto et al. 2003) as compared to those deemed as having an inadequate method of
controlling for potential confounds (i.e., Level 4) (Cifu et al. 1999a; Kennedy et al. 2003).
Several of these studies have demonstrated differences between age groups for a variety of
rehabilitation outcomes although there were also some contradictory findings within these
studies, albeit some of this may have been due to variation between the sampling frames and
methods employed in each study.
For example, Seel et al. (2001) and Cifu et al. (1999a) reported reduced rehabilitation LoS for
those with paraplegia due to trauma whereas no differences were seen in investigations of
those with tetraplegia due to trauma (Cifu et al. 1999b) and also with the mixed sample of
people with both traumatic and non-traumatic SCI (Scivoletto et al. 2003).
Conversely, all studies examining functional change showed that younger individuals
demonstrated greater functional improvements as indicated by increases with the FIM (i.e.,
motor FIM scores, change scores, efficiencies) (Cifu et al. 1999a; Cifu et al. 1999b; Seel et al.
2001) or BI (Scivoletto et al. 2003). These similar results were obtained from studies involving
those with paraplegia (Cifu et al. 1999a; Seel et al. 2001), tetraplegia (Cifu et al. 1999b) and a
mixed sample comprised of those with both traumatic and non-traumatic SCI (Scivoletto et al.
2003). On the other hand, Kennedy et al. (2003) employed the Needs Assessment Checklist
(NAC) developed internally at Stoke-Mandeville, UK and demonstrated that there were few
systematic age-related differences associated with goal attainment in a mixed traumatic, non-
traumatic sample. The NAC is a client-focused outcome measure that assesses the degree to
which specific behavioural outcomes particularly relevant to the client are achieved.
In addition to functional outcomes, effective rehabilitation has also been associated with
increases in neurological status as indicated by AIS or ASIA motor scores. Of the studies
reviewed and possessing measures of neurological status, both studies limited to those with
paraplegia showed no age effects (Cifu et al. 1999a; Seel et al. 2001;). Conversely, similar
studies of those with tetraplegia or a mixed traumatic and non-traumatic SCI sample
demonstrated that younger individuals were more likely to make significant neurological gains
during inpatient rehabilitation (Cifu et al. 1999b; Scivoletto et al. 2003).

Conclusions

There is Level 3 evidence that significantly shorter rehabilitation LoS is associated with
younger vs older individuals with paraplegia. The same may not be true for those with
tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI.

3 - 13
There is Level 3 evidence that younger as compared to older individuals are more likely
to obtain greater functional benefits during rehabilitation.

There is Level 3 evidence that significant increases in neurological status during


rehabilitation are more likely with younger than older individuals with tetraplegia or for
mixed cohorts involving traumatic and non-traumatic SCI. The same may not be true for
those with paraplegia.

Younger individuals with paraplegia are more likely to have shorter rehabilitation
LoS than older individuals.
Younger individuals are more likely to make greater functional gains during
rehabilitation than older individuals.
Younger individuals with tetraplegia (or in a mixed traumatic, non-traumatic sample) are more
likely to make gains in neurological status during rehabilitation than older individuals.

3.4.3 Differences in Traumatic vs Non-Traumatic SCI Rehabilitation Outcomes

Those individuals sustaining damage to the spinal cord due to non-traumatic causes are often
treated in specialized inpatient SCI rehabilitation centres more commonly associated with those
with SCI due to traumatic etiologies. Various reports have estimated that one-quarter to one half
of all cases seen in specialized SCI rehabilitation centers are associated with non-traumatic
etiologies (Muslumanoglu et al. 1997; McKinley et al. 1999b; van der Putten et al. 2001).
Despite these significant numbers, relatively little systematic research is directed at non-
traumatic SCI (van der Putten et al. 2001; McKinley et al. 2002). Common causes of non-
traumatic SCI includes space occupying lesions such as tumours or prolapsed intervertebral
discs, spondylosis such as that seen with degenerative spinal changes resulting in compression
of the spinal cord, vascular ischemia as in arteriovenous malformations or spinal infarction,
inflammation (e.g., idiopathic transverse myelitis, tropical spastic paraparesis, sarcoid) and
those associated with congenital or familial etiologies ( Adams & Salam-Adams 1991; McKinley
et al. 1999b; McKinley et al. 2001). Although estimates of the incidence of non-traumatic SCI
have been provided (e.g., 8 per 100,000) (Kurtzke 1975), it is difficult to ensure accuracy given
the heterogeneous nature of non-traumatic SCI and the variety of facilities and programs where
these patients may receive care.
Studies comparing those with damage to the spinal cord due to non-traumatic vs. traumatic
etiologies have demonstrated a variety of systematic differences between these 2 patient
groups. In general, those with non-traumatic SCI are more likely to be older, female, have
paraplegia and have an incomplete injury than those with traumatic SCI (McKinley et al. 1996;
McKinley et al. 2001; McKinley et al. 2002; New 2005). In the present section, we review the
studies characterizing rehabilitation outcomes between those with SCI due to non-traumatic vs
traumatic causes.

Table 3.7 Individual Studies – Non-Traumatic SCI and Rehabilitation Outcomes


Author Year; Country
Research Design Methods Outcome
Total Sample Size

McKinley et al. 2001; Population: Non-traumatic SCI (n=87) 1. As compared to those with trauma
USA from a single centre vs traumatic SCI (after matching), those with non-
Case Control (n=87) from the US Model Systems traumatic SCI had …

3 - 14
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Initial N=174; database; Matched on level and 2. ↓ rehabilitation LoS (22.46 vs


Final N=174 completeness of lesion and age; 2/3rds 30- 41.49days) (p=0.000)
59 years, 1/3rd 60+ years; 93% were 3. ↓ overall charges (p=0.003) and ↓
admitted within 21 days of injury; 68% daily charges (p=0.019)
were paraplegic; AIS C 36%, AIS D 41%. 4. no difference on motor FIM at
Treatment: No treatment per se, outcomes admission and motor FIM efficiency
associated with non-traumatic vs traumatic with rehabilitation
rehabilitation. 5. ↓ motor FIM at discharge and ↓ motor
Outcome Measures: LoS, charges, motor FIM change
FIM (score, change and efficiency). 6. no difference in discharge destination.
Collected at admission to and discharge
from rehabilitation.

Population: Non-traumatic SCI secondary 1. As compared to those with trauma


to stenosis (n=81) vs traumatic SCI (before matching), those with stenosis
(n=102) within a single centre; Matching were significantly (p<0.01) …
from N=381 sample on paraplegia vs • older (64.1 vs 44.4).
tetraplegia and completeness. • more likely female (38.8 vs
Treatment: No treatment per se, but 21.2%)
various outcomes associated with non- • more likely to have paraplegia
traumatic (stenosis) vs traumatic SCI (69.4% vs 45.5%)
rehabilitation. • more likely to be incomplete injury
McKinley et al. 2002; Outcome Measures: LoS, charges, (AIS C or D) (100% vs 49.3%)
USA Discharge rates to home, FIM (score, 2. As compared to those with trauma
Case Control change and efficiency). Collected at (after matching), those with stenosis
Initial N=381; admission to and discharge from had significantly (p<0.05) …
Final N=183 rehabilitation. • ↓ LoS (22.1 vs 32.2 days)
• ↓ charges
•  admission FIM and FIM motor
scores
• ↓ total and motor FIM change and
FIM efficiency
• no difference in discharge FIM
totals
• No difference in discharge
destination.

Population: Non-traumatic SCI secondary 1. As compared to those with trauma


to neoplastic cord compression admitted (before matching), those with
over 5 years (within a single centre (n=29) neoplastic cord compression were …
vs traumatic SCI (n=29) from the US Model • older (57.8 vs 30.45).
Systems database matched by age, level • more likely to have paraplegia
of injury and AIS; Age = 57.8 years; AIS A- (88.2% vs 52.5%)
D; C4-L2. • more likely to be incomplete
McKinley et al. 1999; Treatment: No treatment per se, but (88.2% vs 56.7%
USA various outcomes associated with 2. As compared to those with trauma
Case Control rehabilitation care of non-traumatic (after matching), those with neoplastic
Initial N = 4,035; (neoplastic cord compression) vs traumatic cord compression …
Final N=58 SCI. • had ↓ LoS (25.17 vs 57.46 days)
Outcome Measures: LoS, Discharge • had ↓ motor FIM change
destination, FIM (total score, change and • had ↓ motor FIM scores at
efficiency). Collected at admission to and discharge
discharge from rehabilitation. • no different FIM efficiency
• no different for discharge
destination

3 - 15
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Non-traumatic SCI; median 1. LoS =55.8 days (7-413 days).


age=69 years (29-86); AIS B-D tetraplegia 2.  FIM motor scores during rehabilitation
32.9%, AIS A paraplegia=8.6%, AIS B-D= from 40.8 to 67.1, cognitive FIM
58/6%; 78.6% had relatively fast onset (<7 showed no change due to initial ceiling
days) and were admitted to effect.
rehabilitation=30.9 days, 21.4% had 3. 17.7% overall and 26.9% over the age
gradual onset and were admitted=11.0 of 70 were discharged to a nursing
New et al. 2005;
months. home.
Australia
Treatment: No treatment per se, outcomes 4. Those subjects male, younger, more
Case Series
associated with non-traumatic SCI mobile, more independent bowel and
Initial N=70; Final N=62
rehabilitation. bladder function and less severe AIS
Outcome Measures: Demographics, grades were more likely to be
clinical characteristics, LoS, Discharge discharged home.
setting, level of lesion and AIS, FIM, 5. Major non-traumatic classifications
mobility, bowel and bladder function. were tumour (32.9%), degenerative
Collected at admission to and discharge (25.7%), vascular (14.3%) and other
from rehabilitation. (27.1%).
Population: Non-traumatic SCI; mean 1. LoS = 31.5 days (9-184 days).
age=55 years (16-88); 54% male; cervical 2.  FIM motor score was associated with
49%, upper thoracic 21%, lower thoracic lower score on admission and reduced
and lumbar 22%; Time from onset to time between onset-admission (overall
rehabilitation=4.8 years (0.1-32 years). predictive model).
Van der Putten et al.
Treatment: No treatment per se, but 3. Age (i.e., younger), etiology (i.e.,
2001; England, UK
optimal outcomes were regressed against hereditary pathology) and lesion level
Case Series
various factors associated with non- (i.e., cervical) were individually
Initial N=100;
traumatic rehabilitation. associated with improved functional
Final N=100
Outcome Measures: Demographics, outcomes but did not improve
clinical characteristics, level of lesion and prediction of overall model.
AIS, FIM motor score and change score.
Collected at admission to and discharge
from rehabilitation.
Population: Non-traumatic SCI secondary 1. LoS = 27 days (7-54 days).
to neoplastic cord compression admitted 2. People showed significant  in 9 FIM
over 5 years within a single centre; Mean categories (0<0.005) associated with
age=64 years; 18 men, 14 women. mobility and self-care during
Treatment: No treatment per se, but rehabilitation.
outcomes associated with rehabilitation 3. 11 individuals improved from AIS C to
care. D at discharge.
McKinley et al. 1996;
Outcome Measures: Medical 4. 27/32 were discharged home, 4
USA
complications, AIS, LoS, bladder function, transferred for medical reasons (and
Case Series
FIM, Discharge destination. All collected at died within 2 months) and 1 died
Initial N=32; Final N=20
admission to and discharge from before discharge.
rehabilitation. Level of ambulation and 5. Of 20 people with assessed at 3-15
dressing ability assessed at 3-15 months month follow-up, 16 had maintained
post-discharge. mobility and dressing function as
compared to discharge. However,
12/20 had eventually died at a mean
of 101 days post-discharge.

Discussion

Studies examining non-traumatic SCI typically make use of retrospective case series designs
describing rehabilitation outcomes directly (McKinley et al. 1996; van der Putten et al. 2001;
New 2005) or involve case control designs employing matching techniques to make
comparisons with traumatic SCI while controlling for such things as age and level and

3 - 16
completeness of injury (McKinley et al. 1999; McKinley et al. 2001; McKinley et al. 2002). As
noted above, those with non-traumatic SCI were more likely to be older, female, have
paraplegia and have an incomplete injury than those with traumatic SCI (McKinley et al. 1996;
McKinley et al. 2001; McKinley et al. 2002; New 2005).
When direct comparisons of traumatic and non-traumatic SCI of various etiologies have been
conducted using matching procedures, it is clear that shorter rehabilitation LoS was seen for
those with non-traumatic SCI (McKinley et al. 2001). In addition, this shorter LoS was
associated with reduced hospital charges for both an overall and a per diem basis (McKinley et
al. 2001). These findings were replicated with similar studies examining subsets of those with
non-traumatic SCI including those with stenosis (McKinley et al. 2002) and those with neoplastic
cord compression (McKinley et al. 1999). However, these findings have only been established
with data from the US Model Systems. For example, others have reported longer rehabilitation
LoS (van der Putten et al. 2001; New 2005) although these reports were conducted in other
jurisdictions (i.e., Australia, UK respectively) and employed case series designs such that direct
comparisons with traumatic SCI were not possible.
None of the studies employing matching procedures noted differences in discharge destinations
for those with non-traumatic SCI as compared to those with traumatic SCI (McKinley et al. 1999;
McKinley et al. 2001; McKinley et al. 2002). although New et al. (2005) did note that within non-
traumatic subjects, those individuals male, younger, more mobile, more independent with bowel
and bladder function and having less severe AIS grades were more likely to be discharged
home. In addition, the relatively poor prognosis and low survival rate of those with neoplastic
cord compression has specific implications for discharge disposition (McKinley et al. 1996)
although no specific differences were noted in a matched comparison (McKinley et al. 1999).
All studies reviewed employed the FIM to assess the functional status of individuals and
generally demonstrated improved function with rehabilitation. Typically, motor FIM scores were
employed or in the event total FIM scores were used it was acknowledged that changes were
due primarily to the motor FIM subscale given a ceiling effect associated with the cognitive FIM
subscale (McKinley et al. 1999; New 2005). For the most part, improvements seen in FIM during
rehabilitation for non-traumatic SCI were lesser as those compared to traumatic SCI as reflected
by lower FIM change scores (McKinley et al. 1999; McKinley et al. 2001; McKinley et al. 2002).
When examining a mixed population of non-traumatic SCI, there were no differences between
trauma and non-trauma groups with respect to admission FIM but there was a reduced FIM at
discharge for the non-traumatic group accounting for the lower FIM change score (McKinley et
al. 2001). This lower FIM change did not result in a lower FIM efficiency given the reduced LoS
for the non-traumatic group. When examining only those with stenosis vs those with traumatic
SCI, those with non-traumatic SCI had higher FIM scores on admission, similar scores on
discharge, resulting in reduced change scores and lower efficiency (McKinley et al. 2002). On
the other hand, those with neoplastic cord compression demonstrated similar FIM scores on
admission, reduced scores on discharge, resulting in reduced change scores but no difference
in efficiency (McKinley et al. 1999).
Van der Putten (2001) assessed a variety of factors using multiple linear regression techniques
in order to predict those most associated with increases in FIM motor scores during
rehabilitation. They included 100 consecutively admitted patients with non-traumatic SCI with
rehabilitation periods of > 1 week. The primary factors associated with improved motor FIM
scores accounting for 54% of the variance were having a lower score on admission and reduced
time between symptom onset-admission. Age, specific diagnostic subgroup (i.e., space-
occupying, vascular, spondylosis, inflammation or hereditary), or lesion level did not improve the
prediction significantly.

3 - 17
Conclusions

There is Level 4 evidence that those with non-traumatic SCI are more likely to be older,
female, have paraplegia and have an incomplete injury as compared to those with
traumatic SCI.
There is Level 3 evidence that those with non-traumatic SCI have generally reduced
rehabilitation LoS, reduced hospital charges but similar discharge destinations as
compared to those with traumatic SCI.
There is Level 3 evidence that those with non-traumatic SCI have generally reduced
motor FIM improvement during rehabilitation as compared to those with traumatic SCI.

Individuals with non-traumatic SCI have reduced LoS and less functional improvement with
rehabilitation as compared to those with traumatic SCI although controlled comparisons are
limited to data from the US Model Systems.

3.4.4 Effect of Gender and Race on Rehabilitation Outcomes

Potentially, there are many additional factors that may affect rehabilitation outcomes following
inpatient SCI rehabilitation. Two of these factors include gender and race, although neither has
been examined comprehensively. With respect to gender effects, studies investigating
rehabilitation outcomes associated with women have focused on long-term psychosocial
outcomes associated with issues such as marriage or motherhood or issues associated with
community and vocational reintegration (Westgren & Levi 1994; DeVivo et al. 1995; Shackelford
et al. 1998; Krause et al. 1998). Studies of the effects of race on rehabilitation outcomes have
been limited to evaluations of the differences between whites and African Americans using US
Model Systems data (Meade et al. 2004a; Putzke et al. 2002), although as with studies of
gender, investigations of the effects of race have focused more on vocational issues and
satisfaction with life (James et al. 1993; Krause et al. 1998; Krause 1998; Meade et al. 2004b).

Table 3.8 Individual Studies – The Effect of Gender and Race on Rehabilitation Outcomes
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Traumatic SCI from US Model 1. No significant differences between


Systems database; matched white vs whites vs African Americans for ASIA
African American subjects matched by and FIM motor index scores.
level of function, ASIA Impairment Scale, 2. No significant differences for
age and primary care sponsor; 84.2% discharge disposition (P=0.622).
Meade et al., 2004; male; age=34.2±15.3 years; tetraplegia, 3. African Americans were more likely to
USA paraplegia; ASIA A-D. be injured as a result of violence and
Case Control Treatment: No treatment per se, but whites were more likely to be injured in
Initial N=628; various outcomes associated with inpatient MVCs.
Final N=628 acute and rehabilitation care focusing on 4. African Americans were significantly
race effects by comparing outcomes of more likely to receive laparotomies
African Americans and whites. (p<0.001) and be catheter free in
Outcome Measures: ASIA motor index comparison to caucasians.
scores, FIM motor score, Medical 5. Whites were more likely to receive
complications, discharge disposition, spine surgeries (p<0.001) and have

3 - 18
Author Year; Country
Research Design Methods Outcome
Total Sample Size

medical procedures and medical more suprapubic cystomies in


management. Collected at admission to comparison to African Americans.
acute care and admission to and discharge 6. No significant differences between
from rehabilitation. racial groups in the occurrence of
medical complications during either
acute care or rehabilitation.

Population: Traumatic SCI from US 5. No significant differences were seen


Model Systems database; matched male for acute care or rehabilitation Length
vs female by level of function, AIS and age; of Stay or charges between males and
50% were 18-34 years, 42% were 36-64 females.
years and 8% were >64 years old; 6. No significant differences were seen in
tetraplegia, paraplegia; ASIA A-D; 86% discharge destinations between males
were admitted to Model systems within 21 and females.
days post-injury. 7. No significant differences were seen in
Treatment: No treatment per se, outcomes admission, discharge, or change
associated with inpatient acute and scores for both functional (i.e., FIM)
rehabilitation care focusing on gender and neurological (i.e., ASIA)
Greenwald et al., 2001; effects. assessments between males and
USA Outcome Measures: Length of Stay, females.
Case Control Charges, ASIA motor index total score, 8. Gender differences in the
Initial N=1074; FIM motor score, FIM motor change development of complications during
Final N=1074 scores, FIM motor efficiency scores, and rehabilitation, notably, pressure sores
medical complications. Collected at (p<0.001) and DVTs (p=0.003) were
admission to acute care and admission to more likely in men.
and discharge from rehabilitation. 9. Younger patients had better functional
outcomes than older patients with
significantly higher FIM motor scores
at discharge.
10. Older patients had significantly greater
ASIA motor scores on admission and
discharge than middle-aged patients,
who had significantly greater scores
than younger patients.
Population: Traumatic SCI admitted within Study 1
1 day of injury to integrated (acute and 1. Significant differences between race
rehabilitation) US Model Systems Center were not found relating to any of the
(Study 1: eligible N=2438) or having 1 year outcome measures including FIM,
or later follow-up data in the US Model Length of Stay (acute or rehabilitation
Systems database (Study 2: eligible care), Discharge destination and
N=3301), matched white and African charges (p>0.05).
Putzke et al. 2002; American by various injury and 2. The 2 groups were significantly
USA demographic factors, tetraplegia, different (p<0.001) on numerous other
Case Control paraplegia, complete, incomplete, Study 1: demographic and injury-related factors
Study 1: Age=34.8±15.9 (white) & 35.3±15.6 including age, education, gender,
Initial N=2438; (African American) years, Gender 90% race, marital and occupational status,
Final N=374 male (both groups), Study 2: lesion level, and injury duration.
Study 2: Age=37.7±12.2 (white) & 37.8±12.0 Study 2
Initial N=3301; (African American) years, Gender 93% No significant differences were seen
Final N=316 male (both groups). with SWLS, SF-12 and CHART
Treatment: No treatment per se, but race (p=0.25).
effects on various outcomes associated None of the medical outcome
with integrated acute and rehabilitation variables differed significantly (p>0.05)
care (study 1) or long-term (study 2) with race, including days
studied by comparing results between rehospitalized and number of
whites and African Americans. rehospitalizations in the previous year,
Outcome Measures: Study 1: FIM motor impairment level, and total medical

3 - 19
Author Year; Country
Research Design Methods Outcome
Total Sample Size

and efficiency scores, Length of Stay, complications.


Discharge destination, medical Despite non-significant results with
complications, Charges. Study 2: FIM multivariate analyses, univariate
motor and efficiency scores, CHART, analyses were also conducted and
Satisfaction with Life Scale (SWLS), SF-12 were generally non-significant except
(measured the individual’s perception of that whites reported less handicap on
his/her health status), medical the CHART mobility subscale
complications and number of (p=0.03).
hospitalizations. All collected at admission, As with Study 1, both groups differed
discharge or at annual follow-up (Study 2 significantly on numerous
only). demographic and injury-related factors
(p<0.001).

Discussion

Greenwald et al. (2001) employed a mixed, block design, matching male and female subjects so
as to control for covariant effects of injury characteristics (level and AIS) and age at injury. They
retrospectively analyzed 1,074 subjects over a 10-year period from 1988-1998 by using US
Model Systems data culled from 20 different SCI centers from a variety of geographic regions.
In general, there were no significant differences between males and females for rehabilitation
outcomes including discharge disposition, LoS, FIM motor scores (including change scores and
efficiencies) or ASIA motor scores. There were also no reported gender-related differences for
the incidence of most medical complications encountered during rehabilitation stay including
pneumonia, autonomic dysreflexia, pulmonary embolism, cardiac arrest, kidney calculi or
gastrointestinal hemorrhage. However, men did have significantly higher rates for DVT and
pressure sores although the authors reported that these differences were not robust and did not
result in increased stays, charges or lower functional outcomes.
Similar case control designs employing matched groups of whites vs. African Americans from
the US Model Systems database have also been employed to examine race effects on
rehabilitation outcomes. Putzke et al. (2002) matched race groups according to age, education,
gender, occupational status, impairment level, etiology, primary sponsor of care and geographic
region whereas Meade et al. (2004) matched according to level of injury, AIS, age and primary
sponsor of care. By controlling for all these variables, these authors were able to establish that
race acts more as a proxy variable than a predictor of outcomes (Putzke et al. 2002). For
example, differences did exist in a wide variety of demographic, rehabilitation outcomes and
specific medical conditions provided to African Americans vs. whites when considering but
these were generally accounted for by socio-demographic and etiological differences associated
with these groups (Putzke et al. 2002; Meade et al. 2004). For example, African Americans
were significantly more likely to be injured as the result of violence and have 11th grade
education or less while whites were more likely injured as a result of motor vehicle crashes and
had high school education or more (Putzke et al. 2002; Meade et al. 2004). For the most part,
there were no differences between the two groups with respect to rehabilitation outcomes when
the variables noted above were accounted for in the matching process.

Conclusions

There is Level 3 evidence that there is no difference with respect to gender on discharge
destination, rehabilitation LoS and neurological or functional outcomes associated with
rehabilitation.

3 - 20
There is Level 3 evidence that there is no difference with respect to race (white vs
African-American) on rehabilitation LoS and neurological or functional outcomes
associated with rehabilitation that are not otherwise explained by socio-demographic or
etiological differences.

Neither gender nor race effects have been demonstrated for discharge destination,
rehabilitation LoS and neurological or functional status in US Model Systems data.

3.5 Specialized vs General SCI Units (Acute Care)

Donovan et al. (1984) contend that best practice for SCI care consists of a situation in which
every individual sustaining a SCI is admitted to an integrated, comprehensive system where
expertise, facilities and equipment are focused on optimal patient care and cost effectiveness.
At the other extreme is the situation condemned by Bedbrook and Sedgley (1980), of piecemeal
care for those with SCI characterized by “the occasional patient being treated by the occasional
doctor”. In practice, care provided by most SCI centers likely falls somewhere in between these
extremes of specialized vs. general care. The present section outlines the studies that are
focused on examining the hypothesis that care provided through specialized SCI centers is
more efficient and effective than that delivered at general centers.
The reader should note that while the majority of these studies were conducted from
rehabilitation centers the experimental manipulation of interest concerns the degree to ehich
specialist care is delivered during acute care period.

Table 3.9 Individual Studies – Specialized vs General SCI Units


Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: 338 SCI admitted to 1. Those receiving specialized care


Rehabilitation, paraplegia, tetraplegia, made functional gains with
complete, incomplete. significantly greater efficiency and
Treatment: N=185 initially treated in a were transferred to rehabilitation
specialized short-term acute care unit; significantly faster (p<.001).
Heinemann et al. 1989;
Control: N=153 initially treated in general 2. A significantly greater number of
USA
hospitals. people were transferred from general
Case Control
Outcome Measures: Modified Barthel centers with spine instability than from
Initial N=338;
index (MBI), MRSCICS Patient Functional specialized SCI centers (p=.02).
Final N=338
Level Scheme, Length of Rehabilitation 3. There was no difference between
Stay (LoS), Efficiency of Rehabilitation specialized and general acute care
Gains (MBI / natural logarithm of LoS) with respect to functional status at
rehabilitation admission or discharge
nor on rehabilitation LoS.

Population: Traumatic SCI admitted to a 1. Those admitted from the specialized


specialized rehabilitation unit; Males SCI unit had significantly improved
Yarkony et al. 1985; (n=149) and females (n=32); Avg age 28 joint motions (i.e., reduced
USA years; Tetraplegia (54%), paraplegia contractures). More had normal range
Case Control (46%); incomplete (58%), complete (42%). of motion (p<0.05) and fewer
Initial N=181; Treatment: Comparison of those treated abnormalities.
Final N=181 acutely in a specialized interdisciplinary 2. Those admitted from the specialized
spinal unit (n=90) vs a general hospital unit SCI unit were admitted significantly
(n=91). earlier for rehabilitation as compared

3 - 21
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Outcome Measures: Joint motion, time to to those admitted from the general
rehabilitation admission, all collected at hospital unit (p<0.01). Those admitted
admission to rehabilitation. earlier to rehabilitation had reduced
numbers of contractures (p<0.01).
3. Those with tetraplegia had an
increased incidence of contractures
(p<0.01).

Population: Traumatic SCI, admitted to a 1. Subjects who were cared for in the
specialized, integrated rehabilitation unit in integrated, specialized unit (Australia)
Australia (n=66) vs those admitted to the encountered the fewest complications.
US Model Systems (n=1606); tetraplegia, (no statistical analysis was performed)
paraplegia; incomplete, complete. 2. People sustained progressively more
Donovan et al. 1984; Treatment: Those treated in an integrated, complications with longer periods of
USA / Australia specialized interdisciplinary spinal unit delayed admission (US Model
Case Control (Australia) admitted <48 hours post-injury Systems). Individuals admitted at
Initial N=1,672; vs those admitted to the US Model these longer delays were cared for
Final N=1,672 Systems at 1-15, 16-30, 31-45 or 46-60 initially in general hospital units.
days post-injury (reflecting progressively
less specialized care).
Outcome Measures: Incidence of 7
complications collected at 1-15, 16-30, 31-
45 or 46-60 days post-injury.
Population: traumatic SCI; 201/220 1. Subjects who were admitted to the
consecutive admissions to a newly specialized SCI unit had significantly
established specialized interdisciplinary shorter acute care LoS than those
acute SCI unit vs 351 admissions to one of admitted to the general units
two general hospital trauma units; (p<0.001). Within the specialized unit
tetraplegia, paraplegia; incomplete, subsample, an increased delay from
Tator et al. 1995; complete; Male/female ~ 4/1; Median age - accident to admission resulted in
Canada 27 years (SCI Specialist unit), 32.0 years longer LoS (p=0.032).
Case Control (general hospital). 2. Subjects who were admitted to the
Initial N=552; Treatment: Comparison of those treated in specialized SCI unit had significantly
Final N=552 a SCI specialist spinal unit (1973-1981) vs reduced mortality than those admitted
a general hospital trauma unit (1947-1973). to the general units (p=0.022). This
Outcome Measures: LoS, Mortality rate, was especially evident in those with
Cord Injury Neurological Recovery Index. complete SCI.
All collected at 6 months (complete) or 12 3. Subjects who were admitted to the
months (incomplete). specialized SCI unit had significantly
greater neurologic recovery (p<0.001).

Discussion

The majority of the studies examining the effect of specialist vs. general SCI care settings
focused on this issue during the acute period of care only, with the primary outcome measures
being taken at admission to rehabilitation and no follow-up after this point. Of the four studies
reviewed, only one investigated the results associated with a specialized, integrated unit
comprised of both acute and rehabilitation services (Donovan et al. 1984). In this study, rates of
six of seven different medical secondary complications typically encountered by individuals with
SCI were lowest for the cohort admitted initially (i.e., typically within 48 hours post-injury) to the
specialist SCI centre. This cohort was analyzed retrospectively with complication rates
determined at various times throughout rehabilitation (i.e., 1-15, 16-30, 31-45, 46-60 days) and
compared with those being admitted to specialist SCI centers from more general care settings
at similar time periods. Most striking was the absence of decubitis ulcers during any time period

3 - 22
for those under more specialized care vs. a progressively greater incidence for those with
greater time spent in general care. No statistical analysis was conducted for this study.
In the remaining 3 studies all comparisons were limited to specialized vs. general acute care
and were retrospective in nature. Two of these studies compared subjects as they were being
admitted for comprehensive rehabilitation (Yarkony et al. 1985; Heinemann et al. 1989). In both
studies, patients were transferred significantly faster to comprehensive inpatient rehabilitation
from more specialized acute care settings than from general hospital settings. In the remaining
study by Tator et al. (1995), the same issue was investigated by examining outcomes
associated with a seven year experience of a newly developed specialist SCI unit as compared
to historical data culled from pre-existing trauma units reflecting more general settings (Tator et
al. 1995). In this study, subjects were also transferred to rehabilitation faster from the specialist
SCI unit resulting in a reduced length of stay (LoS) in acute care.
In general, all of these studies demonstrated improved medical outcomes associated with more
specialized care. In addition to the reduced complication rates noted above by Donovan et al.
(1984), others have noted that more specialized acute care resulted in less spine instability
(Heinemann et al. 1989) and significantly improved joint motion with reduced incidence of
contractures (Yarkony et al. 1985) upon admission to a comprehensive rehabilitation program.
In addition, reduced mortality and improved neurological recovery (as demonstrated by higher
scores on the Cord Injury Neurological Recovery Index) were seen in the newly developed
specialist SCI unit as compared to the data from pre-existing general trauma units (Tator et al.
1995). It should be noted that a gradual reduction of mortality was seen over the entire study
period and that reductions attributed to the specialist unit might also be due to many general
gradual improvements in medical care, especially as a historical control was used as the
primary basis for comparison.
Only one study has examined the functional benefits realized during rehabilitation associated
with SCI-specific acute care vs. that delivered in more general settings. Heinemann et al. (1989)
used the Modified Barthel Index to show that those individuals receiving more specialist care
made functional gains during subsequent rehabilitation with significantly greater efficiency (i.e.,
functional change/LoS) than those referred from general settings. No statistically significant
differences were seen between the specialist vs. general groups for either admission or
discharge functional levels nor were significant differences seen with LoS. There was, however,
a significant reduction in the time from injury to rehabilitation admission for those receiving care
in the specialist SCI unit. This implies an overall reduced length of total hospitalization for this
group, although this data was not reported. Functional benefits associated with early admission
and reduced LoS will be reviewed in the next section.
A primary limitation of all studies reported here was the use of retrospective data collection
methods and in the case of Tator et al. (1995), the use of historical controls. Another important
limitation of some of these studies is the failure to control for (or at least adequately describe)
the time to admission to initial care following injury, especially with respect to control subjects
(e.g., Donovan et al. 1984; Yarkony et al. 1985; Heinemann et al. 1989). This is an important
confounding variable as early admission to a specialized system of care is likely associated with
better outcomes as demonstrated in the following section. Therefore, the present conclusions
are limited to a Grade 3 level of evidence and some findings have been reduced to Grade 4 if
not corroborated and involving inadequate controls. While more carefully controlled prospective
studies would be difficult to implement, they would be required to strengthen the evidence in this
area.

3 - 23
Conclusions - Benefits of Specialized vs General SCI Units

Based on several retrospective, case-control studies there is Type 3 evidence that


individuals cared for in interdisciplinary, specialist SCI acute care units soon after injury
(most being admitted within 48 hours) begin their rehabilitation program earlier.

There is Level 3 evidence that individuals cared for in interdisciplinary, specialist acute
care SCI units have fewer complications upon entering and during their rehabilitation
programs.

There is Level 4 evidence that individuals initially cared for in interdisciplinary, specialist
acute care SCI units make more efficient functional gains during rehabilitation (i.e., more
or faster improvement).

There is Level 4 evidence that individuals cared for in interdisciplinary, specialist SCI
units have reduced mortality.

More specialized, interdisciplinary acute SCI care is associated with faster transfers to
rehabilitation and may result in fewer medical secondary complications, more efficient functional
gains and reductions in overall mortality.

3.6 Early vs Delayed Admission to Specialized SCI Units

As noted by others and in the previous section, earlier as opposed to delayed admission to
interdisciplinary, specialized SCI units has been associated with a variety of beneficial outcomes
(DeVivo et al., 1990). The question of whether earlier admission to an organized system leads
to enhanced outcomes is inexorably linked to the question of specialist vs general care for
individuals with SCI. In all studies in this and the preceding section the authors framed their
studies as addressing either the question of delay or the question of interdisciplinary, specialist
care yet similar designs were employed for each (i.e., retrospective case control). For those
subjects experiencing a delay to admission to a specialized SCI unit, it was either presumed or
established that preceding acute care was conducted at a general hospital unit. The author
simply chose to characterize this as either a delay or more general care. For the present review
we have maintained this distinction as originally intended by each author, especially, as in some
cases, there is little or no verification of the general nature of the pre-admission care or the time
of first admission, respectively. However, the reader is advised that the specific findings and
conclusions reached in both sections are most likely associated with a delay to an
interdisciplinary, specialized acute or rehabilitation SCI unit with prior care delivered at a general
hospital facility.
In addition, much variation exists in the literature that addresses the question of delayed
admission. There is no uniform or accepted definition of what constitutes a delay and this varies
depending on the context of the study, most notably whether it is conducted from an acute vs
rehabilitation perspective. For the present review, all studies which examine this question by
comparing 2 or more groups within the first week post-injury have been examined separately

3 - 24
from those with an initial time period greater than 1 week post-injury. These have been termed
1) Acute and 2) Post-acute studies, respectively.

Table 3.10 Individual Studies – Early vs Delayed Admission (Acute Studies)


Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: 661 people with SCI admitted 1. Those with complete paraplegia
to a US Model Care System Centre with (p=0.0169) & incomplete tetraplegia
specialized SCI rehabilitation services. (p=0.0001) admitted earlier (<24
Subjects included those with tetraplegia hours) had significantly shorter total
and paraplegia and also those with hospitalization LoS. A similar trend for
incomplete vs complete injuries but those with incomplete paraplegia
frequencies were not provided. Average (p=0.0568), no difference for those
ages for early vs delayed admission with complete tetraplegia (p=0.928).
groups were 29.5 and 32.0 years old 2. Mean hospital charges were less for
respectively. subjects with complete (p=0.0099) and
Treatment: No tx per se, comparison of incomplete (p=0.0134) tetraplegia who
those admitted earlier (< 24 hours post were admitted earlier. Similar trend for
injury) vs later (> 24 hours) to a specialized those with incomplete paraplegia
integrated spinal unit (i.e., combined acute (p=0.0607), no difference for complete
DeVivo et al. 1990; USA care and rehabilitation). Subjects were paraplegia (p=0.4777).
Case Control sub-grouped into i) paraplegia, incomplete, 3. In general, no overall differences were
Initial N=661; ii) paraplegia, complete, iii) tetraplegia, seen in the development of medical
Final N=661 incomplete, iv) tetraplegia, complete. complications between the early vs
Outcome Measures: Length of Stay late admission groups. A few
(LoS), Hospital charges, Incidence of differences for incidence specific
medical complications, Neurologic complications.
recovery, Mortality all collected at 4. Trend for increased neurologic
Discharge. recovery with early admission in that
10/315 (3.2%) vs 4/401 (1.0%) in early
vs late groups had complete recovery
(p=0.08). Author warns of bias in this
finding.
5. Mortality comparisons not possible
within sample for early vs late
admission groups. Comparison with
historical data suggests enhanced
survival rates with early admission.
Population: 482 men and women with 1. Subjects who were admitted earlier
traumatic SCI admitted to a US Model (<24 hours) had significantly fewer
Systems SCI Centre with specialized SCI contractures than those admitted later
acute care and rehabilitation services. (>24 hours – 60 days) (p=0.05).
Subjects included those with tetraplegia 2. Other factors associated with an
(256) & paraplegia (226) and ASIA A, B, C increased incidence of contractures
Daylan et al. 1998; USA
(362) & D (120). included tetraplegia vs paraplegia
Case Control
Treatment: No tx per se, comparison of (p<0.01), presence of a pressure ulcer
Initial N=482;
those admitted 1. (< 24 hours post injury) (p=0.05), co-existence of head injury
Final N=482
vs 2. (> 24 hours – 60 days post-injury) to (p<0.05).
a specialized spinal acute care and
rehabilitation unit.
Outcome Measures: Incidence of
contractures during initial post-traumatic
hospitalization.

3 - 25
Table 3.11 Individual Studies – Early vs Delayed Admission (Post-Acute Studies)
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: SCI, tetraplegia, paraplegia, 1. Those admitted earliest (<30 days)


complete, incomplete, traumatic. had significantly  performance on
Treatment: No tx per se, comparison of activities of daily living (i.e., Barthel
those admitted to a specialized Spinal Index scores) at discharge than those
Rehabilitation unit at one of 3 time periods with longer delays (>60 days)
following injury (<30 days, 31-60 days, > (p=.006). They also demonstrated
60 days). significantly greater changes (p=.003)
Outcome Measures: LoS, ASIA motor and greater efficiency (p<.001) for the
scores and impairment grade, Barthel Barthel Index.
Scivoletto et al. 2005; Index (BI), Rivermead Motor Index (RMI), 2. Those admitted the earliest (<30 days)
Italy Walking Index for SCI (WISCI), Efficiency had significantly better mobility (i.e.,
Case Control measures for all were calculated by RMI) at discharge than those with
Initial N=150; dividing by LoS. longer delays (>60 days) (p=.03).
Final N=150 They also demonstrated significantly
greater changes (p=.001) and greater
efficiency (p=.04) for the RMI.
3. There were no significant differences
between the early vs later admissions
with respect to walking (WISCI) or
ASIA motor scores (p=.63 or p=.81).
4. Those admitted earliest had the
shortest LoS; these differences were
not significant (p=.15).
Population: SCI, tetraplegia, paraplegia, 1. Those admitted with a delay (> 7
traumatic. days) following referral had
Treatment: No tx per se, comparison of significantly longer LoS (p<.001). This
those admitted to a specialized integrated was for people with both complete
spinal unit (i.e., combined acute and (N=59) and incomplete (N=29) injuries
rehabilitation) with or without a delay but not for those without spinal cord
between injury and referral (>3 days) and damage (N=24).
between referral and admission (>7 days). 2. More severe injuries (as determined
Outcome Measures: LoS. by Injury Severity Scores) were more
Amin et al. 2005; likely to have longer LoS (Spearman’s
England = 0.593, p<0.0001).
Case Control 3. Those who were admitted with a delay
Initial N=432; between injury and referral (>3 days)
Final N=432 did not differ on LoS with those who
did not experience a delay (p=0.44).
4. The primary reasons for delays
between referral and admission for
those with complete injuries were I)
achieving medical stability and ii)
absence of beds. For those with
incomplete injuries the same primary
reasons were identified but in reverse
order.
Population: 197 people with traumatic SCI 1. Those admitted earlier had
admitted within 1 year of injury to a Level 1 significantly shorter total
trauma Centre with specialized SCI hospitalization LoS (p<.01).
Oakes et al. 1990; USA
rehabilitation services. Male / female (158 / 2. Those admitted earlier with tetraplegia
Case Control
39); Tetraplegia / paraplegia (102 / 95); had fewer medical complications and
Initial N=197;
Average ages for groups were 27.2 –32 less frequent spinal surgery vs those
Final N=197
years old. admitted later (no group analysis
Treatment: No tx per se, comparison of performed). Those admitted earlier
those admitted earlier (< median) vs later with paraplegia had no difference in

3 - 26
Author Year; Country
Research Design Methods Outcome
Total Sample Size

(> median) to a specialized integrated medical complications and more


spinal unit (i.e., combined acute care and frequent spinal surgery.
rehabilitation). Subjects were grouped by 3. Similar reductions in total
tetra vs para and by early vs late hospitalization LoS with earlier
admission by median admission values of admissions for both those with
11 (Tetra) vs 21 (Para) days. tetraplegia (p<.01) and paraplegia
Outcome Measures: LoS, incidence of (p<.05) in a re-analysis of the sample
medical complications, incidence of with groupings based on admissions <
surgical intervention. 24 hours vs > 24 hours post-injury.

Population: 123 people with SCI admitted 1. Subjects who were admitted earlier
to a Japanese Hospital System with (<2 weeks) had significantly shorter
specialized SCI rehabilitation services LoS than those admitted later
following acute care. Subjects included (p<0.0005).
those with tetraplegia and paraplegia 2. FIM gain (p<0.0001) and FIM
(frequencies not provided) with ASIA A efficiency (p<0.0001) were
(51), B (8), C (35) and D (29). significantly greater for subjects
Sumida et al. 2001; Treatment: No tx per se, comparison of admitted earlier vs later. Note: the
Japan those admitted earlier (< 2 weeks post early admission subjects had lower
Case Control injury) vs later (> 2 weeks) to a specialized initial motor and total FIM scores than
Initial N=139; spinal rehabilitation unit. Subjects were did the delayed admission group
Final N =123 sub-grouped into i) tetraplegia, ii) (p<0.05).
paraplegia, iii) central cord. 3. Correlations between ASIA motor and
Outcome Measures: LoS, FIM, FIM motor FIM scores in various subgroups and
score, FIM gain, FIM efficiency all collected at admission and discharge yielded a
at Discharge. variety of associations ranging from
very weak to strong correlations
(r=0.03-0.92) with the majority of these
correlations significant (p<.05).

Population: 173 men (mean age 35.5) 1. Subjects with paraplegia who were
and 46 women (mean age 44.2) with admitted earlier (<1 week and < 2
traumatic SCI admitted to a Spinal Injuries months) had significantly shorter LoS
Centre with specialized SCI acute care and than those admitted later (p<0.05).
rehabilitation services. Subjects included 2. Subjects with tetraplegia who were
those with tetraplegia (116) and paraplegia admitted earlier (<1 week) had
Aung & El Masry 1997;
(103). significantly shorter LoS than those
UK (Wales)
Treatment: No tx per se, comparison of admitted later (>2 months) (p<0.05).
Case Control
those admitted 1. (< 1 week post injury) vs 3. The incidence of most secondary
Initial N=219;
2. (< 2 month) vs 3. (> 2 months) to a conditions did not differ between early
Final N=219
specialized spinal acute care and vs later admissions for those with
rehabilitation unit. paraplegia or tetraplegia. However,
Outcome Measures: LoS, incidence of those with paraplegia or tetraplegia did
secondary complications all collected at have lower incidence of pressure
discharge (i.e, during initial post-traumatic sores with earlier admission (<1 week)
hospitalization). (p<0.001).

Discussion

The present section describes a series of studies in which investigators examined the effect of
delayed admission to a specialist SCI unit. However, there is not a common definition of what
constitutes a “delayed” admission. Therefore, to assist the reader in summarizing these delays,
the details of the various time frames under examination are outlined along with their respective
results in Table 3.12.

3 - 27
Table 3.12 Studies Examining Delayed Admission to SCI Unit
Study Experimental Groups (time post-injury) Outcome Measure Result

LoS +
• <= 24 hours*
DeVivo et al. 1990 Secondary complications -
• > 24 hours
Neurological Status ~

• <= 24 hours* Secondary complications +


Daylan et al. 1998
• > 24 hours (contractures)

• <= 30 days* LoS ~


Scivoletto et al. 2005 • 30-59 days Functional Status +
• > 60 days Neurological Status -

• <= 3 days LoS -


• > 3 days
Amin et al. 2005 or
• <= 7 days from referral* LoS +
• > 7 days from referral

• <= 11 days (for tetra)* LoS +


• > 11 days Secondary complications + (tetra only)
Oakes et al. 1990 or
• <= 21 days (for para)*
• > 21 days

LoS +
• <= 2 weeks*
Sumida et al. 2001 Functional Status +
• > 2 weeks
Neurological Status

• <= 1 week* LoS +


Aung & El Masry 1997
• < 2 months Secondary complications -
(*= Condition with most positive result, + = Positive results, ~ = Trend, - = No effect)

Two acute studies were reviewed which each employed retrospective, 2 group (case control)
designs with a definition of 24 hours as to what constituted an “early” vs a “delayed” admission
(DeVivo et al. 1990; Dalyan et al. 1998). Each study examined a fairly large cohort admitted to a
multidisciplinary, specialized SCI unit (i.e., US model system center) within 24 hours post-injury
vs those admitted after 24 hours. Neither study reported the actual injury to admission times for
the “delayed” admission group and both failed to provide information about the referral sources
(e.g., specialist vs. general nature). DeVivo et al. (1990) noted that total hospital LoS (i.e., acute
and rehabilitation) was reduced for all patient groups except for those with complete tetraplegia
when admission was not delayed. Mean hospital charges were also reduced for early admission
subjects except those with complete paraplegia and there were some reductions in the
incidence of specific medical complications with early admission for some patient groups, most
notably a trend for a reduction in pressure sores for all but those with incomplete paraplegia. In
addition these authors also reported a trend for increased neurologic recovery and reduced
mortality with earlier admission, although they also noted methodological concerns associated
with the actual measures employed. Dalyan et al. (1998), in a study focusing on the
development of contractures, noted an increased incidence of contractures for those admitted
within 24 hours to a specialized unit.
Of the studies examining time periods longer than one week (i.e., post-acute), five studies have
been reviewed (Oakes et al. 1990; Aung & el Masry 1997; Sumida et al., 2001; Amin et al.
2005; Scivoletto et al. 2005). The initial admission delays examined ranged from 1 week (Aung
& el Masry, 1997) to 1 month (Scivoletto et al. 2005). All studies employed retrospective case

3 - 28
control designs and all examined LoS for the entire period of initial hospitalization as a primary
outcome measure. In all cases, those admitted earlier had reduced LoS, regardless of the
considerable variation between studies in the definition of what constituted a delay in admission.
It should be noted that this difference was statistically significant for all studies but one; for
which it was reported as a trend (p=0.15). This study examined the longest delay of 1 month
(Scivoletto et al. 2005).
Functional benefits were also demonstrated for individuals admitted earlier. Scivoletto et al.
(2005) reported that those admitted earlier than 1 month had significantly greater gains and
greater efficiency associated with the Barthel Index as well as greater mobility gains and
efficiency as measured by the Rivermead Mobility Index but there was no difference with
respect to walking as measured by the Walking Index for SCI (WISCI). Similarly, Sumida et al.
(2001) reported increased Functional Independence Measure (FIM) gains and efficiencies for
those admitted earlier than 2 weeks post-injury as compared to those admitted later.
Interestingly, these investigators also showed that for a majority of the various patient groups
tested (i.e., paraplegia and tetraplegia, early and late), significant associations were seen
between a measure of function (i.e., FIM) and a measure of impairment (i.e., ASIA motor
scores). However, Scivoletto et al. (2005) found no effect of early vs. late admission on ASIA
motor scores.
Other investigators examined the role of early vs late admission on the incidence of secondary
medical complications. Oakes et al. (1990) reported that earlier admissions were associated
with a reduced incidence of secondary medical complications in those with tetraplegia and Aung
and el Masry (1997) noted a reduction in the number of pressure sores for all subjects with
earlier admission.
Despite the apparent benefits of earlier admission to a multidisciplinary, specialized integrated
SCI unit, there are significant issues which serve to constrain the strength of evidence in this
area. First and foremost is the retrospective nature of all studies conducted to date. It is difficult
to ascertain how comparable the “early” vs “later” groups truly are with respect to potential
confounding variables. In particular, there is a paucity of information on the pre-admission level
of care and medical status, especially for the delayed admission groups. In addition, it is difficult
to discern the potential role that medical status or the presence of secondary medical
complications may have played in admission delays. The retrospective nature of the studies
outlined in this and the previous section makes it difficult to determine if individuals prone to
complications and with poorer medical status would have naturally comprised a greater
proportion of the delayed admission groups. Therefore, as noted earlier, more carefully
controlled prospective studies would be required to strengthen the evidence in this area.

Conclusions - Benefits of Early vs Later Admission

Based on several retrospective, case-control studies there is Type 3 evidence that


individuals admitted earlier to interdisciplinary, integrated specialist SCI units have a
shorter total hospitalization length of stay than those admitted later.

There is Level 3 evidence that individuals admitted earlier to interdisciplinary, integrated


specialist SCI units make greater functional gains in a shorter period of time (i.e., greater
efficiency) than those admitted later.

There is Level 3 evidence that individuals admitted earlier to interdisciplinary, integrated


specialist SCI units have fewer secondary medical complications (especially pressure
sores) than those admitted later.

3 - 29
Because of the variability between studies as to what constitutes “early” admission to
interdisciplinary, specialist integrated SCI units it is not possible to determine a specific
period for optimal admission. At least one study has demonstrated benefits with an early
admission described as anything within 30 days post-injury. The majority of studies
defined early admissions as 1-2 weeks post-injury, while studies focused on acute care
describe early admission as within 24 hours post-injury.

Earlier admission to specialized, interdisciplinary SCI care is associated with reduced length of
total hospital stay and greater and faster rehabilitation gains with fewer medical secondary
complications.
Prospective studies with stronger designs are needed to strengthen the evidence and provide
more direction as to the optimal model of care.

3.7 Outpatient and Follow-up Care

Various authors have noted the importance of providing continued, regular, specialized follow-
up care following discharge from rehabilitation (Ernst et al. 1998; Cox et al. 2001; Dryden et al.,
2004). In a recent review, Bloemen-Vrencken et al. (2005) described various follow-up
programmes for persons with SCI. These authors noted that the vast majority of the papers in
this area offered little more than a description of the program with 5 of these being identified as
either experimental or quasi-experimental in nature. Of these, 3 studies were focused on
evaluations of telemedicine or nursing education for the prevention of pressure sores or UTIs
(Barber et al. 1999; Phillips et al. 1999; Phillips et al., 2001), whereas the remaining two had
broader goals of general heath and well-being (Dinsdale et al. 1981; Dunn et al. 2000). Those
articles evaluating programs addressing specific goals (i.e., pressure sores or UTIs) will be
reviewed in the chapters related to these specific issues. The present section focuses on those
studies with more generic aims.
Cox et al. (2001) performed a needs assessment of 54 community-dwelling individuals with SCI
using structured telephone interviews and reported a perceived high need for a specialist,
multidisciplinary SCI outreach service. Some of the issues identified as the greatest areas of
need included dealing with physical changes, transportation, work issues, ongoing education
and pain management. The primary barriers to needs being met were overwhelmingly related to
limitations of local expert knowledge but also included inadequate funding, complicated
processes or service fragmentation and no knowing where to go for help. Preferred service
delivery options in order of preference included telephone advice, home visits, SCI outpatient
clinics, community-based service and regional hospital clinics (Cox et al. 2001). Similar
suggestions have been provided by clinicians, especially as they observe the consequences of
inadequate care received by some individuals upon discharge from inpatient rehabilitation
programmes (Vaidyanathan et al. 2004). Despite these reports, little direct evidence has been
established for the effectiveness of different methods of providing follow-up care.

Table 3.13 Individual Studies – Outpatient and Follow-up Care


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size

Dunn et al. 2000; USA Population: People with SCI receiving 1. Those receiving regular follow-up
Downs & Black score=12 SCI-specialist follow-up care (N=235) vs scored higher on all 3 subscales of

3 - 30
Prospective Controlled those not (N=136); Age = 56.6 vs 47.9; CYH, Health (p=0.0068),
Trial Gender = 99% Male vs 66% Male; Independence (p=0.005) and Absence
(inadequate control) paraplegic, tetraplegic; complete, of Depression (p<0.0001).
Initial N=371; incomplete; Time since injury = 19.4 vs 2. Those receiving regular follow-up
Final N=371 18.2 years. reported similar secondary conditions
Treatment: Follow-up care (routine check- as those without routine follow-up but
ups in SCI Outpatient Clinic) vs no Follow- with reduced frequency and rated it as
up care (presumably problem-based less severe.
primary care).
Outcome Measures: Secondary Condition
Surveillance Instrument (SCSI), Check
Your Health (CYH) Questionnaire. One
time survey of both groups.

Discussion

Dunn et al. (2000) performed an exploratory study of the value of receiving regular,
comprehensive outpatient health care follow-up as compared to those who were deemed to
have no access to these services. Although this investigation was limited by a poor description
of the specific services offered to both the experimental and control groups, there were
significant differences in the perceived health, independence, and absence of depression in
those seen regularly in outpatient clinics. In addition, this group had significantly less frequent
occurrences of specific secondary conditions and also rated the severity of these conditions as
less than those having no access to these clinics (Dunn et al. 2000). Although this trial was
prospective in nature and attempted a quasi-experimental controlled methodology, the potential
confounds (i.e., gender, completeness, race, age, veteran status) varied greatly between the
experimental and control groups. In addition, it was uncertain if selection bias may also have
been an issue, as the authors did not specify what percentage of individuals within their own
service provision cohort refused or did not receive regular outpatient care. These limitations
resulted in this study being assessed as having a Level 4 level of evidence.

Conclusions

There is Level 4 evidence that provision of routine, comprehensive, specialist follow-up


services may result in perceived improvements of health, independence and less
feelings of depression.

Routine, comprehensive, specialist follow-up services may result in improved health

3.8 Summary

There is Level 3 evidence (with US data only) that rehabilitation LoS has become
progressively shorter up to the mid-1990s. No other jurisdiction has published data that
supports this contention.

There is Level 3 evidence that those with higher level and more severe injuries have
longer rehabilitation LoS.

There is Level 4 evidence that a significant proportion of people (~50%) initially assessed
as AIS B and C will improve by at least 1 AIS grade in the first few months post-injury

3 - 31
concomitant with inpatient rehabilitation. Fewer individuals (~10%) initially assessed as
AIS A and D will improve by 1 AIS grade.

There is Level 4 evidence that individuals make significant functional gains during
inpatient rehabilitation, more so for those with complete and incomplete paraplegia and
incomplete tetraplegia.

There is Level 4 evidence based on a single case series that increased therapeutic
intensity may not be associated with any functional benefit as measured by the FIM.

There is Level 3 evidence that significantly shorter rehabilitation LoS is associated with
younger vs older individuals with paraplegia. The same may not be true for those with
tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI.

There is Level 3 evidence that younger as compared to older individuals are more likely
to obtain greater functional benefits during rehabilitation.

There is Level 3 evidence that significant increases in neurological status during


rehabilitation are more likely with younger than older individuals with tetraplegia or for
mixed cohorts involving traumatic and non-traumatic SCI. The same may not be true for
those with paraplegia.

There is Level 4 evidence that those with non-traumatic SCI are more likely to be older,
female, have paraplegia and have an incomplete injury as compared to those with
traumatic SCI.

There is Level 3 evidence that those with non-traumatic SCI have generally reduced
rehabilitation LoS, reduced hospital charges but similar discharge destinations as
compared to those with traumatic SCI.

There is Level 3 evidence that those with non-traumatic SCI have generally reduced
motor FIM improvement during rehabilitation as compared to those with traumatic SCI.

There is Level 3 evidence that there is no difference with respect to gender on discharge
destination, rehabilitation LoS and neurological or functional outcomes associated with
rehabilitation.

There is Level 3 evidence that there is no difference with respect to race (white vs
African-American) on rehabilitation LoS and neurological or functional outcomes
associated with rehabilitation that are not otherwise explained by socio-demographic or
etiological differences.

Based on several retrospective, case-control studies there is Type 3 evidence that


individuals cared for in interdisciplinary, specialist SCI acute care units soon after injury
(most being admitted within 48 hours) begin their rehabilitation program earlier.

There is Level 3 evidence that individuals cared for in interdisciplinary, specialist acute
care SCI units have fewer complications upon entering and during their rehabilitation
programs.

3 - 32
There is Level 4 evidence that individuals initially cared for in interdisciplinary, specialist
acute care SCI units make more efficient functional gains during rehabilitation (i.e., more
or faster improvement).

There is Level 4 evidence that individuals cared for in interdisciplinary, specialist SCI
units have reduced mortality.

Based on several retrospective, case-control studies there is Type 3 evidence that


individuals admitted earlier to interdisciplinary, integrated specialist SCI units have a
shorter total hospitalization length of stay than those admitted later.

There is Level 3 evidence that individuals admitted earlier to interdisciplinary, integrated


specialist SCI units make greater functional gains in a shorter period of time (i.e., greater
efficiency) than those admitted later.

There is Level 3 evidence that individuals admitted earlier to interdisciplinary, integrated


specialist SCI units have fewer secondary medical complications (especially pressure
sores) than those admitted later.

Because of the variability between studies as to what constitutes “early” admission to


interdisciplinary, specialist integrated SCI units it is not possible to determine a specific
period for optimal admission. At least one study has demonstrated benefits with an early
admission described as anything within 30 days post-injury. The majority of studies
defined early admissions as 1-2 weeks post-injury, while studies focused on acute care
describe early admission as within 24 hours post-injury.

There is Level 4 evidence that provision of routine, comprehensive, specialist follow-up


services may result in perceived improvements of health, independence and less
feelings of depression

3 - 33
Appendix – Studies Describing Rehabilitation Outcomes

Table 3.14 Individual Studies Describing SCI Rehabilitation Outcomes


Author Year; Country
Research Design Methods Outcome
Total Sample Size
Population: Traumatic SCI, 82% male, 1. Tetraplegics had significantly longer
Mean age=28.3 years, tetraplegia (55%), stays in rehabilitation than the
paraplegia (45%), incomplete, complete, paraplegic group (121 vs 81 days,
Mean time post-injury to admission=28.8 p<0.001). Those who were diagnosed
days. with incomplete lesions also had
Treatment: No treatment per se, but significantly shorter stays than those
outcomes associated with inpatient diagnosed with complete injuries
Yarkony et al. 1987; rehabilitation. LoS 69.6 + 39.2 days. regardless of level of injury (p=0.001).
USA Outcome Measures: LoS, Modified Barthel Incomplete (107.6 days) vs complete
Case series Index (MBI) collected at admission and (135.3) tetraplegia and incomplete
Initial N=711 discharge. (78.2 days) vs complete (83.4)
Final N=711 paraplegia.
2. Overall, patients showed significant
increases in total MBI and self-care
and mobility MBI subscores (p<0.001).
Improvements and discharge scores
were greater for incomplete vs
complete (p<0.001) and for those with
paraplegia vs tetraplegia (p<0.001).

Population: Traumatic central cord 1. Significant improvements were noted


syndrome, 67 males, 14 females, in the MBI self care subscores, MBI
Age=45.5±20.0 years Tetraplegia, Frankel mobility subscores and MBI total
C and D, Mean time post-injury to scores from admission to discharge
admission=29.8±18.0 days. Treatment: No (p<0.001 for all). At least 70% of
treatment per se, but outcomes associated patients were independent on each of
with inpatient rehabilitation. LoS 69.6 + 39.2 the individuals tasks comprising the
days. MBI at discharge.
Roth et al. 1990; USA
Outcome Measures: Modified Barthel 2. 89% of patients were discharged
Case series
Index (MBI) collected at admission and home.
Initial N=81
discharge. 3. Continent spontaneous voiding was
Final N=81
achieved by 84% at discharge as
compared to 23% at admission.
4. Regulation of bowel management was
achieved by 99% at discharge as
compared to 54% at admission.
5. Medical complications requiring
management occurred in 66.7% of
patients during rehabilitation.

Population: Patient Database (N=412), 1. Most gains in motor and sensory


traumatic, incomplete tetraplegia admitted scores were found in first year. An
within 90 days post-injury (N=95). average of 35 motor points (18%
Treatment: No treatment per se, but during acute care, 53% during
various outcomes associated with inpatient rehabilitation, 8% during the remainder
Pollard & Apple 2003;
acute care and rehabilitation. Main factors of the year) and 46 sensory points
USA
examined were effect of intravenous (46% during acute care, 46% during
Case Series
steroids, early definitive surgery (<24 hours rehabilitation, 8% during the remainder
Initial N=412
after injury) and early decompression of the year) were recovered.
Final N=95
surgery. Mean acute care LoS was 15±16 2. Younger individuals (<18) had more
days and mean rehabilitation LoS was improvement in motor scores but not
47±30 days. sensory scores than older people
Outcome Measures: Change in sensory (p=0.002).
score, final sensory score, change in motor 3. People with Brown Sequard and

3-34
Author Year; Country
Research Design Methods Outcome
Total Sample Size

score, final motor score. All collected at Central Cord injuries had more
admission and discharge (also for some at improvement in motor scores but not
time of injury and 1, 2, 3 years post-injury sensory scores than those with anterior
or the latest anniversary). cord (p=0.019).
4. There was no effect of
methylprednisolone (MP)
administration, early anterior
decompression, decompression of
stenosis without fracture, gender or
race. Those with MP administration did
have greater improvements in sensory
scores (p=0.027) although there was
no difference in the final sensory score
for those with and without MP.
Population: Traumatic Complete Thoracic 1. Overall, significant increases were
SCI, 81% male, Mean age=27.2±11.4 seen from admission to discharge with
years, Mean time post-injury to total MBI (p<0.001), self care subscore
admission=46 days. (p<0.001) and mobility subscore
Treatment: No treatment per se, but (p<0.001).
outcomes presented associated with 2. Discharge functional status was
Yarkony et al. 1990; inpatient rehabilitation. Length of stay 84 dependent on the admission functional
USA days. status (p<0.001) and the rehab LoS
Case series Outcome Measures: Modified Barthel (p<0.05) but not on acute care LoS,
Initial N=184 Index (MBI) collected at admission and level of paraplegia or presence of
Final N=184 discharge. surgical stabilization.
3. No statistically significant differences
were noted between those with high vs
low paraplegia on 14 of the 15
components of the MBI other than low
paraplegic patients were more likely to
walk 50 yards (p<0.001).

Population: Traumatic SCI, 30 males, 3 1. All patient groups (i.e., levels and
females, Age=48.4±15.6 years, 24 severity of injury) had similar FIM
tetraplegia and 9 paraplegia. motor scores at discharge as noted by
Treatment: No treatment per se, but American Consortium for Spinal Cord
various outcomes associated with inpatient Medicine.
rehabilitation. 2. All groups showed increases in FIM
Outcome Measures: FIM, LoS. All motor scores from admission to
collected at admission, discharge, and 1 discharge but these were only
and 3 months post-discharge. significant for tetraplegia ASIA D
(p<0.05) given small group sizes.
Chan & Chan 2005;
3. Little change in cognitive FIM was
Hong Kong, China
seen between admission and
Case Series
discharge due to ceiling effects.
Initial N=33
4. FIM motor scores generally continued
Final N=33
to increase at 1 and 3 months post-
injury although small N sizes and
missed follow-ups precluded statistical
significance.
5. LoS was generally longer for
tetraplegia (low level was significant,
p<0.0005) although there were low N’s
for each group (varied from 52.0-215.9
days).

3 - 35
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Gender: 51 males, 17 1. Performance on ADLs was the only


females, Age=43 years. direct predictor of LoS, while subjective
Treatment: No treatment per se, but LoS is well-being and gender affect LoS
Chung et al. 2003;
modeled (predicted) by various measures indirectly through other predictors
Taiwan
associated with inpatient rehabilitation. (subjective well-being via ADLs).
Case Series
Outcome Measures: LoS and various 2. LoS increases as ADL performance
Initial N=68
predictor variables (age, gender, ADLs, deteriorates. Clients with good
Final N=68
subjective well-being and cognitive-social subjective well-being scores will tend
skills). Predictor variables collected at to perform better on ADLs, resulting in
admission to inpatient rehabilitation. shorter LoS.

Population: Traumatic (42) and non- 1. Neurological assessments (Motor


traumatic (10) SCI, 32 males, 20 females, scores and light touch scores) showed
Age=36.4 ±17.7 (5-75) years, complete (6) increases from admission to discharge
and incomplete (18) tetraplegia and for those with incomplete injuries
complete (9) and incomplete (19) (p<0.001) but not complete injuries.
Mϋslϋmanoğlu et al. paraplegia. 2. FIM showed increases from admission
1997; Turkey Treatment: No treatment per se, but to discharge for those with incomplete
Pre-Post various outcomes associated with inpatient injuries (p<0.05) and those with
Initial N=52 rehabilitation of 93.9 ±44.95 (14-258) days. complete paraplegia (p<0.05) but not
Final N=10 Outcome Measures: Motor scores, light complete tetraplegia.
touch scores and FIM. All collected at 3. FIM scores (p<0.05), but not motor
admission, discharge, and 1 year post- scores or light touch scores showed
discharge (N=10 only). significant increases from discharge to
1 year post-discharge in a subsample
of 10 with paraplegia.

Population: 127 males and females with 1. In general, the group with shorter LoS
acute traumatic SCI with motor complete did not differ dramatically from the
paraplegia or tetraplegia (C5-L2) admitted group with longer LoS. Subjects also
for acute rehabilitation. Ages range from spent less time in PT and OT from
11-60 years (mean 28.81). 1991 to 1995 (p<0.001).
Treatment: No treatment per se, but effect 2. There were higher discharge scores for
of Length of Stay on functional and medical bowel management, stairs, manual
status was examined by comparing those locomotion, rolling supine to prone and
admitted in 1991 vs those in 1995. (LoS rolling side to side for those with longer
was significantly reduced in 1995, LoS in paraplegics. No significant
p<0.001). differences were seen in tetraplegic
Outcome Measures: FIM (Individual patients. (Many results showing no
Morrison & Stanwyck, scores for 11 items), Functional motor skills differences not presented).
1999; USA (5 skills, custom), Locomotor skill (5 skills, 3. Post discharge performance skills in
Case Control custom), incidence of medical those with tetraplegia showed that
N = 127 complications (pressure sores, UTIs, pain), those with shorter LoS had higher
employment status all collected at function in the following areas: bathing
discharge and 2 month post-discharge. (p=0.39), bed transfer (p=0.27), and
toilet transfer (p=0.047). For those
with paraplegia, the shorter LoS group
was higher in the following areas:
grooming (p<0.011), upper body
dressing (p=0.003), car transfer
(p=0.018) and manual locomotion
(p=0.031).
4. The proportion of subjects who
reported UTIs, pressure sores and pain
was higher in the shorter LoS group.

Yarkony et al. 1990; Population: Traumatic SCI, 83% male, 1. Rehabilitation Length of Stay
USA incomplete tetraplegia (30%), complete decreased over study period from 56.5

3 - 36
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Case Series tetraplegia (27%), complete paraplegia days in 1974 to 68.1 days in 1986
N=1,382 (27%) and incomplete paraplegia (16%). (82.8 for tetraplegia and 54.3 for
Treatment: No treatment per se, but paraplegia).
various outcomes associated with inpatient 2. Days hospitalized prior to rehabilitation
rehabilitation. admission decreased over the years of
Outcome Measures: LoS, Discharge the study from 56.5 days in 1974 to
destination. 33.4 days in 1986.
3. 93% were discharged to a private
residence 5% to nursing homes.
Population: US Model Systems database, 1. Of 4,934 admitted within 24 hours
Traumatic SCI, Gender: 82.3% males, post-injury, the proportion showing
Age=30.5±14.9 years, Tetraplegia, increases in ASIA were 10.3% (A),
Paraplegia, ASIA A-E. 45.2% (B), 55.9& (C), 7.3% (D) vs no
Treatment: No treatment per se, but change 89% (A), 50.3% (B), 41.5%
various outcomes associated with inpatient (C), 90.5% (D) vs declined 4.5% (B),
acute care, rehabilitation and follow-up. 2.6% (C), 2.0% (D). Some people
Outcome Measures: ASIA, FIM, Total continued to improve neurologically for
hospital LoS, Discharge destination, up to 18 months after discharge,
Education, Employment, Marital status, thereafter only rarely.
Readmission, Mortality. Collected at 2. From 1973-1990 the proportion of
admission, discharge and in some cases incomplete patients discharged
annually thereafter. increased from 40% to 55.2% whereas
the proportion of complete patients
decreased accordingly.
3. Of 751 patients, average FIM gain was
37 (incomplete paraplegia, 36
(complete paraplegia), 34 (incomplete
tetraplegia and 15 (complete
tetraplegia).
4. Total hospital LoS declined from 1974-
1989. For tetraplegia it went from
DeVivo et al. 1991; USA 149.6 to 92.4 days and for paraplegia
Case Series from 122.3 to 74.9 days.
Initial N=13,763 5. 94.1% patients were discharged to a
Final N=13,763 private residence, 4.0% to nursing
homes, 1.5% to other hospitals. Of
1,306 followed 10 years, 98.0%
resided in private residences.
6. 51.2% of those with grade 9-11
completed high school within 5 years
after injury and 11.6% of those with
high school education completed a
higher academic degree within 5 years.
7. The proportion of people employed
increased from 12.6% 2 years after
injury to 38.3% 12 years after injury.
8. In the second year post-discharge,
35.7% of people were rehospitalized
and this declined to 25% at 12 years.
9. Overall survival rate was 76.9%.
During the first 12 years after injury,
cumulative survival rate increased to
88% of what it would be in the absence
of injury. Highest causes of death were
pneumonia, pulmonary embolism and
septicemia (due to pressure sores,
respiratory infections or UTIs).

3 - 37
Author Year; Country
Research Design Methods Outcome
Total Sample Size

Population: Multi-centre Italian prospective 1. Neurological improvement was


survey, Traumatic SCI, Gender: 80.1 % associated with ASIA B and C, shorter
males, Age: mean=38.5, median=33.7 (11- LoS, greater chance of seeing
94) years, Tetraplegia, Paraplegia, ASIA A- neurological improvement with earlier
E. admission (3-30 days vs > 30 days,
Treatment: No treatment per se, but p<0.001). Presence of complications
various outcomes associated with inpatient (especially pressure sores) on
acute care and rehabilitation. 7 participating admission or during stay reduced
centers provided integrated acute and likelihood of attaining neurological
rehabilitation care while 30 centres improvement. Multivariate analysis
provided only rehabilitation care. also showed incompleteness was
Outcome Measures: ASIA (neurological independently predictive of
status), various complication incidence, improvement.
LoS, Bladder management method, Bowel 2. Average rehabilitation LoS was 135.5
status, Feeling of dependency, Discharge days (median 122 days). Longer LoS
destination. Collected at admission and was associated with younger age,
discharge. longer time from injury to admission,
previous place of management,
surgical management, tetraplegia,
completeness, presence of
complications at admission or during
Pagliaccu et al. 2003; stay and marginally, admission to an
Italy integrated (vs Rehab only) centre.
Case Series 3. 81.9% of people were discharged to
Initial N=684 home (private residence). Increased
Final N=684 likelihood of being discharged home
were seen with paraplegia, bladder
and bowel autonomy, absence of
pressure sore on discharge, longer
Length of Stay and marginally, younger
age.
4. Bladder autonomy was attained in 65%
of patients. Reduced likelihood of
achieving bladder autonomy was seen
with tetraplegia, completeness, at least
1 complication, longer time from injury
to admission, longer LoS.
5. Reduced likelihood of feelings of
dependency was associated with
paraplegia, neurological improvement,
discharge home, bladder and bowel
autonomy, no pressure sores and
incompleteness. Multivariate analysis
also showed a shorter time between
injury and admission was
independently predictive of lower
feelings of dependency.
Population: Traumatic SCI, 77.8% males, 1. Mean acute care LoS was 45.6±35.9
Age=34.9±17.1 (13-90) years, incomplete days and median rehabilitation LoS
tetraplegia (47.9%), complete tetraplegia was 83 days (3-317 days) (Mean =
Tooth et al. 2003;
(13.2%), incomplete paraplegia (16.2%) 99.6 days).
Australia
and complete paraplegia (22.8%). 2. Rehabilitation LoS was significantly
Case Series-
Treatment: No treatment per se, but longer for those with complete
Initial N=587
various outcomes associated with tetraplegia as compared to those with
Final N=167
admission to an integrated unit for acute incomplete tetraplegia or
and rehabilitation care. Sub-analysis incomplete/complete paraplegia
focused on effects of level of impairment as (p<0.001).

3 - 38
Author Year; Country
Research Design Methods Outcome
Total Sample Size

measured by neurological status and by the 3. Mean total FIM increased from 68.7
Australian National Sub-acute and Non- (admission) to 102.2 (discharge) due
acute Patient Classification System (AN- almost entirely to gains in motor FIM
SNAP) on Length of Stay. scores. Total FIM scores were lowest
Outcome Measures: LoS, FIM (motor, for those with complete tetraplegia and
cognitive and total), Discharge destination. highest for those with incomplete
All collected at admission and discharge. paraplegia with significant differences
found between the various neurological
categories. Those with complete
tetraplegia had the least change in FIM
scores.
4. 75.4% were discharged to a
community dwelling and 10.8% to a
transitional rehabilitation program.
Those with greater impairment were
less likely to be discharged to a
community setting (i.e., 92.6% with
incomplete paraplegia vs 72.7% with
complete tetraplegia).
5. AN-SNAP-predicted LoS was generally
much shorter than actual LoS.
Population: 209 males, 53 females, 1. 31% of people improved neurologically
Frankel A-E, tetraplegia and paraplegia. as indicated by Frankel, 66% remained
Treatment: No treatment per se, but unchanged, and 3% deteriorated. 23%
various outcomes associated with initially complete became incomplete
admission to an integrated unit for acute and 40% of those initially incomplete
and rehabilitation care. improved.
Outcome Measures: Frankel scale, 2. Of those discharged “normally”, Total
Mortality, Urinary tract management and hospital LoS ranged from 113 (D, E
pathogen status, physical independence paraplegia) to 282 (A, B tetraplegia)
(Walking, Dressing, Transfers, Driving, days with completeness having a
Burke et al. 1985; Finances), Total hospital LoS. All collected greater impact on stay than level.
Australia at admission and discharge. 3. 69.1% of people were discharged
Case Series catheter-free with 14.9% (26.4% of
Initial N=352 females and 12.0% of males)
Final N=262 discharged with an indwelling catheter.
77.9% were discharged with sterile
urine.
4. 77% could dress themselves
independently at discharge (95% with
complete paraplegia and 27% with
complete tetraplegia).
5. 79% could transfer independently at
discharge.
6. 40% with complete tetraplegia could
drive with hand controls at discharge.

Population: 100 traumatic SCI in VA SCI No statistical analysis.


Service, all males, tetraplegia (62) and 1. The higher the injury, the more likely
Woolsey, 1985; USA paraplegia (38), incomplete (27) and an individual did not meet goals of self-
Downs & Black complete (73), time post-injury: < 1 month care and mobility.
score:n/a (59), < 2 months (28), > 2 months (13). 2. 83/100 were discharged to their
Case Series Treatment: No treatment per se, but homes, 13 to nursing homes.
Initial N=100 various outcomes associated with inpatient
Final N=96 rehabilitation. LoS = 3.3 (paraplegia) and
5.5 months (tetraplegia).
Outcome Measures: Attainment of

3 - 39
Author Year; Country
Research Design Methods Outcome
Total Sample Size

functional goals by discharge or in some


cases later follow-up.

Population: Traumatic SCI from US Model 1. Rehabilitation LoS was reduced from
Systems database, age categories from 74.1 days in 1990 to 60.8 days in 1997
<21 to >51, 80.9% males, tetraplegia and (p<0.001). Acute care LoS was 21
paraplegia, incomplete and complete. days in 1990 and 20 days in 1991.
Treatment: No treatment per se, but 2. Many variables significantly predicted
various outcomes associated with inpatient increases in LoS at p<0.001 level of
rehabilitation to predict LoS, significance (in descending order): low
rehospitalization, residence, days out of admission FIM, earlier discharge year,
residence (QoL) and pressure sores. complete tetraplegia, indwelling
Outcome Measures: Rehabilitation LoS, catheter, intermittent catheterization,
rehospitalization, residence, days out of condom catheter. Other variables
residence (QoL), pressure sore incidence included being African-American,
and many predictor variables. Collected at having a high-school education or less,
admission, discharge and 1 year post- being married, being <21 years old and
injury. being retired or engaged in other non-
paid activities.
Eastwood et al. 1999;
3. Individuals initially discharged to a
USA
skilled nursing facility were more likely
Case Series
to return home by 1 year if they were
Initial N=5,180
young, had higher admission and
Final N=3,904
discharge FIM scores, greater FIM
change, if they were able to leave the
institution more frequently and more
likely to use IC vs indwelling catheter.
4. Individuals were more likely to be
rehospitalized if they had lower
discharge FIM scores, complete
paraplegia, having an indwelling
catheter or using intermittent
catheterization and with a shorter
rehabilitation Length of Stay.
5. Predictors of having pressure sores at
year 1 were having complete
paraplegia, not having incomplete
tetraplegia, lower FIM scores and older
age.

3 - 40
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3 - 44
CHAPTER FOUR

Community Reintegration
Following Spinal Cord Injury

William C Miller, PhD, OT


Susan J Forwell, PhD, OT(C), FCAOT
Luc Noreau, PhD
Lyn Jongbloed, PhD, OT
Emily S Procter, BSc
Caroline Abramson, MA
Key Points

Attitudes towards disability may be positively influenced by having contact with an


individual with SCI.
For women with SCI, a supportive social network may positively influence their ability
to participate in an occupation.
The main barriers to community reintegration are barriers in the natural environment,
transport, home services, health care and government policies.
Assistive equipment, such as modified vans and environmental control units, may
contribute to better reintegration.
Consumer-directed personal assistance services and independent living programs
may facilitate community reintegration; however, services are not always available.
Successful community reintegration may promote productivity and physical and
mental well-being.
Employment specialists may aid in the process of job placement and work
reintegration.
There is a dearth of high quality research in this field therefore conclusions are based
on observational research methodology.
At discharge from a rehabilitation unit there is improvement in self care and mobility
that is preserved for 1 year.
Persons with tetraplegia who completed a driving training program were more likely to
drive if younger in age, were able to perform transfers independently, had a lower level
of SCI, drove prior to SCI and were employed and involved in sports.
Employment following SCI was positively correlated to being male, and having more
years since injury, younger age, the ability to drive a car, a higher education and a
professional job prior to the SC.
Having tetraplegia has a negative impact on gaining and maintaining employment.
Employed persons with SCI had greater satisfaction with employment and finances
while those unemployed had lower activity levels and higher economic dissatisfaction.
Persons with disabilities experience discrimination and are less likely to obtain an
interview or be hired.
Facilitators for leisure involvement are social support, being healthy and being
employed or attending school. Barriers are lack of physical ability, health concerns,
cost, and lack of opportunity or interest.
Participation in leisure occupations have a positive impact on adjustment to SCI,
physical independence, mobility, hours in activities of daily living and social
integration.
Use of the GAMEWHEELS system showed physiological and motivational benefits for
engaging in wheelchair exercise.
FES is a motivator to engage in exercise and standing, augments ability to do more
things and enhances the sense of well-being. Drawbacks included lack of time to use
the system and reluctance to wear all day.
Average level of QOL after SCI is slightly lower than in people without disability but a
substantial number of people with SCI report good or excellent QOL.
Severity of injury and other diagnostic factors do not significantly impact QOL. There
influence may become significant through restrictions in community integration/social
participation.
A limited amount of variation in QOL has been explained by quantitative research methods.
Qualitative reports suggest that factors affecting QOL after SCI do not seem to differ
from those impacting QOL in people without disability. They are related to life issues
such as achieving meaningful social roles, having control over one’s life and
maintaining adequate access to the environment.
Overall, there is a paucity of information from clinical trials on the most appropriate
interventions favouring subjective QOL on people with SCI and their significant others.
QOL can be indirectly enhanced through use of an exercise program designed to
reduce pain and stress.
Providing group therapy to spouses of individuals with SCI can decrease their symptoms
of depression, anxiety, psychological distress with a potential impact on QOL.
Table of Contents

4.1 Introduction ......................................................................................................................4-1

4.2 Environment .....................................................................................................................4-2


4.2.1 Social Environment .........................................................................................................4-3
4.2.2 Other Environmental Factors ..........................................................................................4-4
4.2.2.1 Physical Environment ..................................................................................................4-5
4.2.2.2 Institutional Environment..............................................................................................4-7
4.2.3 Summary – Environment ..............................................................................................4-10

4.3 Occupation .....................................................................................................................4-11


4.3.1 Daily Living Activities ....................................................................................................4-11
4.3.2 Work..............................................................................................................................4-13
4.3.3 Leisure and Recreation.................................................................................................4-17

4.4 Quality of Life .................................................................................................................4-20


4.4.1 QOL Definitions and Models .........................................................................................4-21
4.4.2 Exploring QOL after SCI from a Scientific Perspective .................................................4-22
4.4.3 Quantitative Measurement Approach of QOL Determinants.........................................4-22
4.4.4 Qualitative Research Methods to Understand QOL and its Determinants....................4-25
4.4.5 Trials Examining QOL as an Outcome .........................................................................4-25
4.4.6 Summary – QOL ...........................................................................................................4-28

4.5 Summary – Community Reintegration.........................................................................4-28

References..............................................................................................................................4-31

This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising
from the use or misuse of this material.

Miller WC, Forwell SJ, Noreau L, Jongbloed L, Procter ES, Abramson C. (2006). Community Reintegration Following
Spinal Cord Injury. In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC,
Connolly S, editors. Spinal Cord Injury Rehabilitation Evidence. Vancouver, p 4.1-4.37.

www.icord.org/scire
Community Reintegration
Following Spinal Cord Injury

4.1 Introduction

There are more than 286,000 North Americans currently living with a spinal cord injury (SCI)
and incidence rates suggest that approximately 1000 Canadians and 11,000 Americans survive
a traumatic SCI each year (Canadian Paraplegics Association [CPA] 2000; National Spinal Cord
Injury Database 2005). The majority of injuries occur in males (75%) and over 60% occur in
individuals under the age of 50 (median age 35 years) (Dryden et al. 2003). Over the past 20
years, the life expectancies of individuals have improved vastly due to advances in medicine
with life expectancy reaching to within 10% of the general population. As a result the number of
individuals living with SCI is steadily increasing (CPA 2000).

The journey from acute care through inpatient rehabilitation and back to community living
following a spinal cord injury is one that is filled with challenges. Individuals with SCI face
numerous secondary medical conditions including spacticity, pain, pressure ulcers, bladder
infections, depression and anxiety, all of which can make daily tasks of living demanding and, at
times, impossible. Beyond impairments the severity of disability for SCI survivors spans the
dependence – independence continuum. The usual simple self-care activities of dressing,
bathing or getting around, for example, can be monumental. For instance, even individuals who
are capable of dressing independently often don’t because of the time (up to an hour) and effort
required (Weingarden & Martin 1989). Walking with or without a walking aid(s) or use of a
wheelchair for mobility can result in an increased energy cost that ranges from 9-74%
depending on the floor surface (Waters & Lundsford 1985; Glasser et al. 1995) and the
condition of the wheelchair (Sawatzky et al. 2005) compared typical bipedal walking.

Returning home after rehabilitation is the most common goal of individuals with SCI. On
average 75% of those who survive their trauma return to a private residence including over 60%
with complete tetraplegia (CIHI 2006). Interestingly even the majority of individuals with high
cervical lesions who are respiratory dependent can return to the community to live out the
majority of their lives (Anzai et al. 2006).

The direct cost of SCI to the Canadian healthcare system is estimated to be $750 million each
year (Rick Hansen Foundation 2006) with an average $530,000 resulting from new injury for
hospitalization alone (SmartRisk 1998). The overall economic burden of healthcare for idividuals
with SCI in Canada is between $1.25 million and $25 million each during their lifetime
depending on injury severity (Rick Hansen Foundation 2006).

Sixty-two percent of individuals with SCI are employed prior to injury and only 10-14% return to
work post injury (CIHI 2006). The lost contributions from these potentially employable
individuals to the economy and tax base is substantial in addition to the loss of productivity by
family caregivers who stop or reduce employment to take on this role.

The environment surrounding the delivery of rehabilitation services has changed substantially
over the decade. Cost containment strategies have emphasized efficiency and effectiveness
resulting in reduced hospital length of stay (Rhoads et al. 1992; Holcomb 2000). As a result of

4-1
the shorter hospitalization prior to discharge, people with spinal cord injuries have more
complex needs, are more dependent and use more equipment than they did 10-15 years ago.
An advantage associated with reduced length of stay is that the home environment usually
promotes recovery. But the transition to the community needs to occur with appropriate
supports to facilitate successful integration. The complex requirements of those with SCI and
the fact that their disabilities are permanent, suggest there are wider gaps in supports which
have profound impact for these people and their family members. Transition is a difficult
process, made even more challenging by lack of/gaps in support. Successful transition from
hospital to the community is influenced by a combination of factors at the individual,
social/family, environmental and provincial policy levels (White & Holloway 1990; Pollack et al.
1992; Clandinin & Connelly 1994).

The term community reintegration is used to refer to returning to the mainstream of family and
community life, engaging in normal roles and responsibilities, actively contributing to ones social
groups and of society as a whole (Dijkers 1998). Thus successful reintegration means
resumption of those occupations that are important to each individual, such as taking care of
oneself and participating in productive occupations of work and leisure. The environment,
whether social, institutional, cultural or physical, can either create barriers or facilitate access to
the community at large. Without exception successful reintegration can lead to improved quality
of life (Anderson 2004).

This chapter summarizes the results of selected studies to provide an overview of community
reintegration post SCI. The chapter incorporates research about the person engaging in
occupations and in context to the environment. The issues related to participation are described
as self care, work and leisure while the environmental issues are primarily related to social
aspects of study in SCI. This chapter closes with a review of evidence related to quality of life,
an area of research that brings together the impact of participation and the environment relative
to community reintegration.

4.2 Environment

Rehabilitation assists persons with spinal cord injuries to regain independence and during this
time, the primary focus is on the individual. Following discharge into the community, the
emphasis shifts to people engaging, or attempting to engage, in activities that are important to
them and this is strongly influenced by the environment. Broadly defined as the cultural,
institutional, physical and social aspects that surround the individual (Law et al. 1997), the
environment is the dynamic and inseparable situational context that shapes what a person
chooses to do, how successful and how satisfied they are in doing it. The environment can
support people or constrain them in their performance of activities and thus has a powerful
impact on community re-integration.

A review of studies on the impact of the environment on the community integration of those with
spinal cord injuries indicates that the term ‘environment’ is infrequently used. This is likely
because the environment is a broad construct which includes the social environment as well as
health and social policies. Many of the studies below focus on one aspect of the environment.
In this chapter, studies related to the environment are divided into two areas: the social
environment, and other environmental factors. The social environment includes the individual’s
network of friends and family members as well as societal attitudes about disability and spinal
cord injury. Other environmental factors include adapted vans for transportation, environmental
control units, government policies that influence the availability and accessibility of

4-2
transportation and the availability of personal assistance in the home. The studies are
summarized in Table 4.1 below.

4.2.1 Social Environment

The social environment can be defined as social and cultural institutions and processes that
influence the life of an individual. Family members and friends form the person’s social network
and provide him/her with social support and encouragement. People who experience a spinal
cord injury have to deal with changes in their social network as well as changes in how they are
perceived by society.

Table 4.1 Social Environment


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 45 non-disabled students (27 1. There was a significant difference
treatment, 18 control) and 18 disabled between the groups on their pre- and
patients, mean age 27.4 years, 13 C2-C6 post-scores for the Attitude Toward
(quadriplegic), 5 T7-T12 (paraplegic); DOI Disabled Persons scale (F=7.36,
2wk - >1yr. p=.001) (treatment group (t=5.6,
Treatment: Information and social p<.001), comparison group (t=2.5,
meetings between female students and p<.05)).
Haney & Rabin 1984; individuals with SCI. The comparison group 2. Significant positive correlation between
USA had information alone. After the activity the prior degree of contact and changes in
Downs & Black score=13 students had posttest measurements, and ATDP scores of the treatment group
Post-test patients had a verbal posttest (r=.49, p<.01).
Initial N=45; Final N=18 Outcome Measures: Attitude Toward 3. 60%-100% of the patients found that
Disabled Person (ATDP) scale, Student the contact experience affected
Comfort Level Scale (SCLS), Patient boredom, morale, social skills and a
Comfort Level Scale (PCLS), Student sense of attractiveness to the opposite
Satisfaction Measurement Form (SSMF), sex from moderately to very much so.
Patient Satisfaction Measurement Form 4. 67% of the women students returned to
(PSMF), Patient Post-Measurement (PPM) see the patients whom they were
form. originally introduced (~weekly).
Population: all female, age range 25- 1. The women described an emotional
61yrs, traumatic or non-traumatic, 4 need for social support and practical
cervical (tetraplegia) and 9 thoracic social support in order to participate in
(paraplegia), DOI 2-11yrs. occupation.
Isaksson et al. 2005; Treatment: Two interviews obtaining 2. The women reported having developed
Sweden etiology info and current situation regarding new habits through close cooperation
Downs & Black score=8 social network and their ability to with members in the social network.
Observational participate in occupation. 3. They felt that they had become more
N=13 Outcome Measures: perceptions of responsible for the development of their
change in social network and participation. relations. Some relations improved,
others deteriorated and several new
ones were made with other persons
with disabilities.

Discussion

The social environment includes societal attitudes and values as well as networks of
relationships. The studies above suggest that the social environment may be a powerful factor
in community integration of people with SCI.

The complex interactions between the social environment and those with spinal cord injuries are
difficult to study. Popular culture tends to present people with disabilities as tragic victims and

4-3
attitudes towards those with SCI may be biased by these stereotypes, by the lack of social
recognition of people with SCI and other disabilities and by a lack of exposure to individuals with
disabilities. Simply reading or watching a television program about a person with SCI may not
be sufficient to change attitudes. In their experiment, Haney & Rabin (1984) demonstrate that
individuals’ attitudes can be positively influenced by exposure to people with SCI. Developing a
relationship with a person with SCI will likely reduce stigma by enabling people to recognize that
those with SCI are similar to them and contribute to the opportunity for individuals with SCI to
reintegrate into the community. Introducing people with spinal cord injuries to young people
who have never been exposed to someone with a severe disability may also be a good strategy
to influence society’s invisible barrier, thereby promoting community re-integration.

Isaksson et al. (2005) describe how practical and emotional support assisted women with SCI to
participate in occupation. Although not evidenced in the literature, it seems plausible that
individuals who have experienced a SCI may need support following the injury as they deal with
changed relationships. Strategies that encourage them to be assertive in developing new
relationships may be warranted.

Conclusion

There is Level 4 evidence from a single post-test study that having contact with a person
who has an SCI has a significant impact on attitudes towards disability.

There is Level 5 evidence based on a qualitative study that SCI results in a changed
social network - some relationships are lost but others improve.

Attitudes towards disability may be positively influenced by having contact


with an individual with SCI.

For women with SCI, a supportive social network may positively influence their ability to
participate in an occupation.

4.2.2 Other Environmental Factors

In this chapter, studies on other environmental factors focus on equipment and services that
assist people with SCI to function in the community. These include adapted vans and
environmental control units (physical environment, see Table 4.2) as well as follow-up services
after discharge, independent living services, personal assistance services and support to re-
enter competitive employment (institutional environment, see Table 4.3). Government policies
have a large impact on availability of equipment and services and on definitions of eligibility.
Policies are purposeful sets of actions aimed to address identified social problems in a particular
way. Policy may address structures (e.g. resources), processes (e.g. access, roles) and
outcomes (e.g. justice, equity) (Boyce 2002).

4-4
4.2.2.1 Physical Environment

Table 4.2 Physical Environment


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 2762 subjects (78%M, 22%F), 1. The top five environmental barriers
DOI: 30% 1yr, 20% 5yrs, 15% 10yrs, 13% reported by the CHIEF scores were
15yrs, 13% 20yrs, 10% 25yrs. barriers in the natural environment,
Treatment: Initial information from National transportation, help at home, health
Spinal Cord Injury database. Also in- care and government policy.
person or telephone interviews. 2. Significant predictors of higher CHIEF
Outcome Measures: Craig Hospital total scores (i.e. more perceived
Inventory of Environmental Factors - Short environmental barriers): mid age range
Form (CHIEF-SF), Craig Handicap at time of injury, female, minority
Assessment and Reporting Technique ethnicity, more recent injury, more
Whiteneck et al. 2004; (CHART-SF), FIM instrument, Satisfaction severe injury, higher degree of activity
USA with Life Scale (SWLS). limitations (p<0.05 for all).
Downs & Black=12 3. Significant predictors of low CHART
Observational total scores (i.e. low participation): older
N=2762 age at time of injury, minority ethnicity,
less education, being unmarried at
injury, higher level of injury, injury by
falling or violence and low FIM scores.
4. Significant predictors of low life
satisfaction: more recent injury, high
scores of physical/structural,
services/assistance and
attitudes/support (CHIEF) and low
scores on mobility, occupation and
social integration (CHART).
Population: from initial sample, n=58 Equipment Utilization
completed all three phases of testing 1. No significant changes over time in use
mean age 43yrs, 40 C1-C4, 11 C3, 6 C2, 1 of power wheelchairs, house hold lifts,
C1, mean DOI 18.5yrs. adaptive bathroom equipment or vans.
Treatment: In-person interviews and chart Participation
review. 2. Hours/day out of bed and # of days out
Outcome Measures: High Quadriplegia of the house remained constant.
Questionnaire (HQQ), Level of Free Time 3. Hours spent reading and listening to
Activities Scale, and Rosenberg Self radio were significantly higher in phase
Esteem Scale (RSE). 1 compared to phase 2 (p=0.02).
4. Participation was correlated to age –
Bushnik 2002; USA
older individuals spent fewer hours out
Downs & Black score=11
of bed and out of the house compared
Observational
to younger individuals and participated
N=168
in fewer leisure activities at home
(phase 3) (p<0.01).
Self Esteem and QOL
5. 94% of participants stated they were
glad to be alive.
Access to Equipment
6. Having a van with a lift caused
increased time spent out of bed
(p<0.02) and correlated to increased
hours spent out of the house (p<0.01)
in phases 2 and 3.

4-5
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: mean age 24.2yrs, 89.7% 1. 93% of the subjects perceived the ECU
males, injuries C6 and above, tetraplegia. as increasing their independence.
Treatment: Structured interview. 2. Operation of the telephone was
Outcome Measures: Environmental indicated as the most important function
Control Unit (ECU) use. (61%), followed by TV (21%).
McDonald et al. 1989; 3. Of the subjects who worked or went to
USA school, only two used their ECUs for
Downs & Black score=5 those purposes.
Observational 4. Subjects felt comfortable for longer
N=29 periods without attendant care when
the ECU was available.
5. Some of the subjects felt that they had
received inadequate training (30%) and
that their attendants lacked
understanding of the ECU (36%).

Discussion

People with SCI have reduced physical abilities and consequently require specific equipment to
function in their environment. The studies above illustrate the following associations: a) various
demographic characteristics and perceived environmental barriers, b) having a van with a lift
and increased time out of bed and out of the house, and c) the increased control of telephones
and televisions with the use of environmental control units; however, the study designs limit the
conclusions that can be drawn from these associations. It should be noted that obtaining
equipment such as environmental control units and vans requires considerable personal
financial means and/or public support. The support team should investigate an individual’s
eligibility for various sources of income, services and equipment.

Conclusion

There is very limited (Level 5) evidence that people with SCI consider the following
factors as the main barriers to community integrations: barriers in the natural
environment, transport, help at home, health care and government policy.

There is very limited (level 5) evidence from two observational studies that assistive
equipment may promote increased activity and participation in and outside of the home.

The main barriers to community reintegration are barriers in the natural environment,
transport, home services, health care and government policies.

Assistive equipment, such as modified vans and environmental control units, may contribute
to better reintegration.

4-6
4.2.2.2 Institutional Environment

Table 4.3 Institutional Environment


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: sex, age, injury location and Physical Well Being
etiology-matched groups. 1. Bladder function: Community based
Treatment: Randomization into a n=12 (residual urine 100cc's n=4 sterile
community based or hospital based SCI urine n=4 requires catheter n=1)
rehabilitation program. (Hospital = Hospital based n=11 (residual urine
physiatrist and physician, assessments at 100cc's n=5; sterile urine n=4; requires
6wks and 6-12mo post-injury; Community = catheter n=3)
physician, with rehabilitation nurse to lead 2. Bowel function: more use of enemas by
assessment/follow-up). the hospital based program.
Outcome Measures: Comparison of 3. Hospital Readmissions: n=7
Dinsdale et al. 1981;
physical and psychosocial variables at one community; n=13 hospital.
Canada
year post-discharge from the Rehab 4. ADL’s: similar between groups.
PEDro=1
Centre. Psychological Functioning
RCT
1. Professional emotional support: n=5
N=23
community; n=2 hospital.
2. Major emotional crisis: n=3 community;
n=1 hospital.
3. “Good” adjustment: n=8 community;
n=6 hospital.
Social Vocational Functioning
1. Both groups have similar integration,
spare more extensive use of health
agency and vocational support by the
community group.
Population: 440 SCI, mean age 39.7yrs, 1. Participants with TBI were significantly
46.5% paraplegia, 53.6% tetraplegia, more productive than participants with
89.7% incomplete, 10.4% % complete, SCI (74.5% of TBI vs. 28.9% of SCI).
Harker et al. 2002; mean DOI 27.4yrs. (Demographics for TBI 2. 70% of SCI participants reported
Canada patients not reported here, n=47.) receiving weekly assistance compared
Downs & Black score=13 Treatment: mailed surveys (SCI patients), to less than 15% of TBI participants.
Observational in-person interviews (TBI patients). 3. Productivity status was correlated to the
N=487 Outcome Measures: Independent living subjective experience of community
outcomes (DeJong & Hughes 1982), integration (r=-.4013, p<.0001).
Reintegration to Normal Living Index,
environmental support.
Population: mean age 44yrs, 16 women 1. Changed personal relationships owing
and 14 men, cerebral palsy, multiple to lack of access to primary care
sclerosis and SCI (10 in each category). services or durable medical equipment.
Treatment: semi-structured, in-depth And greater need to rely on others due
Neri & Kroll 2003; USA
telephone interviews. to this.
Downs & Black score=12
Outcome Measures: perceptions of 2. Depression, frustration, stress, and
Observational
barriers, access, participation, experience. devaluation were frequently reported,
N=30
but 4x as much by women (p=0.012).
3. A general deterioration in health was
the most frequent complaint regarding
physical health.
Population: Agency-Provided Model 1. An initial MANOVA showed significant
(n=29, mean age=35.3 yrs, tetraplegia C1- differences (Wilk's Lamda=.32; p<.01)
Prince et al. 1995; USA C4, complete, mean 7.9yrs post-injury), in outcomes between the 2 groups.
Downs & Black score=12 Self-Managed Model ( n=42, mean age 2. In terms of overall health, those in the
Observational 37.1 yrs, tetraplegia C1-C4, complete, self managed care group had
N=71 mean 11.5yrs post-injury). significantly higher scores on Rand-36
Treatment: Telphone interview. (i.e. perceived better health).
Outcome Measures: Personal Assistance 3. Fewer persons in the self managed

4-7
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Satisfaction Index (PASI), Personal group reported hospitalization during
Independence Profile (PIP), Craig the past 6 mos (19% vs. 31%).
Handicap Reporting Technique (CHART), 4. The self-managed care group
Rand-36, Life Satisfaction Index-Acute perceived having more control over
(LSI-A). their day-to-day lives and personal care
(from mean PIP scores, p<0.01).
Population: n=24 (intervention), mean Independent Living Services (ILS)
age: 38.6yrs, 14% ASIA D, 35% paraplegia Received and Reported Needs
ASIA A,B,C, 51% tetraplegia ASIA A,B,C; 1. Both groups reported a similar number
n=56 (control) mean age 34.4yrs. of unmet and met needs.
Treatment: Questionnaires. 2. Participants of the program used
Outcome Measures: The Independent support services more frequently and
Living Services Evaluation Questionnaire, were more satisfied compared to
Craig Handicap Reporting Technique program non-participants and (p<0.01).
(CHART), Satisfaction With Life Scale 3. Program participants were more likely
(SWLS), Personal Independence Profile to report assistance from government
(PIP), Institutional and CIL Surveys. benefits, vocational services and legal
advocacy while non participants were
more likely to report assistance from
insurance sponsors and from personal
attendants.
Forchheimer & Tate
4. The most commonly reported unmet
2004; USA
needs while using ILS were legal rights,
Downs & Black score=10
recreation, and obtaining government
Case Series
benefits.
N=81
Program Intervention
1. Participants and non-participants levels
of control, QOL and societal
participation along the five domains of
CHART were not significantly different.
2. PIP - personal independence was
significantly lower for those who
received housing services or had unmet
needs compared to those without
housing or unmet needs (p<0.005).
Those without needs for legal services
had higher PIP, QOL and CHART
scores (p<0.01).
3. Overall there was no benefit noted for
the ILS follow-up program.
Population: n=92 (n=60 consumer- 1. PAS were more likely to be "extremely"
directed PA, n=32 on waiting list), mean or "very" satisfied than the WL grp
age: 41.7yrs (PAS group), 43.7yrs (WL (non-consumer directed) on the 6
group), 51 males and 41 females. individual PASI items.
Treatment: Mail or telephone survey. 2. 85% of PAS and 59.4% of WL were
Outcome Measures: Personal Assistance “extremely” or “very” satisfied with the
Satisfaction Index (PASI). cost of PA.
Beatty et al. 1998; USA 3. 88.3% of PAS and 46.9% of WL were
Downs & Black score=8 “extremely” or “very” satisfied with the
Observational amount of control they had over the
N=92 choice of PA.
4. 93.3% of PAS and 59.4% of WL were
satisfied with the amount of authority
they had to direct their PA’s.
5. 53.3% of PAS and 31.3% of WL were
“extremely” or “very” satisfied with the
availability of assistance in an
emergency.

4-8
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 2 males, 1 female, age range 1. Two individuals required only low
38-53yrs, traumatic SCI, C5-C7 technological accommodations (e.g.
tetraplegics, DOI range 11-34 yrs. learning a computerized cash and book
Treatment: Employment specialists lead database system, electronic letter
Inge et al. 1998; USA
job development and restructuring opener) to support their return to work.
Downs & Black score=8
ventures, involving the SCI individual and 2. One individual required more intense
Observational
identified potential businesses. support, as well as more conscious
N=3
Outcome Measures: the effect of workplace cooperation, prior to
supported employment and assistive independent work. An employment
technology on job placement. specialist stayed on the job site full-time
for ~3mos.
Population: Individuals with cerebral 1. 56.5% and 39.6% indicated that they
palsy, multiple sclerosis, or SCI. needed assistive equipment in the last
Bingham & Beatty 2003; Treatment: Survey. 12 and 3 months, respectively.
USA Outcome Measures: rates of access to 2. Of those who indicated a need in each
Downs & Black score=7 assistive equipment and medical area, 28.4% and 52.2% did not receive
Observational rehabilitation services, health plan type. assistive equipment and rehabilitation
N=500 services, respectively, each time they
were needed.
Population: 7 physicians, 8 PTs, 7 OTs, 9 1. A positive relationship was found
social workers, and 10 nurses in 5 rehab between the adequacy of personal
hospitals. assistance and the ability of individuals
Treatment: Standardized, open-ended, disabled primarily by stroke, SCI, or
taped interviews by trained interviewers traumatic brain injury (TBI) to maintain
who were also users of PA services. good physical & mental health.
Nosek 1993; USA Outcome Measures: views and Inadequate PA led to extended hospital
Downs & Black score=4 experience of/with PA services. stays, threats to safety, poor nutrition, &
Observational poor personal hygiene.
N=41 2. Reliance on family alone for assistance
was considered inadequate and
common adverse effects were burnout,
family role changes & economic strain.
3. Persons with the best health combined
assistance by relatives & unrelated
persons.

Discussion

The above studies illustrate aspects of the institutional environment faced by those with SCI –
independent living services, consumer and non-consumer directed personal assistance
services, financial aid services and job placement.

The health care system is of primary importance during the acute care and rehabilitation phases
of treatment of people with SCI. Once these people have been discharged and are in the
community, other factors and resources assume considerable importance. People want
assistance with self-care at home, they desire the ability to move around freely in their
communities, and they want to work. As noted previously, it can be a considerable financial
burden to access personal assistance services and government or insurance support is not
always obvious or available.

4-9
Conclusion

There is moderate (Level 2) evidence from one RCT study that a community based
system for post discharge monitoring in no more effective in terms of community
integration than a hospital based system.

There is very limited (Level 5) evidence from one observational study that productivity
was correlated to the individuals’ subjective experience of community reintegration.

There is very limited (Level 5) evidence from two observational studies that a positive
relationship exists between the adequacy of personal assistance and the physical and
mental health of those with SCI.

There is very limited (Level 5) evidence from two observational studies that people who
receive consumer directed personal assistance services are more satisfied with services
than those who receive services that are not consumer directed.

There is limited (Level 4) evidence from one case series that an independent living
follow-up program is more beneficial than no program.

There is very limited (Level 5) evidence from one observational study that supported
employment assists job placement of some people with SCI.

There is very limited (Level 5) evidence from one observational study that individuals
with disabilities did not receive adequate equipment or services on more than half of the
occasions in which they were requested.

Consumer-directed personal assistance services and independent living programs may


facilitate community reintegration; however, services are not always available.

Successful community reintegration may promote productivity and physical and mental well-
being.

Employment specialists may aid in the process of job placement and work reintegration.

There is a dearth of high quality research in this field therefore conclusions are based on
observational research methodology.

4.2.3 Summary – Environment

There are limitations to examining the impact of the environment on community reintegration of
persons with spinal cord injuries. The environment is not easily manipulated as an independent
variable. Consequently, many of the studies are not experimental in design. They describe the
impact of social policies or access to health care on a sample and may use regression analysis
to assess which factors are the most significant influences on an outcome. Overall, the
evidence provided in most of the above studies is insufficient to warrant firm conclusions in this
field of study.

4-10
4.3 Occupation

Occupation, meaning the way and means by which people occupy themselves in meaningful
activities, may refer to time limited activities such as preparing meals, enormous undertakings
such as years of training to compete in the Olympics, or monumental milestones such as taking
the first steps after a SCI or returning to work after months of retraining. Because occupation
refers to a broad range of activities that occupy daily lives it is useful to have a system to
organize such activities into occupational groupings. Occupations may be categorized by the
routines or sequences, the physical environment(s) in which they are completed, the social
network involved (or not, as the case may be) or the nature of the activities. For the purposes of
community integration for persons with SCI, which involves the transition to daily occupations in
one’s relevant community, the nature or type of activity as typically described in the literature is
used in this chapter. As such, the following occupational groupings are described: activities of
daily living, work, and leisure. The literature that examines interventions that enhance the
experience of activities of daily living tasks, work and leisure is in its infancy and is limited to
evidence level 4 and 5 studies. It is these preliminary studies that are summarized here.

4.3.1 Daily Living Activities

Daily living activities refers to tasks completed to take care of oneself and the surroundings and
includes eating, dressing, bathing, grooming, dental hygiene, meal preparation and maintaining
the home. Also grouped in this category is function related to mobility and includes standing,
transfers, walking and driving. Often it is these very basic occupations that are interrupted with
SCI, though following rehabilitation, there is improved performance in self care and mobility
skills (Lysack et al. 2001). In the community, the use of standing frames showed several
benefits and few drawbacks (Dunn et al. 1998) and a driver-training program was successful for
persons with tetraplegia who had driven prior to SCI, had a lower level of SCI, were able to
perform bed, tub and toilet transfers and dressed their lower extremity (Kiyono et al. 2001).
In society, ability for adults to perform personal self care functions is a basic and assumed
independent skill set. The impact of traumatic SCI can dramatically alter that independence and
change subjective evaluation of oneself and future possibilities. Lysack and colleagues (2001)
show that with rehabilitation most function, though modified, can be restored.

Table 4.4 Daily Living Activities


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 21 complete, 34 incomplete, 1. Self Care Importance: at admission
mean age at admit: 38.8 yrs, at discharge: 76% eating independence was of
37.7 yrs, at f/u: 43.2 yrs. "upmost importance", 84% at
Intervention: 3 structured questionnaires discharge & 92% at 12 mo f/u. Bathing
administered by an OT assistant at independently, dressing, & grooming
admission, at discharge, and at 1 year post followed a similar trend.
Lysack et al. 2001; USA
injury. 2. Self Care Expectations- at admission
Downs & Black score=17
Outcome Measures: Functional 70% of pts expected to eat "all by
Observational
Independence measure (FIM), self-care themselves without any help at all",
Cross-sectional Design
questionnaires (focused on eating, bathing, 15% had goal of independence & 15%
N=55
dressing, and grooming). thought they would need some
personal assistance.
3. Actual Self Care Performance -
subjects underestimated their skills at
admission for eating, bathing, dressing
(p<0.001) & grooming (p<0.003), but
showed improvements in mean FIM

4-11
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
motor scores from 22.2 to 47.6
(p<0.0005).
4. Subjects tended to rank skills that they
did well with more importance that
other life tasks. This was apparent for
all skills, but was significant only for
grooming & dressing (p<0.02 and
p<0.05, respectively).

Discussion

The data suggests that over 90% of persons with SCI are eating and feeding themselves
independently (Lysack et al. 2001). This prospective study (n=55) that included three data
collection points (admission to a rehabilitation unit, discharge and 1-year follow-up) showed that
at discharge (n=45) significant gains were demonstrated in the performance of the daily
activities specifically related to personal self care and mobility and that this function was
preserved at the 1-year follow-up (n=25). Regrettably, there are no intervention trials for other
daily living tasks such as bathing, maintaining the home, or meal preparation.

Conclusion

There is level 5 evidence (1 cross sectional study) that suggests that at discharge from a
rehabilitation unit there is improvement in self care and mobility that is preserved for 1
year.

At discharge from a rehabilitation unit there is improvement in self care and


mobility that is preserved for 1 year.

Driving is one of the key elements of community reintegration. It provides access to the larger
community and is highly valued. The consequences of SCI can complicate the level of
independence related to driving.

Table 4.5 Driver Training


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: mean age 34.5 yrs; all 1. As SCI level and age increased, the
complete injuries. ability to drive decreased.
Intervention: Subjects completed the 2. 20/33 subjects that were able to drive
Driver training program at Nagano after training had driven before their
Kiyono et al. 2001; Japan
Rehabiliation Centre. Driving ability was SCI.
Downs & Black score=13
subdivided into three categories - 3. Toilet transfer was most correlated
Observational
independant, assisted, or unable. with driving ability.
N=62
Outcome Measures: car driving status, 4. 27/31 (87%) of subjects who could
vocational and sport questions. transfer from the toilet independently
were able to drive independently
(p<0.0001).

4-12
Discussion

Kiyono et al. (2001) showed that of the 62 patients with tetraplegia involved in a driver-training
program 33 were able to drive following the training. Ability to drive was positively related to
independence in activities of daily living (p<.001), specifically toilet, bed and tub transfers as
well as lower extremity dressing. It was also related to lower level of SCI, a younger age,
driving a car prior to SCI, being employed and active participation in sports.

Conclusion

There is level 5 evidence (1 observational study) suggesting that following a driving


training program, persons with tetraplegia who drove tended to be of younger age, have
a lower level of SCI, drove prior to injury, were able to perform independent transfers,
employed and involved in sports.

Persons with tetraplegia most likely to drive following a driver training program were younger in
age, were able to perform transfers independently, had a lower level of SCI, drove prior to SCI
and were employed and involved in sports.

4.3.2 Work

Being employed or having productive and meaningful responsibility is an important and critical
aspect for adults in society, despite disability. It is, however, acknowledged that for persons with
SCI certain work is better suited for individuals with injuries at different lesions and is related to
several factors. The literature related to employment for persons with SCI primarily focuses on
factors contributing to obtaining, returning to, and staying employed as well as adjustment after
SCI.

There is general consensus in level 5 evidence cross-sectional studies that a number of factors
are associated with or predictive of post-injury employment. Table 4.6 provides a summary of
these factors as well as the positive or negative direction of the impact.

Table 4.6 Factors Contributing to Employment Among Individuals with SCI


Factors identified to have a
Impact
relationship with employment Study (N) Study reference
( + positive; - negative)
among SCI
Demographic Characteristics
+ 234 Tomassen et al. 2000
+ 259 Krause 2003
Male gender
+ 277 Ville & Ravaud 1996
- 195 Anderson & Vogel 2002
- 259 Krause 2003
- 301 Krause 1996
- 195 Anderson & Vogel 2002
Level of injury - 231 Krause & Anson 1996
(cervical or tetraplegia) - 418 Noreau et al. 1999
- 192 Young & Murphy 2002
- 114 Castle 1994
- 170 Tate et al. 1993
+ (more yrs) 5925 Meade et al. 2004
Years since injury
+ (more yrs) 154 Crewe & Krause 1990

4-13
Factors identified to have a
Impact
relationship with employment Study (N) Study reference
( + positive; - negative)
among SCI
+ (more yrs) 170 Tate et al. 1993
+ (less yrs) 301 Krause & Anson 1996
+ (ages 36-45yrs) 234 Tomassen et al. 2000
Age
+ (younger) 301 Krause & Anson 1996
+ (younger) 170 Tate et al. 1993
+ (younger) 418 Noreau et al. 1999
Age at time of injury
+ (before 15 yr) 277 Ville & Ravaud 1996
+ 234 Tomassen et al. 2000
+ 259 Krause 2003
+ 301 Krause & Anson 1996
+ 266 MacKenzie et al. 1986
Higher education pre-injury
+ 24 Goldberg & Freed 1982
+ 277 Ville & Ravaud 1996
+ 418 Noreau et al. 1999
+ 114 Castle 1994
+ 234 Tomassen et al. 2000
Education & training post injury
+ 259 Krause 2003
Higher number of children + 24 Goldberg & Freed 1982
Higher income + 301 MacKenzie et al. 1986
Private insurance + 170 Tate et al. 1993
Racial & ethnic minorities - 5925 Meade et al. 2004
Pre-injury job factors
Ability to return to pre-injury job1 + 259 Krause 2003
Pre-injury work of light to 234 Tomassen et al. 2000
+
moderate physical intensity
+ 259 Krause 2003
Professional job-type pre-injury1 + 277 Ville & Ravaud 1996
+ 192 Young & Murphy 2002
Personal issues
Independent living + 195 Anderson & Vogel 2002
+ 234 Tomassen et al. 2000
Independence in daily activities
+ 195 Anderson & Vogel 2002
+ 195 Anderson & Vogel 2002
Ability to drive independently + 418 Noreau et al. 1999
+ 114 Castle 1994
Health issues (UTIs, spasticity, - 195 Anderson & Vogel 2002
pressure sores etc.) - 231 Krause & Anson. 1996
Lower activity level - 256 Krause 1996
Use of illicit drugs - 195 Anderson & Vogel 2002
Psycho-social factors
Presence of social network + 301 MacKenzie et al. 1986
Quality of Life with SCI + 362 Krause & Anson 1997
Motivation to work + 24 Goldberg & Freed 1982
Discharge planning
from hospital/rehab
Includes vocation and/or 24 Goldberg & Freed 1982
+
education goals
Workplace issues
- 231 Krause & Anson. 1996
In-accessibility of the workplace
- 70 Yavuzer & Ergin 2002
Job accommodations + 96 McNeal et al. 1999
School participation
and performance
among adolescents
Curriculum changes/ modifications + 53 Dudgeon et al. 1997
Human assistance + 53 Dudgeon et al. 1997
In-accessibility of school - 53 Dudgeon et al. 1997

4-14
Factors identified to have a
Impact
relationship with employment Study (N) Study reference
( + positive; - negative)
among SCI
- (extra-curricular Dudgeon et al. 1997
Lack of transportation 53
participation)
- (extra-curricular Dudgeon et al. 1997
Health concerns 53
participation)
Adaptive writing techniques + 53 Dudgeon et al. 1997
1
Also associated with a much shorter interval between injury and return to work.

Discussion

Several factors emerged in repeated studies to have significant impact on the employment of
persons with SCI. In 4 studies, the factor of being male was shown to have a significant impact,
of which 3 studies suggested it was positive (across studies total n = 770) and one study (n =
195) indicated it had a negative impact. There are 4 studies that suggest years since injury had
an impact on employment with 3 of these showing that more years had a positive impact (total n
= 6249 across studies) and one study (n = 301) indicated that fewer years post-injury was
positively related. In 8 studies, having tetraplegia (total n = 1880) was found to have a negative
impact, while higher education prior to the SCI (total n = 1893 across studies) had a positive
impact on employment. Employment is also positively related to the factors of younger age (3
studies, total n = 705), professional pre-injury job (3 studies, total n = 728) and ability to drive a
car (3 studies, total n = 727).

Conclusion

There are several level 5 evidence studies that show the following factors have a positive
impact on employment: male, more years since injury, younger age, car driving ability,
higher education and professional job prior to the SCI. Many studies also show that
having tetraplegia has a negative impact on gaining and maintaining employment.

Being male, more years since injury, younger age, the ability to drive a car and having a higher
education and a professional job prior to the SCI positively impact employment.
Having tetraplegia has a negative impact on gaining and maintaining employment.

In terms of adjustment to SCI, being employed significantly facilitates the coping and adjustment
to disability.

Table 4.7 Employment


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: n=559 highly qualified Effect of Qualifications
disabled applications, n=557 highly 1. Across all company sizes,
Ravaud et al. 1992; France qualified AB applications, n=556 modestly disabled persons had less
PEDro=2 qualified disabled applicants n=556, chance of obtaining an interview
RCT modestly qualified AB applicants. irrespective of their qualifications
N=2228 Intervention: Fictional resumes of (p<0.01).
varying qualities were randomly assigned 2. Highly qualified disabled
to be sent to one of four companies in applicants had fewer favorable

4-15
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
France. responses (2.60%) compared to
Outcome Measures: level of response to highly qualified AB applicants
application (negative or positive), effect of (4.54%).
qualification, effect of company size. 3. Modestly qualified disabled
applicants had fewer favorable
responses (1.24%) compared to
modestly qualified AB applicants
(3.95%).
Effect of Company Size
4. The larger the company (>500),
the greater the chance of
discrimination against highly
qualified disabled applicants
(p<0.01).
5. For modestly qualified
applicants, discrimination was
more visible in smaller
companies (200-499 employees;
p<0.001) compared to larger
ones (>500 employees; p<0.06).
Population: age at beginning of study: 1. During 15 yrs there was an increase
45.6 yrs, mean DOI: 24.4 yrs, 82% men, in married individuals (1974=31.9%,
68% had tetraplegia, 32% had paraplegia. 1985=48.9%) and a decrease in the
Sample size n=154 (in 1985) and n=135 number of single people
(in 1992 at follow-up). (1974=60.7%, 1989=37.8%).
Intervention: Completion of a 2. More participants were working in
Krause 1992; USA questionnaire. This was the 15-year 1989 (50%) than in 1974 (44%).
Downs & Black score=11 follow-up from phase one of an earlier 3. There were significant increases in
Observational study. years of education (p<0.001), sitting
N=135 Outcome Measures: Life Situation tolerance (p<0.05), satisfaction with
Questionnaire (LSQ). employment (p<0.05) and
satisfaction with finances (p<0.05).
4. There were significant correlations
between the two times for
interpersonal (r=+.31) and activity
(+.45) items.

Population: age at time 2 40.5±7.3yrs, 1. Those who made positive


mean DOI 20±5.3yrs. transitions (POS) into work were
Intervention: Survey at time 1 and time 2 significantly younger (p<0.05) and
(11 year follow-up). had a shorter DOI (p<0.01).
Outcome Measures: Life Situation 2. POS and employed individuals had
Questionnaire (LSQ). significantly higher education than
those chronically unemployed
Krause 1996; USA (p<0.001).
Downs & Black score=15 3. Unemployed and POS groups had
Observational a significantly higher proportion of
N=142 quadriplegics (p<0.05) and
chronically unemployed individuals
had lower activity scores compared
to the employed groups (p<0.001).
4. POS group had significantly lower
interpersonal dissatisfaction
compared to the other grps
(p<0.05).

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Discussion

A longitudinal study showed, that over a 15-year period post-SCI (n=135), significant gains were
realized in work, satisfaction, a reduction in the need for medical services, and improved sitting
tolerance (Krause 1992). The greatest gains were related to employment where significant
improvements were demonstrated in satisfaction with employment and finances and more
individuals were employed (Krause 1992). In another longitudinal study, Krause (1996) showed
that after 11 years (n=142) persons with SCI who were unemployed had significantly lower
activity levels (F(3, 130)=5.0, p<.01) and high levels of economic dissatisfaction (F(3,118)=3.8,
p<.05) than those with SCI who were employed. In addition, having a disability was a significant
discriminating factor for gaining employment.

In a study completed in France, Ravaud and colleagues (1992) reported that persons with
disabilities were significantly less likely to obtain an interview or be hired than their able-bodied
counterparts (p<.01). Larger companies were more likely to discriminate against highly qualified
individuals, while modest qualifications were less discriminated against in medium and large
companies though remained a source of discrimination in small companies.

Conclusion

There are level 5 evidence studies (2 longitudinal) that show that those persons with SCI
that were employed 15 years post-SCI had greater satisfaction with employment and
finances while those who were unemployed 11 years post-SCI had lower activity levels
and greater economic dissatisfaction.

There is level 5 evidence (one cross-sectional study) that persons with disabilities in
France experience discrimination related to employment, as they are less likely to obtain
an interview or be hired.

Employed persons with SCI had greater satisfaction with employment and finances while those
unemployed had lower activity levels and higher economic dissatisfaction.

Persons with disabilities experience discrimination and are less likely to obtain an interview or
be hired.

4.3.3 Leisure and Recreation

In the face of catastrophic events such as a SCI, adjustment generally involves engaging in the
necessary or important tasks to sustain life. Typically these activities consume available time
with leisure and recreational occupations relegated to one’s memory. This, however, is
unfortunate as the enjoyment and satisfaction of participating in leisure occupations have
positive effects on other aspects of life and should not be disregarded.

The studies in leisure and recreation among persons with SCI primarily use cross-sectional
research designs. Collectively this research investigates the influence of engaging in leisure
and its impact on adjustment to SCI, community integration, and employment. Table 4.8
provides a summary of these studies and the factors related to leisure and recreational
engagement of persons with SCI.

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Table 4.8 Factors Relating to Leisure Among Individuals with SCI
Factors identified
Impact Study Study reference
to have a relationship with
( + positive; - negative) N
leisure among SCI
Involvement in leisure + adjustment to SCI 178 Loy et al. 2003
activities
+ physical independence 48 Hanson et al. 2001
+ mobility
1
+ occupation
+ social integration
Characteristics of
leisure occupations
Leisure Diversity + subjective well-being 178 Loy et al. 2003
Leisure Intensity + subjective well-being 178 Loy et al. 2003
Facilitators to leisure
participation
Social support system + 178 Loy et al. 2003
+ 14 Dattilo et al. 1998
- if lack of support 72 Scelza 2005
Being healthy + 178 Loy et al. 2003
Being employed or attending + 48 Hanson et al. 2001
school
Expectations for leisure
participation
Adventure activities - 388 Kennedy & Smith 1990
Crafts -
Intellectual activities -
Perceived Barriers to
Leisure Participation
Health concerns - (tetraplegia) 72 Scelza 2005
Cost of program - 72 Scelza 2005
Lack of leisure opportunities in 14 Dattilo et al. 1998
the community
Intrinsic (Intrapersonal)2 - 72 Scelza 2005
Physical ability3 - 14 Dattilo et al. 1998
72 Scelza 2005
Having a SCI
Engaging in sporting activities - 45 Tasiemski et al. 2000
Engaging in recreation activities - 45 Tasiemski et al. 2000
1
Items include # of hours per week to engage in homemaking, working, school, self improvement, maintenance,
recreation and volunteering.
2
Refers to lack of motivation, energy and interest in exercise.
3
Refers to lack or loss of physical balance, mobility and strength.

Discussion

Studies suggest that the primary facilitator for leisure involvement is a supportive social network
(3 studies, total n = 264). Other facilitators are being healthy and being employed or attending
school. The main barrier to leisure participation was lack of physical ability (2 studies, total n=
86) with other barriers noted as health concerns, cost, and lack of opportunity or interest.
Participation in leisure occupations were shown to have a positive impact on adjustment to SCI,
physical independence, mobility, hours in activities of daily living and social integration.

Conclusion

Level 5 evidence (several cross-sectional studies) suggests that facilitators for leisure
involvement are social support, being healthy and being employed or attending school.

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Facilitators for leisure involvement are social support, being healthy and being employed or
attending school. Barriers are lack of physical ability, health concerns, cost,
and lack of opportunity or interest.
Participation in leisure occupations have a positive impact on adjustment to SCI, physical
independence, mobility, hours in activities of daily living and social integration.

Limited research has also been reported on the use of 2 technologies to support the
engagement in leisure activities. These are a computer video game called GAMEWHEELS and
functional electrical stimulation (FES). Each of these is described in turn.

Table 4.9 Wheelchair Exercise


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 10 males, 5 females, age 1. Mean Ve was significantly higher
34.7yrs (male) and 39.6yrs (female), all for the GAME group at the 16 and
incomplete injuries at C6-L2. 20 min time points (during
Intervention: Submaximal oxygen exercise); however, there were no
O’Connor et al. 2001; consumption test with and without significant differences in Ve max
USA simultaneous use of the GAME system (a values at these time points.
Downs & Black score=12 video game device). The order in which the 2. Mean VO2 was significantly higher
Prospective Controlled trials were administered was randomized. for the GAME group at the 16 and
Trial Outcome Measures: HR, ventilation rate 20 min time points (during
N=15 (Ve), VO2. exercise).
3. There were significant differences
in Ve and VO2 between conditions
during transition points (warm-up
to exercise).

Discussion

A study (n = 15) investigated the effects of the GAMEWHEELS system (an interface between a
portable roller system and a computer that is controlled by propulsion of a wheelchair’s wheels
on the roller) on physiological responses during and motivators for engaging in fitness and
exercise activities when wheeling a wheelchair. Results suggest that metabolic activity was
greater and significantly different (specifically, oxygen consumption (p<.05) and ventilation rate
(p<.05) when exercising using the GAMEWHEELS than when not. There was no difference in heart
rate between the two conditions. The system also allowed individuals to achieve their target
exercise training zone faster and to maintain it for the entire session. 87% (13) reported that the
system assisted them to work out on a regular basis.

Conclusion

Level 2 evidence (1 non-randomized controlled study) showed the physiological and


motivational benefits of using the GAMEWHEELS system when engaging in wheelchair
exercise.

Use of the GAMEWHEELS system showed physiological and motivational benefits


for engaging in wheelchair exercise.

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Table 4.10 FES Assisted Exercise

Author Year; Country


Score
Methods Outcome
Research Design
Total Sample Size

Population: N=5, age 17-20yrs, LOI T4- 1. FES was used mainly for exercise
T11, all complete, at least 1 year post- purposes (51%-84% of total days
injury, all ASIA A. used) and less for mobility.
Intervention: FES system implanted into 2. Even though all subjects had
the major muscles used for standing previous brace training, standing
(quadriceps, gluteus maximus, gluteus balance training was needed
medius, and posterior fibers of the before progressing to functional
adductor magnus). Sometimes erector skills training with FES. Eventually,
spinae, hamstrings, adductor longus, and subjects showed a range of
Moynahan et al. 1996; tibialis anterior were included. Stimulation proficiency at manoeuvring and
USA patterns were conducted every 1-4 weeks. short-distance ambulation.
Downs & Black score=12 The protocol was changed in order to fine- 3. The primary factor that motivated
Post-test tune the timing, intensity and coordination FES standing was enjoyment of
N=5 of muscle activity. Subjects wore either being able to stand.
hinged, molded ankle-foot orthosis or 4. Most common reason for non-use
molded shoe inserts depending on was not having time during the day,
requirement for ankle stability. All subjects not wanting to wear the device all
underwent an 8-week FES exercise day and not wearing it in public.
program designed to increase muscle
strength and endurance.
Outcome Measures: FES usage,
adherence, functional skill level and
mobility.

Discussion

Home use of FES training was investigated in a 1 year study with 5 adolescents who had
paraplegia. Results showed that the FES was primarily used for exercise and standing, both of
which were regarded as motivators for use. Other benefits were ability to do more things and a
sense of well-being. Barriers were lack of time to use the system and reluctance to wear the
FES all day.

Conclusion

There is level 4 evidence (one uncontrolled study) that suggests that FES is beneficial as
a motivator to engage in exercise and standing. Drawbacks included lack of time to use
the system and reluctance to wear all day.

FES is a motivator to engage in exercise and standing, augments ability to do more things and
enhances the sense of well-being. Drawbacks included lack of time to use
the system and reluctance to wear all day.

4.4 Quality of Life

Spinal cord injury (SCI) is a devastating life situation that occurs suddenly and unexpectedly.
After the initial (acute) phase of care, individuals start a long period of rehabilitation that aims at

4-20
returning them to the community and allowing them to resume, as much as possible, daily
activities and social roles so that they may ultimately begin to enjoy life again. It might be seen
as irrelevant to discuss quality of life (QOL) shortly after SCI, however, being part of the
fundamental nature of life, QOL becomes a significant issue after rehabilitation discharge. Some
reports suggest that compared to the general population people with SCI might experience a
slightly lower QOL (Westgren & Levi 1998) but a substantial number of these individuals regain
a good to excellent QOL after a period of time (Post et al. 1998a). As expressed by Albrecht and
Devlieger (1999), it may be seen as a paradox that “many people with disabilities report
experiencing a good or excellent QOL when to most observers these people seem to live an
undesirable daily existence” (p. 977).

This situation brings out a fundamental issue in the assessment of QOL – unlike other QOL-
related constructs that are described below, subjective QOL (life satisfaction, well-being) is such
an intimate feeling that any process trying to measure QOL from an external observer
indubitably remains imperfect. As it is mostly influenced by one’s personal experiences,
comparisons with societal values usually brought about by an external point of view, are likely to
misjudge one’s QOL. Furthermore, making QOL more difficult to understand, it has been
observed that individuals sustaining alterations in health status or a life event such as a SCI,
may change their internal standards, their values or their conceptualization of QOL (Spranger
1999). These phenomena might partly explain why it is likely that a difference exists between
the external vision of QOL and what is really experienced by people with SCI.

4.4.1 QOL Definitions and Models

Although the term “goodness of life” (Baker & Intagliata 1982) seems appropriate to express the
overall concept of QOL, its apparent simplicity hides a multidimensional concept that is among
the most difficult to define and translate into a functioning and operating reality. Nonetheless,
two main conceptualizations of QOL are well-accepted: (1) the subjective approach, whose
focal point is the person’s emotional or cognitive assessment of the congruence between his/her
life expectations and achievements, usually associated with life satisfaction or well-being and
(2) the objective approach, based on one’s characteristics that can be objectively measured by
an external appraiser (Dijkers 2003). The latter includes the concept of Health-Related Quality
of Life (HRQOL) that focuses mostly on physical and mental health, social and role
achievements, and thus it is more oriented toward functional performance than is subjective
QOL (Wood-Dauphinee et al. 2002).

Several models explaining the overall concepts of QOL and its determinants have been
presented in the field of disability with a particular link to the disablement process (Wood-
Dauphinee & Kuchler 1992; Whiteneck 1994; Post et al. 1999; Dijkers 2003). Post and
collegues (Post et al. 1999; Post & Noreau 2005) proposed a conceptual model that integrates
1) the dimensions of The International Classification of Functioning, Disability and Health (ICF)
(World Health Organization 2001) seen as observable deviations from normal functioning and 2)
a subjective dimension based on one’s perception of satisfaction, perceived health and well-
being. For example, paralysis (Body Function), inability to walk (Activities), level of social
support (Environment) and employment restrictions (Participation) can be assessed from an
external observer and some of these dimensions will potentially influence QOL. Conversely,
perceived health, satisfaction with social participation and general well-being can only be
reported by the person him/herself. All these dimensions form the global (superordinate)
construct of QOL that include the objective and subjective approach. Dijkers (2003; 2005)
proposed a more generic model that integrates different conceptualizations: 1) QOL as
subjective well-being, reflecting the congruence between one’s expectations, values and

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achievements, 2) QOL as achievements focusing on one’s accomplishments, performances and
statuses and including the concept of HRQOL (health and functioning), and 3) QOL as a utility
that compares achievements/statuses with societal norms and standards. These models can
help clinicians to differentiate between QOL as subjective well-being and its objective
determinants. Needless to say, depending on the conceptualization of QOL that would be
valued for a specific research or clinical purpose, the choice of an appropriate measure is a
critical issue.

Some concerns exist regarding the use of the term HRQOL for the conceptualization of QOL
given its emphasis on health status and functioning (Moons 2004) especially given that a shift in
QOL may occur after SCI, and therefore, just because people may have significant health
problems does not necessarily mean they have poor QOL (Smith et al. 1999). Health status
should be considered an important determinant of QOL instead of being regarded as an integral
dimension of QOL itself. Consequently, QOL as an outcome seems to be more appropriately
defined in terms of life satisfaction and this review will mainly focus on that concept.

4.4.2 Exploring QOL after SCI from a Scientific Perspective

An impressive number of studies have addressed Health-related and subjective QOL after SCI.
Several reports have attempted to identify the potential determinants of QOL from different
perspectives but it remains difficult to compare this substantial bulk of information due to the
methodological discrepancy between the studies and the lack of consistency in the assessment
of the construct of QOL (well-being, life satisfaction) with different measures. Moreover, most
studies focused on a single or limited number of variables as very few studies have been
conducted with a conceptual framework that takes into account the spectrum of factors that
influence QOL. As a result, these studies predict only a small percentage of the variance in QOL
(Dijkers 2005) and therefore give a limited scope of the QOL determinants.

4.4.3 Quantitative Measurement Approach of QOL Determinants

To overcome the problem of reduced statistical power in many studies with small sample sizes,
common with SCI studies, researchers recommend the use of meta-analyses which consist of
combining the results of several studies that address similar research hypotheses (e.g. impact
of SCI on QOL). Because of limited rigor of research design and poor validity of measurements
in the reviewed studies, Evans et al. (1994) failed to determine whether or not rehabilitative care
improves QOL. Unlike an overwhelming number of recent reports, this meta-analysis supported
an association between QOL and the level of injury. In his meta-analysis, Dijkers (1997b)
focused on determining the relationships between QOL and each dimension of the International
Classification of Impairment Disability and Handicap (the disablement process). Results showed
that overall, slightly lower mean QOL scores are observed in individuals with a SCI than in
people without disability, but the relationship between the level of injury and QOL (mostly
paraplegia vs. tetraplegia) was almost non existent or weak at best. Conversely, consistent
relationships (r = .30 - .50) were observed between QOL and some aspects of handicap (social
integration, occupation). It remains possible that severity of injury indirectly affects QOL through
its influence on societal participation (Post et al. 1998; Dijkers 1999). If the level of societal
participation valued by a person is not affected because of favourable conditions (e.g.
education, appropriate environmental adaptations, social support), it is likely that subjective
well-being will not be affected, regardless the severity of injury.

The potential predictors of QOL that have been mentioned in studies are summarized in Table
4.11. They were grouped into global dimensions for the purpose of this review and not

4-22
surprisingly, predictors related to community integration/participation are among those most
often cited in the literature, which supports their importance to enhance QOL. However, it is not
necessarily all dimensions of participation that strongly influence QOL. Mobility, occupation, and
community life (including interpersonal relationships) are seen as the most important predictors.
Poor health status and the occurrence of secondary impairments are also known to diminish
QOL.

Interestingly, there is growing interest regarding the impact of the environment on societal
participation and QOL. Perceived social support (particularly from a spouse) has been
considered in several studies as a major predictor of QOL but it is unclear if this variable is a
mediator that will promote the level of community integration/social participation or a direct
contributor to QOL. The physical environment also has the potential to influence QOL. Richards
et al. (1999) observed that access to the environment (home and transportation) was positively
and linearly associated with satisfaction with life. It contributed to the explanatory model
predicting life satisfaction even after all the other independent measures were considered.

As previously mentioned, few studies have used a conceptual framework in order to account for
the spectrum of factors that influence QOL. Even with a strong conceptualization, difficulties still
exist in attempting to capture the complete picture of QOL determinants using quantitative
research methods. For example, Whiteneck et al. (2004) studied the relative impact of
environmental barriers on life satisfaction compared to injury-related variables, demographics
and activity/participation limitations. A limited amount of variance in QOL (10%) was explained
by the environmental barriers compared to participation (15%) and demographics (11%).
Overall, 26% of the variance was explained by all subsets of predictors, meaning that about
75% of the variance is unknown or unexplained by factors measured in such a study. This lack
of prediction is probably attributable to methodological difficulties such as using measures that
do not fully translate the concepts into good metrics rather than a misidentification of the
potential factors that influence QOL.

Despite the large number of studies on QOL after SCI that applied a quantitative approach, our
objective knowledge of how well-being after SCI develops and what factors have a positive or
negative influence on the course of QOL remains limited (Post & Noreau 2005). Further
research is needed using an integrative approach with measures that strongly fit distinct
constructs as those defined in the ICF or other models explaining the consequences of health,
disease and trauma.

Table 4.11 Potential Predictors of Subjective QOL


Issues perceived to influence subjective QOL References

Meta analyses or relationships with the disablement Fuhrer et al. 1992; Evans et al. 1994; Dijkers 1997b;
process Pierce et al. 1999; Whiteneck et al. 2004
Demographics
Age, time since injury, ethnicity, education, marital status Post et al. 1998; Dijkers 1999; Holicky & Charlifue 1999;
McColl et al. 1999; Kennedy & Rogers 2000; Putzke et al.
2001
Injury-related factors Post et al. 1998; Westgren & Levi 1998; Hall et al. 1999;
Putzke et al. 2001
Health-related factors
Mobility, perceived health, rehospitalization, secondary Decker & Schulz 1985; Schulz & Decker 1985; Crisp
impairments (respiratory problems, pressure sores, 1992; Fuhrer et al. 1992; Lin et al. 1997; Post et al. 1998;

4-23
Issues perceived to influence subjective QOL References

spasticity) Kemp & Krause 1999; Pierce et al. 1999 Putzke et al.
2002; Anderson & Vogel 2003; Franceschini et al. 2003
Pain Siösteen et al. 1990; Lundqvist & Siösteen 1991;
Stensman 1994; Anke et al. 1995; Krause 1997; Post et
al. 1998; Vogel et al. 1998; Westgren & Levi 1998; Ville et
al. 2001; Bénony et al. 2002
Psychological factors
Loneliness, boredom Krause & Kjorsvig 1992
Perceived control on life Decker & Schulz 1985; Schulz & Decker 1985; Crisp
1992; Fuhrer et al. 1992; Krause 1992; Krause 1997;
Mcneil et al. 1998; Tate & Forcheimer 1998; Putzke et al.
2002; Franceschini et al. 2003
Community integration/participation
Social functioning/integration Decker & Schulz 1985; Schulz & Decker 1985; Krause &
Crewe 1987; Siösteen et al. 1990; Lundqvist & Siösteen
1991; Crisp 1992; Clayton & Chubon 1994; Dijkers
1997b; Post et al. 1998; Dijkers 1999; Pierce et al. 1999;
Kemp & Ettelson 2001; Ville et al. 2001; May & Warren
2002; Putzke et al. 2002
Interpersonal relationships/social interactions Krasue 1997; Bénony et al. 2002; Putzke et al. 2003;
Franceschini et al. 2003

Community access/participation Schulz & Decker 1985; Fuhrer et al. 1992; Cayton &
Chubon 1994; Nosek et al. 1995; Dijkers 1997a; Hansen
et al. 1998
Occupation/employment status (including satisfaction Krause & Crewe 1987; Lundqvist & Siösteen 1991; Crisp
with), life opportunities 1992; Fuhrer et al. 1992; Krause 1992; Krause & Kjorsvig
1992; Dijkers 1997b; Krause 1997; Lin et al. 1997;
Pentland et al. 1998; Westgren & Levi 1998; Dijkers
1999; Kemp & Krause 1999; McColl et al. 1999; Ville et
al. 2001; Putzke et al. 2002; Franceschini et al. 2003
Environmental issues Decker & Schulz 1985; Schulz & Decker 1985; Crisp
1992; Fuhrer et al. 1992; Rintala et al. 1992; Warren et al.
Perceived social support 1996; Dijkers 1997b; Kemp & Krause 1999

Accessibility (home/health care) Richards et al. 1999; Deconinck 2003

Preferred living situation Cushman & Hassett 1992

Gerhart 1991; Krause 1992; Clayton & Chubon 1994;


Level of income
Vogel et al. 1998; Heck & Makuc 2000; Ville et al. 2001

Residence (nursing home) Dijkers 1999; Putzke & Richards 2001

4-24
Average level of QOL after SCI is slightly lower than in people without disability but a
substantial number of people with SCI report good or excellent QOL.
Severity of injury and other diagnostic factors do not significantly impact QOL. There influence
may become significant through restrictions in community integration and social participation.
A limited amount of variation in QOL has been explained by quantitative research methods.

4.4.4 Qualitative Research Methods to Understand QOL and its Determinants

Because of the difficulty quantitatively capturing complete information on QOL and its
determinants, few reports have used qualitative methods and shed light on the issue of QOL
when living with SCI (Bach & McDaniel 1994; Hillebrand et al. 2001; Manns & Chad 2001;
Whalley Hammell 2004). These studies confirm that several people with SCI enjoy life and have
a good or excellent QOL, even those with a severe injury. Overall, QOL is seen as something
dynamic and subjective. It is generated by the individual’s personal experiences and changes
over the course of life in response to changing priorities and values. The latter is a concept
frequently mentioned and corresponds to the response shift theory (Rapkin 2004).

Several elements that make life enjoyable do not differ in persons with SCI compared to those
without disability. These elements include satisfying interpersonal relationships, financial
security, meaningful social roles (including those related to work and productivity) and
opportunity to pursue leisure and community services. In general, factors reflecting participation
in life situations or reintegration into the community are very influential to QOL. Having control
over one’s life, assertiveness and balance between dependence and independence have all
been reported as major QOL determinants. Access to various resources (physical, emotional,
social) is seen as a necessary foundation to QOL and refers to the overall contribution of the
environment.

There is an interactive process between correlates of QOL that suggests a complex


interrelationship between the domains influencing QOL. Moreover, each domain, taken
independently, is insufficient to maintain QOL and rather, it is the interaction between personal
attributes, meaningful roles and environmental assets that build an optimal QOL. Albrecht and
Devlieger (1999) nicely summarize this perspective by stating that it refers to “the ability of the
self to build and manage a balance between the body, mind and spirit in searching for a state of
well-being and to maintain an harmonious relationship with the environment” (page 986).

Qualitative reports suggest that factors affecting QOL after SCI do not seem to differ from
those impacting QOL in people without disability. They are related to life issues
such as achieving meaningful social roles, having control over one’s life
and maintaining adequate access to the environment

4.4.5 Trials Examining QOL as an Outcome

Unlike the concept of HRQOL, which has been the object of an infinite number of clinical trials,
there is a paucity of experimental studies that examine QOL as subjective well-being or use this
concept as a primary outcome. One reason for this is related to the concept of subjective QOL
itself, resulting from subjective feelings where the appraisal is built on the accomplishment of

4-25
valued life dimensions. Therefore, subjective QOL cannot be the primary outcome of a clinical
intervention and thus, the aim of a study must be to examine the life dimensions valued by the
person (e.g., health status, functional independence, occupation, etc.) and to presume an
indirect effect of enhanced life dimensions on QOL.

The aforementioned findings suggest that dimensions related to community integration (in
particular, active participation and full citizenship) are the most likely to enhance QOL after SCI.
Thus, interventions to enhance QOL should pay careful attention to these determinants. In
Table 4.12 we present 4 studies which use experimental and quasi-experimental designs to
examine changes in QOL after an intervention. Three studies focus on people with SCI while
another one involves spouses.

Table 4.12 Clinical Trials Examining the Effect of Specific Interventions on QOL
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 34 subjects (23 men, 11 1. Exercisers reported less pain,
women), complete-incomplete, LOI: 10±11 depression, stress and greater
years. perceived QOL and self-concept.
Martin Ginis et al. 2003; Treatment: exercise training ( aerobic and 2. Stress and pain mediated exercise
Canada resistive) performed in groups of 3-5 induced-changes in QOL.
PEDro=5 people, twice weekly (24 sessions: avg. 15
RCT wks to complete; range 12-22 weeks).
N=34 Mediators: pain perception, self-efficacy,
stress.
Outcome Measures: self-concept,
depression, subjective well-being.
Population: Total n=111 1. The standard care group spent an
Treatment n=72, Control n=39; average of 8.0 days/yr in the hospital
acute phase and 1 yr post-discharge. vs. 5.2 for the telephone and 3.0 for
Phillips et al. 2001; USA Treatment: Participants randomly the video group.
PEDro=4 assigned into 3 groups (n=36 video, n=36 2. At 1 yr post-discharge, QWB scores
RCT telephone, n=39 standard care) for were slightly higher in the intervention
N=111 education on various SCI issued. groups (video-telephone) (n = only
Follow-up (1 yr) to monitor QOL. 42% of the initial sample).
Outcome Measures: Depression (CES-D),
HRQOL-QALY (Quality of Well-Being).
Population: 36 SCI spouses: 19 treatment 1. All values from QOL were significantly
subjects, 17 controls, Age: Support group improved after the treatment in the
32.5yrs, Control spouse 38.5yrs, DOI: support group compared to the control
Support=21 mo, Control= 36 mo. group (physical, psychological, social
Sheija & Manigandan,
Intervention: Support groups met 7 times relation (p<0.0001).
2005; India
(1 h) over a 2-wk period. Controls did not. 2. Significant reduction in anxiety and
Downs & Black score=16
Program: discussions on previous sessions depression in the support group.
Prospective Controlled
home task, topic specific performance,
Trial
assignment of home task, wind down.
N=36
Outcome Measures: General Health
Questionnaire (GHQ), Hospital anxiety and
depression rating scale (HAD) and QOL
(WHOQOL-BREF).
Population: 25 treatment subjects, 25 1. Significant improvement in all domains
Daniel & Manigandan
control subjects. of the LSS and WHO QOL-BREF in
2005; India
Treatment: Experimental group had five the experimental group (except for
Downs & Black score=15
leisure group sessions (1 hr) included: 1) social relationships) as compared with
Prospective Controlled
intro and group interaction, 2) importance the control group (p=0.0001).
Trial
of leisure, 3) problems faced in leisure
N=50
participation, 4) strategies to overcome

4-26
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
them, & 5) revision and summary, along
with carrying out an activity suggested by
the group members] as intervention while
the control group had none.
Outcome Measures: leisure (Leisure
satisfaction scale), QOL (WHOQOL-BREF)

Discussion

Even though reality is more complex, some studies support the straightforward hypothesis that
an intervention can modify a particular dimension of life, and the latter will directly influence
QOL. For example, Martin Ginis et al. (2003) suggest that the effect of an exercise program on
QOL is mediated by modifying pain and stress. Sometimes, weaker designs and less
sophisticated analyses (prospective controlled trial) can also be used to suggest the indirect
impact of an intervention on QOL, as shown by Daniel and Manigandan (2005). These authors
attempt to determine if a leisure intervention program would influence subjects’ attitudes toward
leisure, the level of leisure satisfaction and, consequently, QOL. One experiment that we
located did not lead to an obvious effect on QOL. In their post-discharge follow-up conducted by
telehealth or telephone Philips et al. (2001) found that telehealth lead to a more positive
outcome than standard care but this did not translate into better subjective QOL. The
aforementioned hypothesis could also be validated with the partners of people with SCI who are
impacted by the new life context. A good example is Sheija and Manigandan’s investigation of a
spouse support program (2005). They found significant improvements in all domains of QOL
and psychological variables while marginal changes were observed in the control group.
Overall, only one study (Martin Ginis et al. 2003) provided strong evidence that a specific
intervention on life domains will have an impact on QOL. The conclusions from the other studies
would have been stronger if secondary analyses had been conducted to demonstrate an
association between the changes in an intermediate outcome (depression, anxiety,
psychological distress, etc.) and QOL. At present we can only assume that eliciting changes in
an individual’s characteristics or life situations would enhance subjective QOL.

Conclusion

There is Level 1 evidence in 1 RCT study that supports the use of exercise to reduce pain
and stress which in turn mediates changes in QOL.
There is level 1 evidence from 1 RCTstudy that suggests that telehealth provides better
prevention education than telephone or standard care, however, there was little influence
on the QOL.

There is level 2 evidence from 1 non-RCT study that suggests the positive impact of a 2-
week leisure educational program (group therapy) on leisure satisfaction and, potentially,
QOL.

There is level 2 evidence from 1 non-RCT study that suggests the use of group therapy to
support spouses of individuals with SCI will decrease the symptoms of depression,
anxiety and psychological distress with a potential impact on QOL.

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Overall, there is a paucity of information from clinical trials on the most appropriate
interventions favouring subjective QOL in people with SCI and their significant others.
QOL can be indirectly enhanced through the use of an exercise program
designed to reduce pain and stress.
Providing group therapy to spouses of individuals with SCI can decrease their symptoms of
depression, anxiety and psychological distress with a potential impact on QOL.

4.4.6 Summary – QOL

One of the highlights of this section refers to the inherent difficulty in studying the concept of
QOL as an outcome. QOL, being such an intimate feeling and influenced by one’s personal
experiences, is difficult but not impossible to study as the primary outcome of an intervention
study. Moreover, the theory of response shift suggests that the essence of QOL (values,
personal standards, expectations) might change over time, making this concept changeable
over the course of life. Nonetheless, some methodological considerations could facilitate the
design of proper QOL studies. Firstly, there is a need to identify and define what construct of
QOL will be the focus of the study as well as the underlying conceptualization (e.g. subjective
vs. objective, general well-being vs. life satisfaction per domain). The proposed measure must
fit the selected construct of QOL and must have sound psychometric properties (validity,
reliability, responsiveness). Secondly, studies that aim to identify predictors of QOL must use
strong conceptual models that will include all the potentially important facets of life (individual
characteristics, environmental dimensions and societal involvement, etc.). Again, appropriate
measures are a critical issue. Thirdly, in the case of clinical trials designed to enhance QOL, the
interventions should be appropriately selected, such that there is a sensical indirect connection
between the intervention and QOL. For example, one could exam the influence of placement in
a long term care facility versus the return to community living on QOL. The outcome should,
therefore, be identified from the dimensions of a conceptual model, such as the ICF model of
health and disability (body functions and structures, activities, participation, contextual factors).
Finally, there is a necessity to carry out further statistical analyses (multivariate analyses, group
differences, path analyses) to provide evidence of the association between the intermediate or
mediating factors and QOL.

4.5 Summary – Community Reintegration

There is Level 4 evidence from a single post-test study that having contact with a person
who has an SCI has a significant impact on attitudes towards disability.

There is Level 5 evidence based on a qualitative study that SCI results in a changed
social network - some relationships are lost but others improve.

There is very limited (Level 5) evidence that people with SCI consider the following
factors as the main barriers to community integrations: barriers in the natural
environment, transport, help at home, health care and government policy.

There is very limited (level 5) evidence from two observational studies that assistive
equipment may promote increased activity and participation in and outside of the home.

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There is moderate (Level 2) evidence from one RCT study that a community based
system for post discharge monitoring in no more effective in terms of community
integration than a hospital based system.

There is very limited (Level 5) evidence from one observational study that productivity
was correlated to the individuals’ subjective experience of community reintegration.

There is very limited (Level 5) evidence from two observational studies that a positive
relationship exists between the adequacy of personal assistance and the physical and
mental health of those with SCI.

There is very limited (Level 5) evidence from two observational studies that people who
receive consumer directed personal assistance services are more satisfied with services
than those who receive services that are not consumer directed.

There is limited (Level 4) evidence from one case series that an independent living
follow-up program is more beneficial than no program.

There is very limited (Level 5) evidence from one observational study that supported
employment assists job placement of some people with SCI.

There is very limited (Level 5) evidence from one observational study that individuals
with disabilities (SCI, cerebral palsy, multiple sclerosis) did not receive adequate
equipment or services on more than half of the occasions in which they were requested.

There is level 5 evidence (1 cross sectional study) that suggests that at discharge from a
rehabilitation unit there is improvement in self care and mobility that is preserved for 1
year.

There is level 5 evidence (1 observational study) suggesting that following a driving


training program, persons with tetraplegia who drove tended to be of younger age, have
a lower level of SCI, drove prior to injury, able to perform independent transfers,
employed and involved in sports.

There are several level 5 evidence studies that show the following factors have a positive
impact on employment: male, more years since injury, younger age, car driving ability,
higher education and professional job prior to the SCI. Many studies also show that
having tetraplegia has a negative impact on gaining and maintaining employment.

There are level 5 evidence studies (2 longitudinal) that show that those persons with SCI
that were employed 15 years post-SCI had greater satisfaction with employment and
finances while those who were unemployed 11 years post-SCI had lower activity levels
and greater economic dissatisfaction.

There is level 5 evidence (one cross-sectional study) that persons with disabilities in
France experience discrimination related to employment, as they are less likely to obtain
an interview or be hired regardless of qualification or size of company.
Level 5 evidence (several cross-sectional studies) suggests that facilitators for leisure
involvement are social support, being healthy and being employed or attending school.

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Level 2 evidence (1 non-randomized controlled study) showed the physiological and
motivational benefits of using the GAMEWHEELS system when engaging in wheelchair
exercise.

There is level 4 evidence (one uncontrolled study) that suggests that FES is beneficial as
a motivator to engage in exercise and standing. Drawbacks included lack of time to use
the system and reluctance to wear all day.

There is Level 1 evidence in 1 RCT study that supports the use of exercise to reduce pain
and stress which in turn mediates changes in QOL.

There is level 1 evidence from 1 RCTstudy that suggests that telehealth provides better
prevention education than telephone or standard care, however, there was little influence
on the QOL.

There is level 2 evidence from 1 non-RCT study that suggests the positive impact of a 2-
week leisure educational program (group therapy) on leisure satisfaction and, potentially,
QOL.

There is level 2 evidence from 1 non-RCT study that suggests the use of group therapy to
support spouses of individuals with SCI will decrease the symptoms of depression,
anxiety and psychological distress with a potential impact on QOL.

4-30
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4-37
CHAPTER FIVE

Upper Limb Rehabilitation


Following Spinal Cord Injury

Sandra Connolly, BHScOT, OT Reg (Ont.)


JoAnne Aubut, BA
Robert W Teasell MD FRCPC
Tal Jarus, PhD, OTR
Key Points

Neuromuscular stimulation-assisted exercise following a spinal cord injury is


effective in improving muscle strength, preventing injury and increasing
independence in all phases of rehabilitation.

Augmented feedback does not improve motor function of the upper extremity in SCI
rehabilitation patients.

Intrathecal baclofen may be an effective intervention for upper extremity hypertonia of


spinal cord origin.

Afferent inputs in the form of sensory stimulation associated with repetitive


movement and peripheral nerve stimulation may induce beneficial cortical
neuroplasticity.

Restorative therapy interventions need to be associated with meaningful change in


functional motor performance and incorporate technology that is available in the
clinic and at home.

The use of concomitant auricular and electrical acupuncture therapies when


implemented early in acute spinal cord injured persons may contribute to neurologic
and functional recoveries in spinal cord injured individuals with ASIA A and B.

There is clinical and intuitive support for the use of splinting for the prevention of
joint problems and promotion of function for the tetraplegic hand. However, there is
very little research evidence to validate its overall effectiveness.

Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity.

Acupuncture and Trager therapy may reduce post-SCI upper limb pain.

Prevention of upper limb injury and subsequent pain is critical.

Reconstructive surgery appears to improve pinch, grip and elbow extension functions
that improve both ADL performance and quality of life in tetraplegia.

The use of neuroprostheses appears to have a positive impact on pinch and grip
strength and ADL functions in C5-C6 complete tetraplegia, however, access to the
devices are limited and continue to be expensive in use.
Table of Contents

5.1 Introduction ......................................................................................................................5-1

5.2 Acute Phase of Rehabilitation ........................................................................................5-2


5.2.1 Exercise and Strengthening............................................................................................5-3

5.3 Augmented Feedback on Motor Functions ...................................................................5-6

5.4 Pharmacological Interventions.......................................................................................5-9

5.5 Restorative Strategies ...................................................................................................5-11


5.5.1 Plasticity of Motor Systems ...........................................................................................5-11
5.5.2 Complimentary Alternative Therapies (CAM) ...............................................................5-13
5.5.3 Splinting of the Hand.....................................................................................................5-14

5.6 Sub Acute Phase of Rehabilitation ..............................................................................5-16


5.6.1 Upper Limb Injuries.......................................................................................................5-16
5.6.1.1 Shoulder Injuries ........................................................................................................5-17
5.6.1.2 Elbow/Wrist and Hand Injuries...................................................................................5-18

5.7 Reconstructive Surgery ................................................................................................5-22


5.7.1 Hand .............................................................................................................................5-22
5.7.2 Elbow Extension ...........................................................................................................5-29
5.7.2.1 Elbow Extension (Biceps to Triceps) .........................................................................5-30
5.7.3 Multiple Reconstructions...............................................................................................5-31

5.8 Neuroprostheses ...........................................................................................................5-35


5.8.1 Types of Neuroprostheses............................................................................................5-36
5.8.1.1 Freehand System.......................................................................................................5-36
5.8.1.2 HandMaster-NMS-1 ...................................................................................................5-42
5.8.1.3 Bionic Glove...............................................................................................................5-43
5.8.1.4 ETHZ-ParaCare System ............................................................................................5-44
5.8.2 Other Surface or Percutaneous Neuroprosthesis Systems ..........................................5-45
5.8.2.1 NEC-FES System ......................................................................................................5-45
5.8.2.2 Neuroprosthesis developed by Rebersek and Vodovik (1973)..................................5-45
5.8.2.3 Belgrade Grasping-Reaching System (BGS).............................................................5-46
5.8.3 Reported Benefits of Neuroprosthesis Use...................................................................5-46
5.8.4 Clinical Results of Neuroprosthesis Use.......................................................................5-46
5.8.5 Challenges in Neuroprosthesis Use..............................................................................5-46

5.9 Summary.........................................................................................................................5-48

References..............................................................................................................................5-50
This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising
from the use or misuse of this material.

Connolly S, Aubut J, Teasell RW, Jarus T (2006). Upper Limb Rehabilitation Following Spinal Cord Injury. In: Eng JJ,
Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S, editors. Spinal Cord
Injury Rehabilitation Evidence. Vancouver, p 5.1-5.58.

www.icord.org/scire
Upper Limb Rehabilitation
Following Spinal Cord Injury

5.1 Introduction

Raineteau and Schwab (2001) defined a spinal cord injury as a lesion within the spinal cord that
results in the disruption of nerve fibre bundles that convey ascending sensory and descending
motor information. A spinal cord injury (SCI) at the cervical level results in tetraplegia, the loss
of hand and upper limb function with impairment or loss of motor and/or sensory function. In
incomplete spinal cord injuries, some neural transmissions can still pass through the spinal cord
but it is often fragmentary or distorted which leads to additional neurological complications such
as chronic pain or spasticity. Tetraplegia results in impairment of function in the arms as well
as in the trunk, legs and pelvic organs. Individuals with tetraplegia rely on the use of their hands
and upper limbs in order to complete basic activities of daily living such as self-feeding,
dressing, bathing and toileting. Mobility needs such as transfers from surface to surface,
transitional movements such as rolling, bridging and sit to lying down, crutch walking and
wheeled mobility are also completed by using their arms (Snoek et al. 2004). The level at which
the injury or lesion occurs and the completeness of the lesion (incomplete or complete) indicate
the level of independence of the person (Ditunno1999).

The Paralyzed Veterans of America (PVA) have published a clinical practice guideline (CPG),
“Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health Care
Professionals,” that outlines the expected skills and outcomes that a person is expected to
acquire and achieve at each significant level of injury (Consortium for Spinal Cord Medicine
1999). As medical care of the spinal cord injured person has improved, life expectancy now
approaches the rest of the population. Secondary complications from SCI and aging are
ongoing challenges and include pain and upper limb musculoskeletal injuries (Sipski and
Richards 2006).

Hanson and Franklin (1976) compared sexual function to three other impairments in patients
with SCI. 75.7% of the subjects gave the highest priority to upper extremity function. Snoek et
al. (2004) surveyed the needs of patients with SCI and found a high impact and high priority for
improvement in hand function in tetraplegics comparable to that for bladder and bowel
dysfunction.

Given the above, the initial care, management, rehabilitation and prevention of injuries in the
upper limb of tetraplegics are of great importance in maximizing and maintaining independence.
According to Murphy and Chuinard (1998), management and care of the upper limb can be
divided into three phases: the acute, the sub acute and the reconstructive phase. The aim of
the first two phases is to: prevent complications; to achieve optimal functioning within the limits
of the neurological deficit; and to create optimal conditions for the reconstructive phase
(Bedbrook 1981; Keith et al. 1991; Curtin 1994; Harvey 1996). In the latter phase, various
surgical options and functional electrical stimulation (FES) are available to improve positioning
and stabilization of the arm as well as key and palmar grasp function (Waters et al. 1996; Triolo
et al. 1996; Johnstone et al. 1988; Snoek et al. 2000; Peckham et al. 2001). In the new clinical
practice guidelines by the Consortium for Spinal Cord Medicine (2005) emphasizes prevention
of upper limb injuries of tetraplegic individuals in maintaining independence.

5-1
Although, there is no overall consensus regarding the management of the tetraplegic upper
limb, Hummel et al. (2005), Snoek et al. (2005) and the Consortium for Spinal Cord Medicine
(2005) provide excellent discussions and recommendations.

There is agreement that restoration of hand function is an important goal in rehabilitation. It is


also worth noting that there are very few upper extremity tests that accurately evaluate upper
limb function in this population (van Truijl et al. 2002). Curtin (1994) and Krajnik and Bridle
(1992) noted a great inconsistency in evaluation and documentation of the tetraplegic upper
limb between therapists.

The main focus in rehabilitation of the spinal cord injured person is compensation of functional
loss and using those parts of the sensorimotor system, which are still intact (van Truijl et al.
2002). Research findings regarding neuroplasticity and neurological recovery of the spinal cord
also include current rehabilitation practices that should focus on strategies to restore function
lost after SCI.

Several studies have explored increased hand function as a result of reconstructive surgery
and/or neuroprothesis. Although these and many other treatment options exist, and have
proven to improve the overall functioning and functional independence of the person with
tetraplegia, clinical practice has shown that suitable candidates for reconstructive surgery or
FES interventions often do not accept the treatment that is offered (Snoek et al. 2004).
According to Moberg (1975), over 60% of the tetraplegic population could benefit from
reconstructive surgery and it continues to be widely advocated (Snoek et al. 2004).
Reconstructive surgeries such as muscle/tendon transpositions of the intact arm or hand
muscles are designed to substitute for lost motor function (van Truijl et al. 2002). Despite this,
controversy still exists among clinicians as to whether or not to perform reconstructive surgeries
and the benefits of reconstructive surgery have not been clarified with good quality randomized
clinical trials (Harvey et al. 2001). Gorman et al. (1997) deduced that 11% of the tetraplegic
population could be candidates for an implanted FES device (Freehand System). Most
implanted FES devices are usually combined with augmentative and substitutional
reconstructive surgery (Keith et al. 1996).

Using the framework proposed by Murphy and Chuinard (1998), this chapter will be divided into
the following sections: acute phase of rehabilitation, sub acute phase of rehabilitation and
reconstructive phase.

5.2 Acute Phase of Rehabilitation

Rehabilitation and management of the person with a spinal cord injury requires an
interdisciplinary team approach during the acute phase of rehabilitation. The level and
classification of the injury is determined and the goals of maintaining range of motion (ROM),
improving strength, managing tone, spasticity, and the prevention of secondary complications in
order to achieve the person’s maximum functional ability for independent transfers, activities of
daily living and mobility are developed (Haisma et al. 2006; Sipski and Richards 2006; Drolet et
al. 1999). Clinicians must be knowledgeable about the change in physical capacity based on
level of injury as a prerequisite to developing optimal rehabilitation programs and for setting
realistic individual rehabilitation goals.

5-2
5.2.1 Exercise and Strengthening

In the acute phase of rehabilitation, the person with a spinal cord injury has a reduced physical
capacity because of muscle weakness, loss of autonomic control below the level of injury,
reduced activity and subsequent changes in metabolic and vascular function (Haisma et al.
2006). The inability to reach one’s maximum potential will result in an increased risk of medical
and secondary complications and has been correlated to a reduced level of functioning and
quality of life. One of the important goals of rehabilitation is to reverse the debilitative cycle of
reduced physical capacity that leads to reduced activity and functioning (Haisma et al. 2006).
With shorter hospital lengths of stay, spinal cord injured person have less training opportunities.
It is important to determine whether people with SCI can maintain their levels of physical
capacity after discharge.

There are very few evidence-based analyses of the effectiveness of specific exercise therapies
(Sipski and Richards 2006). Most research has only focused on one component of physical
capacity (e.g., peak oxygen uptake [VO2 peak] or muscle strength, or respiratory function).

Many physical factors have been associated with optimal functional independence individual
post-SCI and muscle strength is identified as an important contributor to functional
independence (Drolet et al. 1999). Studies by Noreau et al. (1993), Marciello et al. (1995) and
Durand et al. (1996) all noted a correlation between the level of the lesion, performance in
functional abilities in relationship to peak oxygen intake and level of muscle strength. These
associations were significant in individuals with tetraplegia especially in areas of sitting balance,
spasticity of the lower limb, hand-grip strength, wrist extensor strength and global upper
extremity strength. These functional areas have also been related to Functional Independence
Measure (FIM) motor and self-care scores. It was also identified that upper extremity strength
must be adequate to support the body weight during transfers and lower limb strength for
walking. Optimal recovery of muscle strength following a spinal cord injury is an essential
objective of functional rehabilitation of individuals with a SCI (Drolet et al. 1999).

Changes in motor function observed six months after an injury may be partially explained by
collateral sprouting within the spinal cord (Mange et al. 1990). Changes between 2 to 8 months
may be related to peripheral nerve sprouting and muscle fiber hypertrophy after partial
denervation (Mange et al. 1990; Yang et al. 1990). Natural muscle strength recovery may occur
up to two years post injury, with the recovery rate being more important for the first six months
as measured by manual muscle testing (Ditunno et al. 1992; Mange et al. 1992; Waters et al.
1993). Muscle strength gains have been attributed to two different mechanisms in healthy
subjects. In healthy subjects, short-term gains (2-4 weeks) might be explained by improved
capacity to recruit motor units (neural adaptation) and gains observed after 4 weeks have been
attributed to morphological changes within the contractile tissue inducing muscle fiber
hypertrophy (Sale 1988). Additional studies regarding cardiovascular and exercise interventions
will be discussed in another chapter.

Table 5.1 Exercise and Strengthening


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Needham-Shrophire et Population: age 18-45yrs, gender m=31, 1. No significant difference was found at
al. 1997;USA/CA f=3, tetraplegia, time since injury- the 4-week evaluation between
Pedro=8 mean=3yrs. Groups 1 and 2 (p=0.22) or between
RCT Treatment: Subjects randomly assigned to Groups 2 and 3 (p=0.07).

5-3
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Initial N=43; Final N=32 one of three groups: 2. Subjects in Group 1 had a higher
Group 1 – received 8 wks of proportion of muscles improving one
neuromuscular stimulation (NMS) assisted or more muscle grades after 4 weeks
arm ergometry exercise of NMS cycling compared with Group
Group 2 – received 4 wks of NMS assisted 3 (p<0.003).
exercise, then 4 wks of voluntary arm crank 3. Following the second 4 weeks of
exercise training, a significant difference was
Group 3 (control group) - voluntarily found between Groups 1 and 3
exercise for 8 wks without the application (p<0.0005) and between Groups 2 and
on NMS. 3 (p<0.03).
Outcome Measures: Manual muscle test. 4. No statistically difference was found
between Groups1 and 2 (p=0.15).
Population: age19-65 yrs; C4-L1; ASIA A- 1. Overall 11 in the ex group (exercise
D; 1-24 yrs duration adherence 82.5%) and 13 in the
Treatment: Experimental group (EX) control group completed the study
participated in progressive exercise training 2. No sign differences were noted
twice weekly for 9 months-each session between the two groups at baseline
offered on alternative days lasing 90-120 3. Following training, EX gr. had
Hicks et al. 2003;
minutes. significant increases in sub maximal
Canada
Outcome Measures: Perceived stress arm ergometry power output (81%;
Downs & Black score=20
scale, muscle strength, depression, p<0.05) and significant increases in
PEDro=7
physical self-concept pain, perceived upper body muscle strength (19-34%;
RCT
health and Q of L were assessed p<0.05)
Initial N=34; Final N=11
4. EX gr. reported less pain, stress and
depression after training + scored
higher than CON in indices of
satisfaction with physical function,
level of perceived health + overall
quality of life (p<0.05)
Population: Age: approx 40 yrs, Gender: 1. Age was related to the PO peak and
75% male, Level of Injury: both para and handheld dynamometry (HHD) score
tetraplegia; Injury completeness: approx (p<0.05), the older the subject the
67.5% complete injuries; Time since injury: more improvement in either of these
approx 105 days measures was significantly less than it
Treatment: No treatment provided was in younger subjects.
Outcome Measures: Power output (PO) 2. Men had greater PO peak, VO2peak
peak, VO2 peak, strength of upper and HHD score than women did
Haisma et al. 2006; extremity, respiratory function (p<0.05), thus improvement in men
Netherlands was greater than women.
Downs & Black score=13 3. In tetraplegia subjects the PO peak,
Cohort VO2peak, muscle strength and % of
Initial N=186; Final N=42 forced vital capacity (FVC) was lower
(p<0.05) than it was in paraplegics but
tetraplegics improved more in muscle
strength and % of forced expiratory
flow (FEV1).
4. Those with a complete lesion had
greater HHD score and lower % of
FVC than those with incomplete
lesions (p<0.05).
Population: Gender: m=27, f=4; Age: 1. Strength values at admittance were
approx 29.5yrs; ASIA: A-D; length of stay: inversely repeated to strengthen
Drolet et al. 1999; CA approx 4.5 months; time since injury: changes during rehab (Pearson
Downs & Black score=15 approx 2 months correlation coefficients ranging from -
Pre-post Treatment: Rehab included PT, OT and .47 (p=.001 shoulder flexors) to -.73
Initial N=40; Final N=31 physical conditioning. There were 4 1hr (p<.001 shoulder adductors).
sessions of each intervention 2. For those with paraplegia the range
Outcome Measures: Meaning muscle was from -.48 (p=0.049 shoulder

5-4
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
strength was assessed for 6 muscle groups abductors to -.72 (p=.001 elbow
4 times. Muscle strength changes during & flexors) compared to those with
after functional rehab tetraplegia, the correlation coefficients
ranged from -.28 (p=.345 elbow
extensors) to -.68 (p=.010 shoulder
adductors).
3. Patterns of change in muscle strength
from admittance to the 15 month follow
up differed between the 2 groups.
4. Differences in strength have been
observed for: elbow flexors (p=.001)
and shoulder extensors (p=0.04)
Population: Gender m=10, f=1, age 18- 1. All subjects showed improvement in
45yrs, >1yr post injury, level of injury C4- one or more of their manual muscle
C7, neurologically stable score with the most dramatic occurring
Cameron et al. 1998;
Treatment: Testing of hybrid device, 8 wks in the tricep muscle group (average
USA
of NMS assisted exercise with training increase 1.1 +/- 0.2 for L triceps, 0.7
Downs & Black score=9
sessions 3x/wk +/- 0.1 for R)
Case Series
Outcome Measures: Manual muscle test 2. Results show NMS in combination with
N=11
scores biceps, triceps, wrist flexors and resistive exercise can be used safely
extensors. and assists in the strengthening of
voluntary contractions

Discussion

The five studies presented address the long-term change of upper limb strength after the spinal
cord injured person has returned to community living.

Needham-Shophire et al. (1997) found that Neuromuscular stimulation (NMS)-assisted


exercise ergometry alone and in combination with voluntary arm crank exercise was effective for
strengthening of the upper limb for SCI injured individuals well after injury (mean time since
injury 3 years).

Hicks et al. (2003) demonstrated all study participants had progressive increases in muscle
strength in each of the muscle groups tested and that the change scores were significant from
the control group except for the left anterior deltoid. Study participants self-reported decreases
in stress, pain, depression, enhanced physical self-concept and overall quality of life.

Drolet et al. (1999) conducted one of the first longitudinal studies published in muscle strength
changes in individuals with SCI during rehabilitation. Significant improvement of muscle
strength during rehabilitation for individuals with both paraplegia and tetraplegia was noted.
Significant improvements were noted at the three-month post discharge evaluation period with
the tetraplegia group in the four muscle groups (elbow flexors and extensors and shoulder
flexors and extensors) and then began to plateau. One year later elbow flexors showed
significant improvement in both paraplegia and tetraplegia groups and shoulder extension
showed significant gains only on individuals with paraplegia. Large variability was noted
indicating the recovery of strength maybe influenced by a variety of individual factors such as
level and severity of injury, associated health conditions, age, gender, motivation and physical
condition before SCI. Improvements in strength realized in rehabilitation continue to be
maintained or improved when the person with a SCI returned to community living.

5-5
Haisma et al. (2006) found positive changes in the different components of physical capacity
both during and after inpatient rehabilitation. SCI subjects continued to improve and this study
illustrates the importance of regularly assessing the physical capacity of people with SCI after
discharge. It is important to create conditions (education, exercise facilities) that facilitate
further improvements (Haisma et al. 2006).

Cameron et al. (1998) also reported improvements in upper limb strengths in combination with
neuromuscular stimulation.

Haisma et al. (2006) and Sipski and Richards (2006) recommended further research in this
area:
• Further research is needed to document benefits of exercise interventions post-SCI
including optimal methods for strengthening muscles, merits of endurance versus
strength training, range of motion, gait, ADL, and transfer training.
• Due to impact of body composition, age, concomitant medical problems and our limited
knowledge of recovery post SCI, research needs to be performed through well-designed
multicentre trials.
• Longitudinal studies are needed to gain more insight into the changes that occur after
inpatient rehabilitation and the factors which influence these changes.
• Exercise and strengthening of the upper limb in both the acute and subacute phase of
rehabilitation are important in promoting independence and prevention of injury.

Conclusions

For exercise and strengthening of the SCI individual following injury:

There is level 1 evidence based on one RCT that physical capacity continues to improve
after 1- year post discharge.

There is level 2 evidence based on one pre/post study that neuromuscular stimulation-
assisted ergometry alone and in conjunction with voluntary arm crank exercise was an
effective strengthening intervention for chronically injured individuals.

There is level 2 evidence based on one study that muscle strength continues to improve
up to 15 months post hospital discharge for both tetraplegic and paraplegic individuals.

There is level 4 evidence based on one study that neuromuscular stimulation-assisted


exercise improves muscle strength over conventional therapy.

Neuromuscular stimulation-assisted exercise following a spinal cord injury is effective in


improving muscle strength, preventing injury and increasing independence in all phases of
rehabilitation.

5.3 Augmented Feedback on Motor Functions

Several studies have addressed the use of augmented feedback such as biofeedback with
spinal cord injured populations. Van Dijk et al. (2005) conducted a systematic review of RCTs
on the effect of augmented feedback on motor function of the affected upper extremity in

5-6
rehabilitation patients. Much of the information about augmented feedback comes from the
motor learning literature where it has been noted that feedback combined with practice is a
potent variable for affecting motor skill learning (Newell 1991; Schmidt and Lee 1999). There
are two types of performance-related information or feedback. The first type of feedback, task
intrinsic or inherent feedback, is sensory-perceptual information and is a natural part of
performing a skill. The second type of feedback is augmented feedback or information-based
extrinsic or artificial feedback. Augmented feedback refers to enhancing task intrinsic feedback
with an external source (Schmidt et al. 1999; Magill 2001), such as a therapist or device
(biofeedback or timer) (van Dijk et al. 2005). It has been suggested that augmented feedback
may have practical implications for rehabilitation therapy since re-acquisition of motor skills is an
important part of functional motor recovery (Winstein 1991; Kilduski and Rice 2003; Jarus 1994;
Jarus and Ratzon 2005).

The ability to use intrinsic feedback to guide performance is impaired in patients with cognitive
and perceptual impairments (Flinn and Radomski 2002). In persons who are compromised by
neurological sensory impairments, augmented feedback is important (Sabari 2001).

van Dijk et al. (2005) systematic review found three randomized clinical control trials which
studied augmentative feedback in the SCI population (Klose et al. 1993; Klose et al. 1990 and
Kohlmeyer et al.1996). In our literature search we were able to find an additional two other
studies with lower level of evidence that studied augmented feedback applications.

Table 5.2 Augmented Feedback on Motor Functions


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender m=40, f=5, age 1. Comparison of Groups (Increment or
mean=39yrs, injury level C4 –C6, complete Decrement or No Change): no
& incomplete injuries, relationship between treatment group
Treatment: Extremities were randomly and observed change; no treatment
assigned to 1 of 4 treatment groups: 1. produced a significantly higher
conventional strengthening; 2. electrical proportion of individuals that improved
stimulation; 3. biofeedback and electrical relative to the proportion showing no
stimulation; 4. biofeedback. Participation change or a decrement; no change
ranged from 5 to 6 weeks post SCI between treatment groups.
Kohlmeyer et al. 1996;
Outcome Measures: manual muscle test- 2. Influence of Initial Muscle Grade: a
USA
scoring and ADL performance correlation between the initial muscle
PEDro=10
grade and increment in muscle grade
RCT
was seen at the end of treatment;
Initial N=60; Final N=45
poorer initial muscle grades, more
likely to see a larger increment in
muscle grade as a result of treatment.
3. Conclusion-biofeedback and electrical
stimulation both alone + together did
not prove to be more effective than
standard therapy for wrist extensor
recovery during the acute phase of
rehabilitation
Population: Age: 25-70; ASIA A-D 1. A great deal of variance between
incomplete; Time Since Injury: 15-243 participants in most measures due to
Popovic et al. 2005;
days; acute/subacute; tetraplegic low numbers of subjects, no significant
Canada
Treatment: The control group received differences was found between the
PEDro=6
conventional Occupational Therapy; Control and Intervention groups.
RCT
Intervention group received Functional
N=21
Electrical Therapy and conventional
Occupational Therapy

5-7
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Outcome Measures: Functional
Independence Measure (FIM); Spinal Cord
Independence Measure (SCIM);
Rehabilitation Engineering Laboratory
Hand Function Test (REL Test); Consumer
Perceptions.
Population: Age 18 to 35 yrs, Gender 1. Scores after training indicated no
m=24, f=4, level of injury C5-C7, at least significant differences for the muscle
1yr post injury test score and functional activities
Treatment: Both groups received 45 mins score between groups.
Klose et al. 1993; USA
of aggressive exercise therapy 3/wk for 12 2. Analysis of the repeated measures
PEDro=5
weeks along with 30 min of neuromuscular factor showed a significant change
RCT
stimulation to assist with upper extremity (p<0.05) for the manual muscle test
Initial N=31; Final N=28
muscle strength. EX group also received (F=25.17, df=2, 52) and functional
12 wks of 30 min EMG biofeedback 3/wk. activities score (F=8, 86, df=2, 52).
Outcome Measures: Manual muscle test,
functional activities score
Population: Age 18-45 yrs, level of injury 1. No statistically significant differences
C4-C6, incomplete injury, at least 1yr post were noted between the groups.
injury 2. Differences were noted for the
Treatment: All received 3days/wk of repeated measures of mobility, self-
therapy in 2 consecutive eight week care, and the left arm muscle test
treatment blocks. Treatment blocks were scores (p<0.05).
as follows; 3. The repeated measures factor was
Group 1: Biofeedback followed by statistically significant in all of the
Klose et al. 1990; USA
supervised physical therapy exercise (PET) analyses looking at measures of
PEDro=3
Group 2: Biofeedback followed by physical function (p<0.01) but not in
RCT
neuromuscular stimulation (NMS) those that compared EMG values.
Initial N=43; Final N=39
Group 3: NMS followed by PET
Group 4: 16 weeks PET
Outcome Measures: Manual muscle test
assessed the biceps, triceps, wrist flexors
and wrist extensors. Self care measures
looking at feeding, hygiene and dressing.
Mobility measure and a muscle electrical
activity were also measured
Population: Gender m=81, f=19, injury 1. T-test analysis of the differences
level C2-C6, age 17-63yrs, time since before and after initial biofeedback
injury 1-29.7yrs. treatment an increase of 19.21% of
Treatment: EMG biofeedback treatment normal EMG scores for right triceps
sessions. and increase of 19.59% of normal
Outcome Measures: EMG scores. EMG scores from the left triceps from
one biofeedback treatment session,
significant (p<.001).
2. T-test analysis of the difference from
Brucker & Bulaeva 1996;
before initial biofeedback treatments to
USA
after additional treatments, increase in
Downs & Black score=18
percentage of normal EMG scores of
Pre-post
41.55% right triceps and 38.31% left
N=100
triceps, significant (p<.001). Increases
in percentage of normal EMG scores
after initial biofeedback treatment to
after additional biofeedback treatment
22.3% right triceps and 18.72% for left
triceps, significant (p<.001).
3. Correlation coefficient for manual
muscle test score and EMG pretest
before initial treatment was r=.569 for

5-8
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
right triceps and r=.437 for left triceps,
significant (p<.001).
4. Increases in percentage of normal
EMG before, after, and after additional
treatments was significant in right and
left triceps regardless of initial manual
muscle test.

Discussion

All of the studies concluded that there was no firm evidence of the effectiveness of the use of
augmented feedback to improve arm function in rehabilitation.

van Dijk et al. (2005) in their systematic review recommended the following be considered in
future research in this area:

• future studies need to focus on content, form and timing of the augmented feedback to
clarify its importance in rehabilitation
• studies should recognize the difference between performance and learning effects
concerning reacquisition of motor skills by re-examining the study population after a
follow up period

Conclusion

There is level 1 evidence (from 2 RCTs) that augmented feedback is not effective in
improving upper limb function in tetraplegia.

Augmented feedback does not improve motor function of the upper extremity
in SCI rehabilitation patients.

5.4 Pharmacological Interventions

Cervical injuries of the spinal cord frequently lead to hypertonia characterized by disabling
spasticity and dystonia involving the upper and lower limb. Spasticity has been defined by
Lance (1980) as “a velocity exaggerated increase in the tonic stretch reflexes (muscle tone)
resulting from hyperactivity of the stretch reflex.” The EU-SPASM Thematic Network or
Consortium (Support Network for the Assembly of Database for Spasticity Measurement) has
presented an updated definition of spasticity that reflects a recent research findings and current
clinical interpretations. Spasticity has been re-defined as “disordered sensori-motor control,
resulting from an upper motor neurone lesion, presenting as intermittent or sustained
involuntary activation of muscles” (Pandyan et al. 2005).

5-9
Table 5.3 Pharmacological Interventions
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: age 25-64yrs, injury level C4- 1. Significant decline in UE hypertonia
C7, ASIA A-D, length of time since injury during 12 month follow up period.
1.2-24yrs. 2. Average baseline Ashworth score was
Treatment: Intrathecal baclofen. 2.4 ± 1.1 (SD) compared to 1.8 ± 1.0
Outcome Measures: Ashworth Scale; (SD) at 12 months (P<0.0001,
Spasm Frequency Scale; Reflex Scale Friedman).
3. The average spasm score decreased
from 2.3 ± 1.6 (SD) to 0.5 ± 0.9 (SD),
not significant at P=0.2503 (Friedman
test).
4. The difference was significant
Burns & Meythaler 2001;
(P=0.0012 Wilcoxon signed rank test).
USA
UE reflexes, average baseline reflex
Downs & Black score=16
score was 2.3 ± 0.2 (SD) compared to
Case Series
0.9± 0.2 (SD) at 12 months (P<0.0001
N=14
Friedman).
5. Dosage requirements increased during
the 12-month follow-up period,
statistically significant (P<0.0001,
Friedman).
6. Statistically significant declines in
upper extremity spasm scores (1.8
points, p=0.012), reflex scores (1.4
points, P<0.0001) and Ashworth
scores (0.6 points, P<0.0001) for the
1-year follow-up period.

Discussion

The management of severe cases of hypertonia can be challenging as it can be refractory to


oral medications. Many studies have shown that intrathecal delivery of balcofen has been
effective for refractory hypertonia in the lower extremity. Baclofen, 4-amino-3 (p-chlorophenyl)
butyric acid works by binding to the inhibitory presynaptic GABA-B receptors in the spinal cord
(Meythaler et al. 1999). Intrathecal delivery of the drug facilitates achievement of therapeutic
levels in the cerebral spinal fluid (CSF) while minimizing systemic side effects (drowsiness,
confusion). Burns and Meythaler (2001) is the only study published which deals with hypertonia
involving the upper extremity post-SCI. Further discussion regarding the management of
hypertonia can be found in the spasticity chapter.

Burns and Meythaler (2001) showed statistically significant decrease in Ashworth (tone) and
reflex scores in upper extremity hypertonia due to pathology at the level of the spinal cord.

Conclusion

There is level 4 evidence that intrathecal baclofen may be an effective treatment for
upper extremity hypertonia of spinal cord origin.

Intrathecal baclofen may be an effective intervention for upper extremity


hypertonia of spinal cord origin.

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5.5 Restorative Strategies

5.5.1 Plasticity of Motor Systems

It has been reported that 55% of all spinal cord injured persons are classified as having
complete injuries. Through the use of magnetic resonance imaging (MRI) and histopathology
indicates that approximately 65% of the traumatic injuries initially classified as ‘neurologically
complete’ (absence of sensory and motor function in lowest sacral segment) show some tissue
and axonal sparing across the lesion (Bunge et al. 1997). It is now accepted that the CNS is
capable of substantial reorganization, especially in incomplete SCI because cortical, sub cortical
and much of the local spinal cord circuitry remains largely intact and still partially interconnected
by unlesioned fibres (Raineteau et al. 2001). Information may still pass through the level of the
lesion on spared fiber tracts but the information maybe fragmented or distorted (Beekhuizen et
al. 2005). Functional recovery can occur for several years after injury in incomplete spinal cord
injury, with the degree of recovery dependent upon the reorganization of circuits that have been
spared by the lesion (Green et al. 1999). Cortical reorganization occurs after SCI with evidence
that the sensorimotor cortex may play a role in the recovery of function in individuals with SCI
(Green et al. 1999). Results of neuroimaging and neurophysiological techniques (functional
magnetic resonance imaging (fMRI), transcranial magnetic stimulation (TMS) and positron
emission tomography (PET) demonstrate that changes occur in the cortex following damage to
the spinal cord with expansion of cortical areas corresponding to muscles spared after SCI into
the cortical areas previously associated with control of muscle reinnervated at spinal cord levels
below the level of the lesion (Raineteau et al. 2001; Bruehlmeier et al. 1998; Cohen et al. 1991;
Levy et al. 1990).

In ISCI, reorganization might occur at two levels; in pre-existing circuits by modifications of


synaptic strength (synaptic plasticity) or by new circuits through sprouting or anatomical
reorganization, including growth of axonal branches and dendrites (anatomical plasticity)
(Raineteau et al. 2001). Laboratory work is currently explaining and researching cortical
reorganization, cortical plasticity, sub cortical plasticity, plasticity at the red nucleus, plasticity
and spontaneous adaptation of the central pattern generators (CPG) and plasticity of unlesioned
descending pathways. The strengthening and weakening of synapses, axonal and dendritic
sprouting can occur at different levels of motor system in response to spinal cord lesions, in the
cortex, the brainstem, and the spinal descending pathways and in the intraspinal circuits. All
interact with each other; therefore it is difficult to interpret functional recovery processes. A
spinal cord injury interrupts distinct descending fibre populations. The overall complexity of an
incomplete spinal cord injury resides first in the organization of descending spinal tracts. Most
of the descending systems terminate on spinal interneurons, but some direct excitatory or
inhibitory connections to motor neurons also exist. Different tracts are involved in specific
functions. For example, lesions of the cortical and rubrospinal systems lead to more severe and
longer lasting deficits for movement of the distal extremities and lesions of the reticulo and
vestibulospinal systems affect movements of proximal and axial muscles. Functional outcomes
of given spinal cord lesions therefore depends on type of fibres that are interrupted (Raineteau
et al. 2001).

Functional reorganization is based on two mechanisms; synaptic plasticity in pre-existing


circuits and sprouting and anatomical reorganization that leads to the formation of new circuits.
The study of animal models provides further understanding of rehabilitation treatments and
development of new therapeutic approaches for people with spinal cord injury (Raineteau et al.
2001).

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Two studies were found that tested the use of massed practice, a form of constraint therapy,
and repetitive transcranial magnetic stimulation (rTMS) in changing the cortex.

Table 4: Restorative Strategies


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Age: range 22-63 yrs; 1. Pinch grip scores: differences were
Gender: m=9, f=1; ASIA score: C N=4, D noted in the MP+SS group (Z=-2.023,
N=6; Level of injury: C5-C7: time since p<0.05) only.
injury: 12 to 154 mths 2. The MP+SS group also showed
Treatment: Subjects participated in 2h of greater increase in pinch grip strength
massed practice (MP) therapy 5/wk for 3 than the MP group (U=2.0, p<0.05).
wks or MP+median nerve somatosensory 3. Upper extremity Functional tests: the
stimulation (SS). Massed practice training Pre/post Wolf Motor Function Test
focused on continuous repetitions of the timed scores in the MP+SS group
following: gross upper extremity showed a difference (Z=-2.023,
Beekhuizen and Field-
movement, grip, and grip with rotation, p<0.05). No statistical differences were
Fote 2005; USA
pinch and pinch with rotation. Tasks in noted for the MP group.
PEDro=8
each block were performed for 25 min 4. Timed test scores between the 2
RCT
before moving to the next category. groups were also found to be
N=10
Outcome Measures: Maximal pinch grip statistically different (U=1.0, p<0.05).
force, Wolf motor function test timed task 5. Jebsen test scores: pre and posttest
scores, Jebson hand function test scores, scores were different for the MP+SS
stimulus intensity required to elicit motor group (Z=-2.023, p<0.05). The
threshold response in muscles, and motor MP+SS group showed greater
evoked potentials amplitude. improvement than the MP group
(U=3.0, p<0.05).
6. Cortical Excitability: No significant
differences were noted between the 2
groups.
Population: gender m=3, f=1, age 41- 1. No difference between patients when
54yrs, time since injury 1.25-8yrs, lesion looking at the assessments done after
level C5, ASIA-D baseline and after sham intervention.
Treatment: 5 days of sham repetitive 2. The level of intracortical inhibition was
transcranial magnetic stimulation (rTMS) reduced to 37.5 ± 8.0% of
followed by 5 days of therapeutic pretreatment levels during the week of
Belci et al. 2004; UK stimulation (rTMS) therapeutic treatment (p<0.05) and
Downs & Black score=13 Outcome Measures: electrophysiological, returned to 90.2 ± 15% of pretreatment
Prospective Controlled clinical - sensory + motor function (ASIA) & levels during the follow-up period.
Trail Functional - 9 Hole Peg Board 3. This was linked to improvements in
N=4 clinical measures of both motor and
pinprick of 4-10% during treatment
week. (p<0.05).
4. Subjects also improved perceptual
threshold to electrical stimulation of
the skin and peg board test scores
(p<0.05)

Discussion

Beekhuisen et al. (2005) suggested that massed practice or constraint-induced therapy


promotes cortical reorganization that may be an effective rehabilitative tool for improving
strength and function in individuals with cervical spinal cord injury. Improvement may be further
enhanced by the addition of somatosensory stimulation.

Belci et al. 2004 observed clinical changes consistent with the concept that reduced
corticospinal inhibition can facilitate functional recovery. Recovery involved increased ASIA

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sensory and motor scores, improved response to cutaneous electrical stimulation over the
thenar muscles and possibly improved hand/finger function. This preliminary study
demonstrated rTMS treatment in patients with chronic stable incomplete spinal cord injury can
produce reductions in corticospinal inhibition detectable using electrophysiological techniques.
Additional research studies with appropriate controls are needed to confirm the overall
effectiveness of the intervention.

There is lack of studies evaluating the efficacy of restorative strategies. In order for these
therapies to be successful in everyday clinical practice, the therapy interventions need to be
associated with meaningful changes in functional motor performance and incorporate
techniques that are available in the clinic and at home (Beekhuizen et al. 2005).

Conclusion

There is level 1 evidence from one RCT that showed that massed practice (repetitive
activity) and somatosensory stimulation (median nerve stimulation) demonstrated
significant improvement in grip and pinch strength required for functional activity use.

There is level 2 evidence from a before/after study that showed that rTMs treatment in
individuals with chronic stable ISCI may produce reductions in corticospinal inhibition
that resulted in clinical and functional changes for several weeks after treatment.

Afferent inputs in the form of sensory stimulation associated with repetitive movement and
peripheral nerve stimulation may induce beneficial cortical neuroplasticity.
Restorative therapy interventions need to be associated with meaningful change in functional
motor performance and incorporate technology that is available in the clinic and at home.

5.5.2 Complimentary Alternative Therapies (CAM)

Acupuncture is an ancient Chinese therapy practiced for more than 2500 years to cure disease
and relieve pain (Lee et al. 1990). There are 361 identified acupoints that have been formed
into a network of 14 channels called the meridians. Acupuncture therapy has been shown to be
effective in improving functional outcomes in hemiplegic stroke patients and in paraplegic spinal
cord injured patients (Cheng et al. 1998). In electrical acupuncture therapy, electrical
stimulation is provided directly to the acupoint areas. It has been speculated that acupuncture
therapy through the correct acupoints and meridians in the acute spinal cord injury episode will
assist in the minimization of posttraumatic cord shrinkage and sparing of the ventral horn
neurons (Politis et al. 1990; Ran et al. 1992; Tsay 1974; Wu 1990).

Table 5.5 Complimentary Alternative Therapies (CAM)


Author Year; Country
Score Methods
Outcome
Research Design
Total Sample Size
Population: Age mean=35, gender m=80, 1. Acupuncture group - sensory, motor +
Wong et al. 2003; Taiwan f=20, ASIA A-B, tetraplegia FIM scores improved significantly day
PEDro=5 (37)/quadriplegia (63). Time since injury: of D/C + 1yr after injury (p<0.05).
RCT acute, admission to ER after injury Control group - only motor score
N=100 Treatment: Acupuncture was administered significant improvement at 1yr post
to the treatment group via 4 x 5 cm injury F/U p=0.023

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Author Year; Country
Score Methods
Outcome
Research Design
Total Sample Size
adhesive surface electrodes at the 2. Comparison of ASIA + FIM scores of
acupoints of bilateral Hou Has (S13) and both groups not at admission; D/C +
Shen Mo (B62). Frequency was set at 75 1yr post significant improvement ASIA
hz with a pulse duration of 200 usec and + FIM in acupuncture vs. control
the magnitude of stimulation was set at 10 p<0.05
mV 3. More patients in acupuncture group
Outcome Measures: ASIA (sensory + improved to ASIA grade B + C or
motor), FIM, before + after therapy better at D/C + 1yr post p<0.05

Discussion

With acupuncture thin metal needles are inserted into specific body sites and slowly twisted
manually or stimulated electrically. The uncomfortable pain sensation or de qi, a prerequisite for
effective acupuncture therapy, is induced by needle manipulation (Wong et al. 2003).

The randomized control trial by Wong et al. (2003), studied the use of electrical acupuncture
therapy through adhesive surface electrodes and concomitant auricular acupuncture therapy in
improving the neurologic or functional recovery in acute traumatic spinal cord injury patients.
The study demonstrated that in the acupuncture group all sensory, motor and FIM scores
improved significantly when examined on the day of discharge from hospital and one year after
injury (p<0.05). The control group (auricular acupuncture) demonstrated only significant
improvement in motor score at one-year post injury follow up (p=0.023). At discharge and at
one year post injury follow up, the acupuncture group revealed significant improvement in all
ASIA and FIM scores when compared to the control group (p<0.05). An inherent bias may have
been introduced into this study as the reviewer who assessed the participants was not blinded
to the group assignment.

Conclusion

There is level 2 evidence from one RCT that showed that the use of concomitant
auricular and electrical acupuncture therapy may improve the neurological and
functional recovery of acutely injured spinal cord individuals.

The use of concomitant auricular and electrical acupuncture therapies when implemented early
in acute spinal cord injured persons may contribute to neurologic and functional recoveries in
spinal cord injured individuals with ASIA A and B.

5.5.3 Splinting of the Hand

Splinting of the hand in the management of tetraplegia is a well-accepted therapy intervention


and has been an accepted practice for many years in the management of SCI especially in the
acute phase of injury (Curtin1994; Krajnik and Bridle1992). The therapeutic goals of splinting
are immobilization, protection and support of the joints of the wrist and hand, prevention of joint
malalignment, prevention and reduction of soft tissue shortening and contractures, prevention of
soft tissue overstretch, counteracting hypertrophic scars, support of weak muscles,
improvement of function and pain relief (Paternostro-Sluga and Stieger 2004; Curtin1994;
Krajnik and Bridle 1992). There are four most common static hand splints for tetraplegic

5-14
patients; resting pan or paddle splints, wrist extension splints (Futuro-type splint, long opponens
splint and dorsal cock-up splint and spiral splint), short hand splints and tenodesis splints (Curtin
1994).

Table 5.6 Splinting of the Hand


Author Year; Country
Score
Methods Outcome
Level
Total Sample Size
Population: Age 18 to 42 yrs, gender 1. No significant differences were noted
m=12, f=1, time since injury 6–8wks between the 2 groups-all subjects
Treatment: EX gr. was given long or short demonstrated improvement in hand
orthosis to be worn at night (8hrs) as soon function and pinch strength.
as the subject could tolerate it. 2. At 8 weeks the 13 subjects showed
Outcome Measure: pinch strength and improvement in their performance on
functional activity use the checkers subtest (F=10.32, df=1,
DiPasquale-Lehnerz 11, p<0.01), simulated feeding subtest
1994; USA (F=7.58, df=1, 11, p<0.01), and the
Pedro=4 large light object subtest (F=5.49,
RCT df=1, 11, p<0.01).
Initial N=13; Final N=9 3. At the 12-week marker, improvement
could be seen on the card subtest
(F=3.94, df=2, 14, p<0.05).
4. An increase in pinch strength was
noted at 8 weeks for all subjects
(F=4.41, df=1,11, p<0.05) and at 12
weeks 9 remaining subjects (F=4.46,
df=2,14, p<0.05)

Discussion

Even though splinting and orthotic fabrication is an accepted practice, there is minimal research
data on the effectiveness of this intervention (DiPasquale-Lehnerz 1994; Krajnik and Bridle
1992), although there are numerous anecdotal descriptions of orthotic devices and rationales for
orthotic intervention (DiPasquale-Lehnerz 1994). Curtin (1994) and Krajnik and Bridle (1992)
also found formal assessments were often not done due to; a lack of time and staff shortages;
inconsistent documentation; absence of standardized tests available for spinal cord injured
patients; limited funding to purchase equipment; and/or patient declined to participate in formal
assessments due to boredom and frustration. Krajnik and Bridle (1992) noted that therapists
considered observation of the patient when involved in a functional activity as the most
informative assessment although this was not an objective means of documenting a patient’s
status and progress. There appears to be a variety of splints made for similar purposes
because there is little research as to what splint is best for the level and stage of SCI (Krajnik
and Bridle 1992).

In Paternostro-Sluga and Stieger’s (2004) review, the therapeutic aims of splinting and the
choice of splint depend on the disease and the individual functional problem resulting from the
impairment. These authors also concluded that there is insufficient evidence from clinical trials
on splinting strategies in CP or spinal cord injury patients. The studies also referred to research
looking at hand splints for clients with an acquired brain injury or stroke (Rose and Shah 1987;
McPherson et al. 1982).

In the only study which met criteria for our review, by DiPasquale-Lehnerz (1994) noted that
there was no significant improvement in hand function as it related to passive range of motion,
strength of prehension or coordination in subjects with C6 tetraplegia who wore a thumb

5-15
opponens orthoses during sleep as compared to those subjects with C6 tetraplegia who did not
wear such an orthosis. The study did show over time a significant improvement of hand
function especially pinch strength, and functional use (turning cards, picking up small objects,
simulated feeding and holding onto light cans) for those wearing the splint.

There are several published surveys that addressed the use of splints in the spinal cord
population with the majority of splints being functional use splints (i.e., feeding splint, writing
splint, typing splint or an application for an assistive device) (Krajnik and Bridle 1992; Garber
and Gregoria 1990). More research is needed in this area.

Conclusion

There is level 2 evidence based on one RCT that wearing a thumb opponens splint will
improve pinch strength and functional use of the hand.

There is clinical and intuitive support for the use of splinting for the prevention of joint problems
and promotion of function for the tetraplegic hand. However, there is very little research
evidence to validate its overall effectiveness.

5.6 Sub Acute Phase of Rehabilitation

5.6.1 Upper Limb Injuries

A spinal cord injured individual is forced to rely on their upper extremities for their weight
bearing activities such as transfers, mobility needs and activities of daily living (ADLs) using
limbs that were designed to place hands in space (Dalyan et al. 1999; Dyson-Hudson et al.
2004; Consortium of Spinal Cord Medicine, 2005). Repeated use of the upper limb for weight
bearing activities such as manual wheelchair propulsion, transfers, raised ischial pressure
reliefs (weight shifts) and reaching from a seated position in the wheelchair in environments
designed for nondisabled individuals places a great deal of stress on the bones, joints and soft
tissues of the shoulder complex. This places the structures of the upper limb at significant risk
for overuse and subsequent injury (Dyson-Hudson et al. 2004). Pain in the early post injury
period is typically due to increased demands on anatomically weakened muscles or muscle
weakness induced because of deconditioning.

Upper limb pain is known to interfere with a wide range of functional activities, transfers,
ambulation, pressure relief, self-care (Curtis et al. 1995, Dalyan et al. 1999); many individuals
report alternation/cessation of activities critical to functional independence (Pentland and
Twomey 1994; Sie et al. 1992). Shoulder pain may be functionally and economically equivalent
to a higher level of lesion (Salisbury et al. 2003). Dalyan et al. (1999) reported that of
individuals with upper limb pain, 26% needed additional help with functional activities and 28%
reported limitations of independence. Subbarao et al. (1994) and Gerhart et al. (1993) reported
that individuals with SCI reported that their dependence in personal care assistants fluctuated
with upper limb pain and was a major reason for functional decline. The Consortium of Spinal
Cord Medicine (2005) has written clinical practice guidelines “Preservation of Upper Limb
Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care
Professionals,” as a way to address upper limb problems.

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5.6.1.1 Shoulder Injuries

Upper limb pain and injury are highly prevalent in people with SCI and consequences are
significant. The Consortium of Spinal Cord Medicine (2005) and Dyson-Hudson and Kirshblum
(2004) reported through surveys and cross-sectional studies that shoulder pain in chronic spinal
cord injured persons are common in both paraplegia and tetraplegia at a prevalence of 30-73%.
In the acute phase after SCI, shoulder pain is reported in approximately 75% of patients
(Silfverskiold and Waters 1991; Waring and Maynard 1991), and 33% to 63% of patients in the
chronic phase (>6 months) experience shoulder pain (Nepomuceno et al. 1979; Sie et al. 1992;
Silfverskiold and Waters 1991). Curtis et al. (1995), Nichols et al. (1979) and Pentland and
Twomey (1991) reported in cross sectional studies that 60-100% of long-term wheelchair users
experience shoulder pain. Subbardo et al. (1994) and Sie et al. (1992) reported that there is a
high prevalence of shoulder pain during the first year after injury, and in individuals 15-20 years
post injury. Pain experienced above the injury level during the first 3-6 months after injury is
different than the pain experienced 1 year or more after injury (Apple 2001). Pain above the
level of injury in chronically injured person assumes the character of overuse syndromes (Apple
2001). Injury involving the shoulder, elbow, wrist and hand are seen at an earlier age in spinal
cord injured individuals than in the general population because of the stresses of weight bearing
and mobility that are added to the normal use of the upper limb (Pentland and Twomney 1996).
Individuals who are older at the time of injury may experience functional changes earlier than
people who are injured at a younger age (Thompson 1999).

It is also very difficult to determine whether shoulder pain is a function of duration of SCI or
simply a part of the normal aging process (Neer and Walsh 1977). The wide variability in these
numbers is most likely a reflection of the heterogeneity of participant populations between the
studies with respect to duration of injury, age, neurologic level and severity of injury, as well as
body mass index. Small sample size, selection bias and variations in participant populations
across the different studies with respect to duration of injury, age, gender and neurological level
and severity of injury make it difficult to assess the true prevalence of shoulder pain in
individuals with shoulder pain (Pentland and Twomey 1991). The incidence of shoulder pain in
acute tetraplegia (<6 months post injury) has been reported to range from 51% to 78%
(Salisbury et al. 2003).

Nichols et al. (1979) was one of the first groups to report an association between chronic SCI
and shoulder pain coining the term “wheelchair user’s shoulder. “ Due to the prevalence of
shoulder pain, Curtis et al. (1995) developed a Wheelchair Users’ Shoulder Pain Index (WUSPI)
that measures the severity of pain for 14 functional activities.

The following are the many identified risk factors for the development of injury and pain in the upper limb.

• The shoulder is the most common joint above the level of injury where pain complaints are reported with
persons with paralysis (tetraplegia or paraplegia) (Apple 2001).
• The shoulder is not well designed to handle the higher intra-articular pressures required for both weight
bearing and mobility (Apple 2001).
• Partial innervation and impaired balance of shoulder, scapular and thoracolumbar muscles place individuals
with tetraplegia at a higher risk for developing shoulder pain especially during weight-bearing upper limb
activities such as wheelchair propulsion, transfers, and pressure reliefs.
• Due to differences in trunk postural control, differences may also occur between individuals with high
paraplegia (T2-T7) and low paraplegia (T8-T12).
• Individuals with C1-C4 motor levels of injury are also at risk for shoulder pain
• SCI severity also may be associated with shoulder pain (Dyson-Hudson and Kirshblum 2004).

5-17
• Lack of use of immobilization of the shoulder girdle muscles can limit their active joint movement and lead to
muscle shortening and shoulder capsule tightness.
• The development of pain is associated with decreased shoulder ROM
• Weakness and paralysis in these muscles can lead to increased reliance on the trapezius, which can result
in overuse and pain in this muscle.
• Shoulder pain can occur from nerve root injury or radicular pain with dysesthesias or phantom sensations
• People of certain age groups, those with higher cervical lesions and those with shorter lengths of bed rest
may be at a greater risk
• Gender may be associated with shoulder pain in individuals with SCI (Pentland and Twomey 1991).
• Body mass index (BMI) also may play a role in shoulder injuries in manual wheelchair using individuals with
SCI because it directly relates to the amount of physical strain experienced during ADLs in these individuals
(Boninger et al. 2001; Jensen et al. 1996).
• Shoulder pain is more common in individuals with tetraplegia and complete injuries and in women and
duration of injury, older age, and higher BMI all may be risk factors for developing shoulder pain and/or
abnormalities in persons with SCI (Dyson-Hudson and Kirshblum 2004).

5.6.1.2 Elbow/Wrist and Hand Injuries

The prevalence of elbow pain and injury has been reported to be between 5-16% (Consortium
of Spinal Cord Medicine, 2005); Sie et al. (1992) found 15% and 16% rates of pain localized in
the elbow region in persons with tetraplegia and paraplegia. Dalyan et al. (1999) in their study
found 35% complained of elbow pain.

The prevalence of carpal tunnel syndrome is reported to be between 40-66% (Consortium of


Spinal Cord Medicine 2005). There are four studies done by Aljure et al. 1985; Gellman et al.
1988; Schroer et al. 1996, and Sie et al. 1992 that found an association between length of time
since injury and prevalence of carpal tunnel syndrome. Some studies also found median nerve
damage without clinical symptoms.

The most significant activities causing pain in the wrist and hand were propelling a wheelchair
and doing transfers (Subbarao et al. 1994).

Table 5.7 Shoulder Treatment Interventions


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender: m=18, f=6, age: 28- 1. There was a significant effect of time
69yrs, time since injury: 5-33 yrs, SCI; for both treatments on performance
length of shoulder pain: 4mths-22yrs. corrected (PC)-WUSPI (Acupuncture
Treatment: Subjects received either p<0.001 and Trager p=0.001).
acupuncture treatments (sessions lasted 2. Overall a reduction of the PC-WUSPI
20 to 30 min) or Trager Psychophysical could be seen when looking at the
Dyson-Hudson et al.
Integration - sessions lasted approx 45 data from the beginning of treatment to
2001; USA
min. Consisted for both table work and the end for both groups (p<0.05)
PEDro=7
mentastic exercises. 3. There was a significant effect of time
RCT
Outcome Measures: Intake questionnaire for both acupuncture and Trager
N=21
(demographics and medical history), groups for average pain & most severe
Weekly log, Wheelchair users shoulder pain (p<0.01, p<0.001 respectively),
pain index (WUSPI), Numeric rating scale, for the least severe pain the
Verbal rating scale (VRS), Range of Motion acupuncture group showed a
(ROM). significant reduction (p<0.01)
compared to the Trager group.

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Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
4. Verbal response scores- there was a
statistically significant treatment effect
for both groups (p=0.001).
Population: age19-65 yrs; TSCI (C4-L1); 1. EX group reported less pain, stress
ASIA A-D; 1-24 yrs duration and depression after training + scored
Treatment: Experimental group higher than CON in indices of
participated in a progressive exercise satisfaction with physical function,
Hicks et al. 2003;
training twice weekly for 9 months-each level of perceived health + overall
Canada
session offered on alternative days lasing quality of life (p<0.05).
PEDro=6
90-120 minutes. 2. Following training, EX gr. had
RCT
Outcome Measures: Perceived stress significant increases in sub maximal
Initial N=32; Final N=24
scale, muscle strength, depression, arm ergometry power output (81%;
physical self-concept pain, perceived p<0.05) and significant increases in
health and Q of L were assessed upper body muscle strength (19-34%;
p<0.05)
Population: Gender: m=35, f=7, age: 1. There were no significant differences
mean=35yrs, duration of wheelchair use: between control and experimental
mean=24yrs, Injury level: cervical to group in age, years of wheelchair use
lumbar, mixed etiology or activity levels.
Treatment: Both groups completed the 2. When looking at the effect of exercise
Wheelchair Users Shoulder Pain Index of intervention on performance
Curtis et al. 1999; USA
(WUSPI) q2mos x 6mos. The experimental corrected (PC) WUSPI, a 2 factor
PEDro=5
group attended a 60min educational repeated measures ANOVA showed a
RCT
session where they were instructed in 5 significant effect of time only
N=42
shoulder exercises. (p=0.048).
Outcome Measures: Self report
questionnaire (demographic and medical
info), Wheelchair User's Shoulder Pain
Index (WUSPI), and a visual analog scale
(VAS) used to rate intensity of pain.

Discussion

Management of established upper limb pain is very difficult and thus prevention is critical.
Evidence-based best practice standards have not been established for the medical,
rehabilitative or surgical treatment of upper limb injuries in people with spinal cord injury. In
addition, there is little consensus among health-care providers on the best treatment practices
for upper limb injuries in the general population. In general, musculoskeletal upper limb injuries
in the SCI population are managed in a similar fashion as the unimpaired population.

Outcome studies of surgical treatment in SCI also very limited. Two small studies report the
outcome of rotator cuff repair – one showing relatively poor results (Goldstein et al. 1997) and
another study showing relatively good outcomes (Robinson et al. 1993). Both studies
recommend non-surgical approaches prior to surgical intervention. One randomized control trial
found that supervised exercise produced results similar to arthroscopic surgery for patients with
impingement syndrome (Brox et al. 1993), however; this study was not on SCI patients.

Exercise has been shown to reduce pain in a randomized control trial in which subtypes of pain
were not reported (Hicks et al. 2003). Two studies found an association between restricted
ROM and pain, reduced activity and/or injury (Ballinger et al. 2000; Waring and Maynard 1991).
A study incorporating stretching into an exercise program for individuals who use manual
wheelchairs found stretching exercises were associated with decreased reported pain intensity
(Curtis et al. 1999).

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One study demonstrated that acupuncture was no more effective than Trager Treatment in the
treatment of shoulder pain (Dyson-Hudson et al. 2001). There are several studies that address
the use of complimentary or alternative medicine (CAM) with the spinal cord population, which is
used at similar rates to the general population. It was reported that the most common reason
CAM was used, was for dissatisfaction with conventional medicine for treatment of chronic pain
(Nayak et al. 2001). The only CAM technique evaluated in the SCI population is acupuncture
although studies do not provide conclusive evidence of effectiveness (Nayak et al. 2001; Dyson-
Hudson et al. 2001; Rapson et al. 2003).

Psychological interventions among non-SCI individuals with chronic pain are popular and it has
been suggested that selected approaches may be useful for those with SCI (Consortium of
Spinal Cord Medicine 2005). Cognitive-behavioural strategies have been found to produce
changes in pain experience, increase positive cognitive coping and appraisal skills and reduce
pain behaviours (Morley et al. 1999). There are mixed results for the use of relaxation training
for relief of chronic pain (Carroll and Seers1998), which may also have secondary beneficial
effects on muscle tension and emotional distress (Astin et al. 2002; Luebbert et al. 2001).
Cognitive-behavioral interventions have not been subjected to controlled trials as to their
effectiveness in the SCI population (Wegener et al. 2001).

As identified in the Consortium of Spinal Cord Medicine (2005) document, modification of task
performance based on ergonomic analysis has been proven to reduce the incidence of upper
limb pain and cumulative trauma disorders of the upper limb in various work settings (Carson
1994; Hoyt 1984; Chatterjee 1992; McKenzie et al. 1985). It is suggested that these same
interventions can be used to prevent pain and injury in SCI. Although the number of studies
linking activities of individual with SCI to injury may be small, the ergonomics literature provides
a strong basis for evidence-based practice.

The Consortium of Spinal Cord Medicine (2005) Clinical Practice Guideline Preservation of Upper Limb
Function published the following recommendations regarding the upper limb;

• Both the spinal cord injured person and the clinician need to be educated about the prevalence of
upper limb pain and injury and the potential impact of pain and possible means of prevention
• Routinely assess the patient’s function, ergonomics, equipment and level of pain as part of periodic
health review
• Assessment of risk factors, changes in medical status, new medical problems, changes in weight
• Reduce the number of non level transfers per day
• Assess work related activities
• Re-evaluate current exercise program (strengthening, stretching, conditioning)

Dyson-Hudson et al. (2001) in a randomized controlled trial compared acupuncture treatment


to Trager Psychosocial Integration performed by a certified Trager practitioner. The authors
noted that trager therapy is a form of bodywork and movement re-education to induce relaxation
and encourage the patient to identify and correct painful patterns. The theory is that chronically
contracted muscles reduced by stress led to pain (Dyson-Hudson et al. 2001). There was a
significant effect over time for both treatment groups in reducing shoulder pain, but there was no
difference between the two groups.

Curtis et al. (1999) in a randomized control trial and Hicks et al. (2003) studied the
effectiveness of a six-month exercise and stretching protocol on shoulder pain experienced by
wheelchair users. The data supported the effectiveness of this exercise and stretching protocol

5-20
in decreasing the intensity of shoulder pain that was interfering with functional activity of
wheelchair users.

Further Research

The Consortium of Spinal Cord Medicine (2005), Sipski and Richards (2006), Campbell and
Koris (1996), Dalyan et al. (1999), and Nichols et al. (1979), have identified the following as
important areas of further research in the upper limb:

• Research to validate and support the adoption of a standardized classification scheme with accompanying
diagnostic procedures and criteria.
• Research trials could include both primary prevention and treatment of acute and chronic pain.
• Determine the best methods to treat existing painful shoulder lesions and prevent others so that these
individuals are as pain free and independent as possible.
• Further study is needed to elucidate the mechanisms of pain in this group and to establish why some patients
who have pain early in rehabilitation continue to have pain at discharge and others do not.
• Multicentre RCT of intervention are also needed to reduce the severity and impact of different subtypes of SCI
pain.
• Possible links between pain during rehabilitation and pain in long-term SCI.
• Detailed investigation of the biomechanics of activities commonly performed by people with tetraplegia to
enhance understanding of the stresses placed on the shoulder and the mechanical causes of shoulder pain.
• Causes of shoulder pain in the acutely injured individual compared to the chronic spinal cord injured person.
• Implementation of upper limb pain prevention and management programs for persons with SCI- acute and
ongoing patient education about basic biomechanical principles on avoiding impingement and overuse
• Managing the early signs of strain and overuse and knowledge of several alternative techniques of ADL.
• Education and training in endurance and balanced strengthening of muscles acting around the shoulder and
optimizing posture to achieve a normal alignment of shoulder, head, and the spine are critical for avoidance of
injuries.
• Ergonomically designed environmental changes and wheelchair, home and work modifications
• Further clinical and biomechanical research to improve the preventative measures and treatment methods of
upper limb pain in SCI persons in order for them to maintain optimal functional status.

Conclusions

There is level 1 evidence based on two RCTs that a shoulder exercise and stretching
protocol reduces the intensity of shoulder pain post SCI.

There is level 2 evidence that general acupuncture is no more effective than Trager
therapy in reducing post-SCI upper limb pain.

Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity.
Acupuncture and Trager therapy may reduce post-SCI upper limb pain.
Prevention of upper limb injury and subsequent pain is critical.

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5.7 Reconstructive Surgery

5.7.1 Hand

The loss of upper limb function especially the use of the hand is one of the most significant and
devastating losses an individual can experience. Tetraplegia is responsible for many problems
in daily living, mostly related to the recovery and/or preservation of independence for the
tetraplegic individual (Welraeds et al. 2003). In the study by Hanson and Franklin (1976)
showed recovery of hand function was preferred to that of the bladder, bowel or even sexual
function among tetraplegics. In a survey of tetraplegic patients, 75% responded that hand
function was very important for their independence in activities of daily living (ADL) and to
increase their quality of life (Snoek et al. 2004).

Reconstructive surgery is one option to attempt to improve the function of the hand and upper
limb in persons with tetraplegia. Functionally, the benefit of reconstructive surgery may be
evident as improved ability to write, complete catheterizations, dress, self-feed, drive, lift
objects, button, turn dials, propel their wheelchair, catch objects overhead, turn in bed and swim
are only some of the activities that become possible after surgery (Rabischong et al. 1993).
Surgery has been reported to improve quality of life for those people who had little or no upper
limb function (Freehafer et al. 1984). As aptly stated by Sterling Bunnell, one of the preeminent
surgeons when describing improvements of hand and upper limb function as a result of surgery,
“When you have nothing, a little is a lot.”

Despite the many reported studies, over 40 documented studies, hand reconstructive surgery is
not common practice in many spinal units and its importance in improving hand function still
remains controversial (Forner-Cordero et al. 2003). Guttmann (1976), McSweeney (1969) and
Bedbrook (1969) believed that only a small percentage of tetraplegics (5%) benefit from hand
surgery because they re-adjust the function of their arm and hands if properly rehabilitated,
while other authors like Moberg (1975) state that 75% of tetraplegics can obtain benefit from
hand surgery.

Reconstructive surgery and tendon transfers are generally performed following an identifiable
pattern based on the level of injury and results depend on the patient’s residual motor and
sensory function as identified in each group (Freehafer et al. 1984). In 1978, the International
Classification for Surgery of the Hand in Tetraplegia was developed at the International
Conference held in Edinburgh and modified in 1984. The classification takes into account the
residual motor strength below the elbow, considering that only the muscles graded 4 or 5
according to the Medical Research Council Scale (MRCS) are adequate for muscle transfer, as
well as the sensibility in thumb and index. The sensibility was evaluated by the two-point
discrimination test in the thumb and the index. If it is lower than 10mm the classification
belongs to the group Cutaneous (Cu-) and if it is higher than 10mm and the patient needs visual
help it is classified in the group Ocular (O-).

Table 8: Modified International Classification for Surgery of the Hand in Tetraplegia


Sensory
Motor O- Cu- Total
0 Weak or absent Brachioradialis (BR) ≤ grade 3 - - -
1 BR (≥ grade 4) 2 1 3
2 BR, ECRL - 1 1
3 BR, ECRL, ECRB 1 1 2
4 BR, ECRL, ECRB, PT 3 4 7
5 BR, ECRL, ECRB, PT, FCR - 4 4

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Sensory
Motor O- Cu- Total
6 BR, ECRL, ECRB, PT, FCR, Finger Extensors - - -
7 BR, ECRL, ECRB, PT, FCR, Finger Extensors, Thumb Extensors - 1 1
BR, ECRL, ECRB, PT, FCR, Finger Extensors, Thumb Extensors,
8 1 - 1
Finger Flexors
9 Lacks intrinsics only - 1 1
Total 7 13 20
O-: Two-point discrimination in the thumb > 10mm.
Cu-: Two-point discrimination in the thumb < 10mm.
ECRL: Extensor Carpi Radialis Longus
ECRB: Extensor Carpi Radialis Brevis
PT: Pronator Teres
FCR: Flexor Carpi Radialis
The listing of a muscle means that it is functional (grade 4 or better).
(McDowell CL, Moberg EA, House JH. The Second International Conference on Surgical Rehabilitation of the Upper
Limb in Traumatic Quadriplegia. J Hand Surg 1986; 11A: 604-608.)

Candidates for reconstructive surgery are carefully selected and are followed by a rehabilitation
team that includes an orthopedic surgeon, rehabilitation physiatrist, and therapist over a
significant period of time. The identified criteria for selection are as follows:

• At least one year post injury


• Completed a comprehensive rehabilitation program
• Neurologically stable
• Psychologically adjusted to their injury

The measure of outcomes following reconstructive surgery continues to be debated in the


literature. Many of the reported studies on surgical outcomes are older, are case series
evaluations and lack the rigor of randomized control trials, and have subjective outcomes based
on reported client satisfaction. In addition, there is little consensus in the literature on the
assessment instruments and tools to be used in this population as their reliability, validity and
responsiveness have not been adequately proven. The methodology appears to be a major
failing of the various scales and the absence of clear conceptual models forming the basis of
their scales. Also, the scales or instruments have been deemed to be too insensitive to
document the small but meaningful functional gains made by tetraplegics after functional
surgery (Fattal 2004). Many authors state that comparing the post surgical condition is the best
way to evaluate results (Freehafer et al. 1984). There have been several articles published that
discuss the use of the ICF conceptual framework as a way to interpret hand function outcomes
following tendon transfer surgery for tetraplegia (Sinnott et al. 2004; Bryden et al. 2005).

The reconstructions of upper limb to obtain functions of pinch and grasp often require multiple
procedure and are also individualized to each person. The reconstructions performed are also
dependent on what motor muscles/tendons are present and strong enough for transfer. The
most commonly performed surgeries for reconstructive pinch are:

Key-Pinch Grip: Brachioradialis (BR) to Extensor Carpi Radialis Longus (ECRL), Flexor
Pollicis Longus (FPL) split tenodesis. The IP joint of the thumb may need to be stabilized to
prevent excessive IP flexion.

Key-Pinch Grip with or without Hook Grip: Brachioradialis (BR) to Flexor Pollicis Longus
(FPL) with or without Flexor Digitorum Profundus (FDP) tenodesis or Brachioradialis (BR) to
Extensor Carpi Radialis Longus (ECRL).

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Key-Pinch Grip and Hook Grip: Brachioradialis (BR) or Pronator Teres (PT) to Flexor Pollicis
Longus (FPL) and BR or Extensor Carpi Radialis Longus (ECRL) to Flexor Digitorum Profundus
(FDP).

Additional procedures to increase thumb pinch and thumb opposition may also be completed.

Table 9: Reconstructive Surgery: Pinch Studies


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender: m=13 , f=2; Age: 1. Release of the BR and suture to the
range 20-47 yrs; Injury to operation: range FPL. In 16/17 hands , fixation of the
8 months-18 yrs; Operation to follow-up: IP joint of the thumb was obtained with
range 8-48 months; a Moberg screw. 11/17 patients
Treatment: Surgery lacked active thumb extension had
Outcome Measures: Pinch strength; ADL tenodesis of the thumb extensors to
reports. the MCP to prevent excessive flexion
of the MCP joint.
2. EPL and EPB were secured to the
dorsum of the MC. 6/11 patients did
not require tenodesis had sufficient
strength in the EPL to extend the
thumb.
3. 2/6 EIP was transferred to EPL for
active extension.
4. Satisfactory finger flexion present 10
hands. In seven hands: intertendinous
suture of all FDP tendons 4 patients
who had active flexion in the ulnar
Waters et al. 1985; USA profundi of small and ring finger, but
Downs &Black score=12 could not flex index finger;
Case Series 5. Transfer of PT to all FDP tendons in 2
N=15 patients; transfer of ECRL to all FDP
tendons in 1 patient; transfer of FCU to
all FDP tendons one patient.
6. Preoperative lateral pinch ranged from
0- 0.15 lbs post operative lateral pinch
ranged from 2.2-4 (depending on
elbow and wrist position)
7. Residual motor function in triceps (fair
plus)(11 patients) and pinch strength;
lateral pinch 5.1 lbs, strength fair or
less (6patients) 2.0 lbs pinch.
8. 87% (13/15) reported significant
improvement; 4 patients wanted
stronger pinch;
9. 80% (12/15) could name 4 ADL
activities that they were able to
perform.
10. 13% (2/15) were dissatisfied.
11. 20% (3/15) reported discomfort tip of
thumb.
Population: Gender-m=14, f=4, level of (Follow-up 1-10yrs (average 3.5yrs)
injury-C5-C6, Age-16-29yrs, time to 1. All patients reported a significant
House et al. 1992; USA
surgery-16mths to 12/13 yrs increase in independent hand function
Downs & Black score=11
Treatment: Carpal-metacarpal fusion was in relation to ADL's, no patient
Case Series
performed; along with extensor pollicis reported hand function was worse
N=18
longus tenodesis and motor transfer to after surgery
flexor pollicis longus. 2. Technique provided a reliable and

5-24
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Outcome measures: function of the hand, reproducible key pinch
subjective pain scale, & level of satisfaction 3. All patients had significant
with surgery and rehabilitation improvement in functional activities of
daily living and highly satisfied with
results of surgery
Population: Gender m=103, f=30, age 8- 1. All patients had preoperative grip
58yrs, tetraplegia, follow-up 3-24mths. strength of 0. At an average follow-up
Treatment: Extrinsic hand reconstruction period of 31 months, the average final
with intrinsic balancing procedures vs. grip strength was 69N (7kg) and the
extrinsic reconstructions without intrinsic ADL improvement score averaged
balancing procedures 35.5
Outcome Measures: Pre and post- 2. Patients who underwent an intrinsic
operative assessments of grip strength (on procedure had a statistically stronger
the second position of the Jamar grip (72N) than patients who did not
dynamometer) and a patient questionnaire undergo an intrinsic procedure
evaluating 31 activities of daily living (p=0.026).
3. OCU group 5 patients with an intrinsic
procedure had a statistically stronger
grip than patients without an intrinsic
procedure (p=0.028).
4. With the exception of OCU group 7 in
which 8 patients did not undergo an
intrinsic procedure due to their ability
McCarthy et al. 1997;
to balance tension between the
USA
extensors and flexors, all other OCU
Downs & Black score=10
groups with an intrinsic reconstruction
Pre-post
showed stronger grip than patients
N=135
without an intrinsic reconstruction.
5. ADL improvements scores were higher
but not statistically significant for those
with intrinsic rebalancing versus those
without rebalancing.
6. There was significant difference
between the hands treated by FDS
lasso and those treated by intrinsic
tenodesis when patients were stratified
by OCU level.
7. There was also no significant
difference in grip strength results
between the FDS lasso versus the
intrinsic tenodesis procedures when
stratified by both OCU level and type
of extrinsic reconstruction, both
surgical techniques were effective in
improving strength and ADL.

Summary Table 5.10 Pinch Studies


Author N Intervention Main Outcome(s)
15 patients BR to FPL (lateral pinch) with thumb IP +ve lateral pinch strength in all
(17 procedures) joint stabilization (16 hands) test positions
11 patients also had EPL tenodesis +ve ADL functions
Waters et al. 1985
and EPB to metacarpal joint; 2/17 +ve direct correlation between
patients EIP to EPL procedure pinch strength and amount of
residual triceps and wrist
extensor strength
18 patients CMC fusion +ve pinch strength
House et al. 1992
(21 procedures) EPL tenodesis +ve ADL and functional use

5-25
Author N Intervention Main Outcome(s)
BR 0r ECRL or ECRI to FPL
As indicated: stabilization of thumb IP
joint and Zancolli Lasso procedure
135 patients Extrinsic reconstruction with Intrinsic +ve grip strength with intrinsic
McCarthy et al. (183 procedures) Balancing vs. without Intrinsic balancing
1997 Balancing = ADL and functional use
FDS Lasso vs. Intrinsic Tenodesis for = grip strength
Intrinsic Balancing = ADL and functional use
+ positive outcome, = no difference, - negative outcome

Pinch and Grasp (Key-Pinch and Hook Grip)


The most commonly performed surgeries to obtain key-pinch and hook grip are;

Wrist Extension: If the person does not have adequate wrist extension, Brachioradialis (BR) to
Extensor Carpi Radialis Brevis (ECRB) is performed prior to any surgery for pinch
reconstruction.

Key-Pinch and Hook Grip: Extensor Carpi Radialis Longus (ECRL) to Flexor Digitorum
Profundus (FDP). This is a synergistic transfer in which dorsiflexion of the wrist potentiates the
effects of the transfer. The amplitude of excursion provides strong flexion of the fingers into the
palm. Brachioradialis (BR) is also transferred to Flexor Pollicis Longus (FPL).

The aim of these transfers is to provide mass finger flexion for grasp and independent thumb
flexion for key-pinch against the side of the middle phalanx of the index finger. Adjustment of
tension in these transfers is also completed (Lamb and Chan 1983).

Table 5.11 Reconstructive Surgery: Pinch and Grip Studies


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender f=3, m=21, age 21- No statistical findings reported.
57yrs, time since injury 9-59months 1. Operative interventions on the
Meiners et al. 2002;
Methodology: Surgery tetraplegic hand brings gains in
Germany
Outcome Measures: ADL questionnaire, cylindrical and lateral grip and
Downs & Black score=10
Satisfaction Survey, Key grip and lateral improvement in ADL
Case Series
force grip 2. Subjective acceptance is high
Initial N=24; Final N=22
3. Complication rate is high
4. Long duration of treatment
Population: Age: 19-60 yrs Age at injury: 1. 7 extremities had had post deltoid to
15-46 yrs; Injury to operation: 1-17 yrs; triceps transfer before
Follow-up post op: 1-17 yrs ; Gender: 17 opponensplasty; 24 patients, 11 (46%)
m, 7 f; Level of injury; 3 in group III, 11 in had bilateral opponensplasty.
group IV, 7 in group V, 4 in group VI. 2. 35 opponensplasties were done. 22
Intervention: surgery flexor tendon transfers were done for
Outcome Measures: Not specified voluntary grasp and then
Kelly et al. 1985; USA opponensplasty.
Downs & Black score=9 3. 14 patients (22 extremities) evaluated.
Case Series 4. Subjects reported that they would
N=24 have the operation again (95% of the
extremities) and had improved function
(91%).
5. One patient reported that function was
unchanged; 1 was dissatisfied.
Overall value of key pinch 35
extremities was 1.47 +/- 1.29 kg (mean
+/- SD).

5-26
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
6. Grasp measured in 20 extremities;
2.81 +/- 2.89 kg (mean +/-SD) (range
trace to 10kg).
7. Palmar pinch; 9 of 20 extremities
(45%) achieved palmar pinch (1.04 +/-
1.02 kg; mean +/- SD) (range 0.20-3.0
kg). Palmar pinch achieved in 17% of
the extremities in group III, 71% in
group IV, and 33% in group V.
Population: Age: mean=23.6yrs; age at No statistical results reported.
Rieser & Waters 1986;
time of surgery: mean=29.8yrs, time from 1. Self assessment questionnaire results
USA
injury to operation 6.2 yr, follow-up time of indicated: power decreased since
Downs & Black score=8
this study: 7.4 yrs surgery in all patients.
Case Series
Intervention: Surgery
N=23
Outcome Measures: Not specified
Population: at least 1 yr post injury, C5-6 No statistical results reported.
spared quadriplegia 1. All reported they would have surgery
Intervention: Surgery again.
Lo et al. 1998; CA Outcome Measures: not specified 2. Key pinch strength in non-op limbs
Downs & Black score=7 was 1.0 ± 1.3 kg, in surgically treated
Case Series arms it was 1.2 ± 1.1 kg.
N=9 3. Minnesota rate of manipulation: non-
operative limbs were 1 min 29 secs ±
15 secs, post operative limbs was 2
min 56 secs ± 1 min 56 secs.
Population: Age: 16-36yrs, time post No statistical results reported
injury: 4mths-18yrs 1. 6 of 8 subjects were evaluated.
Colyer & Kappelman
Intervention: Surgery Subjects indicated they were pleased
1981; USA
Outcome measures: Not specified with the surgery.
Downs & Black score=7
2. Hand function tests indicated an
Case Series
improvement (16-49% improvement).
N=8
5 of 6 subjects showed key grip
strength remained constant.
Population: age 9-58yrs, tetraplegia No statistical results reported-8 pts
Treatment: Surgery interviewed, 5 completed questionnaire.
Faillia et al. 1990; USA
Outcome Measures: key pinch, grip 1. Conclusion-transfer of brachioradialis
Downs & Black score =6
strength, function in ADL tendon provides key pinch and grip of
Case Reports
sufficient quality to improve the
N=8
activities of daily living in patients with
loss of flexion of the thumb and fingers
Population: age at first operation 20- 1. Strength: key-pinch strength average
62yrs, level of injury C4-C7, time from of 17.2 kPa (5-50 kPa); grasp strength
injury to operation 15-239 months. average 18.8 kPa (3-45 kPa).
Forner-Cordero et al. Treatment: Surgical reconstruction. 2. No relation found between the
2003; Spain Outcome Measures: Increased hand activities of daily living test and the
Downs & Black score=5 movement and strength; improvement in key=pinch strength (P=O.7976) or
Retrospective Follow-up ADL; patient's satisfaction, fulfillment of grasp strength (P=0.6948).
Initial N=15; Final N=14 patient's expectations, surgical 3. Modification of ADL questionnaire;
complications. excellent (3) 21.4%; good (7) 50.0%;
fair (2) 14.3 %; poor (2) 14.3%. Scores
ranged from 54-122 points.
Population: age at time of surgery 20-47 No statistical analysis reported
yrs. 1. Passive range of motion of the elbow
Gansel et al. 1990; USA
Intervention: Surgery. and wrist remained unchanged post
Downs & Black score=4
Outcome Measures: Not specified surgery. Functional active flexion of the
Case Series
fingers was gained in 10 of 11 subjects.
N=19
2. Improved performance of ADLs was
reported.

5-27
Summary Table 5.12 Pinch and Grip Studies
Author N Intervention Main Outcome(s)
+ve lateral and cylindrical
grip
FCR to FDP
22 patients +ve satisfaction with
Meiners et al. 2002 ECRL to FDP
(23 hands) surgery
+ve ADL and functional
use
7/24 also had PD to
Triceps
Opponensplasty- FDS to
+ve satisfaction with
APB
surgery
24 patients Flexor tendon transfers:
Kelly et al. 1985 +ve ADL functional use
(57 procedures) BR (also used PT, FCR,
+ve key-pinch, palmar
ECRL, FCU, PL) to FDP
pinch and grip strength
22/35 Flexor tendon
transfer BR to FDP (also
used PT, FCR, ECRL)
Tenodesis of FPL, thumb
IP joint stabilization
6/9 MP joint tenodesis of -ve result, bowstringing of
9 patients extensor tendons of thumb FPL across MP joint
Reiser and Waters 1986
(10 procedures) 2/9 BR to wrist extensor -ve grasp and lateral pinch
7/9 tenodesis of EPL and strength
EPB

+ve satisfaction with


surgery
8 patients ERCL to FDP and BR to
Lo et al. 1998 +ve key-pinch and grip
(12 procedures) FPL
strength
+ve ADL functional use
+ve improved pinch
strength
Colyer and Kappleman 6 patients FPL tenodesis
-ve finger flexion
1981 (8 hands) 2 also had ECRL to FDP
+ve ADL and functional
use
+ve key-pinch and grip
BR to FDP or FPL
8 patients strength
Faillia et al. 1990 BR or ECRL to FPL
(9 hands) +ve ADL and functional
use
PD to Triceps
BR to ECRB
Tenodesis of FPL
APL to CMC joint or
+ve key-pinch strength
arthrodesis of CMC joint
+ve grip strength
15 patients BR or ECRL or PT to EDC
Forner-Cordero et al. 2003 = ADL and functional use
(20 limbs) and EPL or tenodesis of
+ve patient satisfaction
extensor tendons
-ve patient expectation
BR or ECRL or ECRB to
FPL
PT or ECRL or BR to FDP
Zancolli Lasso of FDS
11/11 PT to FDP +ve finger flexion
Gansel et al. 1990 11 patients 10/11 BR to FPL +ve key-pinch strength
1/11 BR to FDS +ve ADL functional use
+ positive outcome, = no difference, - negative outcome

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5.7.2 Elbow Extension

The most commonly performed surgery for elbow extension is using the posterior third
of the deltoid (PD) to motor the triceps. This converts the transferred portion of the
deltoid into a two joint muscle but causes no functional loss at the shoulder (Moberg
1975).

Table 13: Reconstructive Surgery: Elbow Extension Studies (Posterior Deltoid to Triceps)
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: age-mean 33.6yrs, level of 1. The muscle was tested at 6 different
lesion-C6, time since injury 28-173 months, lengths (130, 110, 90, 70, 45 and O
time prior to sugery-34.5yrs, time since degrees of elbow flexion) with the
surgery-46.1 months shoulder abducted at 90.
Treatment: The arm and forearm were 2. When compared, the absolute values
locked in position and a force transducer (dimension of torque) were
was used to assess the torque output significantly different between groups
Rabischong et al. 1993;
isometrically. The muscle was tested at 6 (0.00001<p<0.002.
France
different lengths with the shoulder 3. The expression of this relation (% of
Downs & Black score=16
abducted at 900 maximum values) revealed significant
Prospective Controlled
Outcome Measures: Maximal torque and statistical differences (p<0.002) at 90
Trial
absolute values. and 70 degree of elbow flexion; peak
N=12
torque was at 130 degrees in
experimental group and 110 degrees
in control group with a plateau
between 110 and 70 degrees.
4. Length-tension relationship was fairly
similar among control group, but great
differences in experimental group.
Population: gender m=11, f=5, age mean 1. Straight Arm Raising-statistically
27yrs, ASIA score 16-20 significant decrease in maximal
Treatment: Surgery. Control group shoulder abduction (mean 57 SEM 12
members sat on a chair, while the before, 14 SEM 6 after surgery)
tetraplegics sat in a wheelchair. All were 2. Shoulder flexion increased after
asked to perform 2 movements; a straight deltoid-to-triceps transfer by 42%
arm lateral and maximal raising and return (mean 113 SEM 11), remained
Remy-Neris et al. 2003;
Outcome Measures: Straight Arm Raising significantly lower (121 SEM 12) than
France
& Hand-to-nape-of-neck movement control group (P<0.0001)
Downs & Black score=13
3. Hand-to-nape-of-neck-movement-no
Pre-post
significant improvements were noted
N=17
after surgery
4. Conclusion-peaks of shoulder and
elbow flexion speed are almost
normal, indicating the importance of
restoring elbow extension torque for
improving the whole kinematic picture
of the upper limb
Population: Age: 23-38yrs; Time since 1. FIM scores: both groups scored
injury: 5-16 yrs; Age at time of injury: 18-27 identically
Dunkerley 2000; UK
yrs. 2. Mobility: no significant differences
Downs & Black score=13
Treatment: Surgery. were noted (p=0.256, and p=0.432
Case-Control
Outcome Measures: Questionnaire; FIM; 3. Questionnaire: answered only by the
Initial N=15; Final N=11
10 m push and the figure of 8 push treatment group-clients gave positive
response to the questions.
Lacey et al. 1986; USA Population: Level of injury: C6 or C7; time No statistical results reported: No
Downs & Black score=7 since injury: average 24 mths, time to statistically significant differences between
Case Series operation: approx 32 months pre and post operative stages.
N=10 Treatment: Surgery 1. Activities that were noted as improved

5-29
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Outcome Measures: Not specified were: the overhead use of the arms,
use of arms while lying supine and
eating.
Population: Time since injury: average 10- No statistical analysis reported.
242 mths, 64.1 mths to surgery. 1. 15 of 18 reported function
Treatment: Surgery improvement after surgery, 13 felt they
Outcome Measures: ADLs, use of gained an increase in independence.
Raczka et al. 1984; USA
wheelchair 2. Functional improvements and
Downs & Black score=4
grooming was noted.
Case Series
3. Improvements were noted in subject’s
Initial N=22; Final N=18
ability to relieve ischial pressure from
their wheelchair, writing improved, and
driving in a small percentage was
positively affected.

Summary Table 5.14 Elbow Extension (Posterior Deltoid to Triceps)


Author N Intervention Main Outcome(s)
Gr 1- 8 pts/11
= initial tension pt transfer at time of
elbows
Rabischong et al. 1993 PD to triceps surgery is important for torque output
Gr 2-control 9 R
+ ve ADL and functional use
hand (female)
5 pts + ve straight arm raise
Remy-Neris et al. 2003 PD to triceps
17 limbs +ve speed of movement
= surgical/control gr: FIM (adapted) 13
items
5 elbows, 6 =surgical/control gr: W/C propulsion 8m&10
Dunkerley 2000 PD to triceps
controls m push
+ve elbow function indicated on
questionnaire
10 pts/16 +ve satisfaction with surgery
Lacey et al. 1986 PD to triceps
procedures +ve ADL and functional use
+ve elbow extension strength
Raczka et al. 1984 18pts/19transfers PD to triceps
+ve ADL and functional use
+ positive outcome, = no difference, - negative outcome

5.7.2.1 Elbow Extension (Biceps to Triceps)

A biceps to triceps transfer can be used to create elbow extension in patients who have active
supinator and brachialis muscles to provide for the lost functions of the transferred biceps (Kuz
et al. 1999).

Table 5.15 Reconstructive Surgery: Elbow Extension Studies (Biceps to Triceps Transfer)
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Tetraplegic No statistical results reported:
Treatment: Surgery 1. subjects indicated they were satisfied
Kuz et al. 1999; USA Outcome Measures: Not specifed with the surgery.
Downs & Black score=7 2. Activities that required precision hand
Case Series placement had improved.
N=3 3. Elimination of the need for some
adaptive aids was possible post
surgery.

5-30
Summary Table 5.16 Reconstructive Surgery: Elbow Extension Studies (Biceps to
Triceps Transfer)
Author N Intervention Main Outcome(s)
+ve elbow extension
3 patients +ve functional improvements through ability
Kuz et al. 1999 Biceps to Triceps
4 elbows to place the hand in space
+ve satisfaction with surgery
+ positive outcome, = no difference, - negative outcome

5.7.3 Multiple Reconstructions

The following studies report results from multiple procedures to reconstruct the upper limb.

Table 5.17 Reconstructive Surgery: Multiple Reconstructions


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Age: mean age 42.9 years; 1. Elbow Extension: bilateral surgery
Mean time since injury: 20.5 years; Mean 9/11 subjects; Hook Grip; 17 right
time since surgery: 15.1 years; 22/24 right hands (av. Grip 46.2 mm Hg in 1991;
handed; Level of Injury: 01: 6 hands; 02: 3 improved slightly, not statistical
hands; 03: 5 hands; 0Cu2: 2 hands; 0Cu3: significant (p=0.30)) Left hand: 15
6 hands; 0Cu4: 17 hands; 0Cu5: 8 hands; hands: significant increase (p=<0.001),
0Cu6: 1 hand; Tetraplegia av. 28.7 mmHg to 53.2 mmHg; no
Treatment: surgery statistical significance between right
Outcome Measures: Lamb and Chan and left hook grip as measured by
questionnaire with additional 10 Burwood SGM and DA in 2001 (p=0.93 and
questions; Swanson sphygmomanometer p=0.97).
(hook grip); Preston Pinch Meter (key 2. Key Pinch: av. key pinch 20 right
pinch); Quadriplegic index of Function thumbs in 1991 25.8 N and decreased
(QIF); Digital Analyzer (key and grip pinch) in time to av. 13.9 N (significant
decrease p=<0.001); average pinch
strength 18 left thumbs decreased
from 17.7 to 8.8 N (significant
decrease p=<0.001). Average pinch
strength measured by DA, increase in
Rothwell et al. 2003;
key pinch when compared to 1991,
New Zealand
significant for both right (p=0.01) and
Downs & Black score=20
left (p=0.01) thumbs.
Case Series
3. Active Transfer Vs. Tenodeses: hook
Initial N=29; Final N=24
grip: active transfers 2x strength of
tenodeses in 1991 (p=0.05) and 2001
(p=0.03). Pinch grip: similar to 1991
data (p=<0.001), 2001 data does not
follow trend. 2001 DA data did not
reach significance (p=0.06);
4. Longitudinal Comparison: hook grip
strength 25 hands with active transfers
significant increase 42.1 to 60.2 mm
Hg (p=<0.001) and pinch grip increase
from 24.0 to 38.4 N in 31 thumbs that
had active transfers using 2001 DA
data (p=0.03). Hook strength obtained
from a tenodesis in 7 hands did not
weaken over time (p=0.05) but pinch
strength in 7 thumbs significantly
increased (p=<0.001) using 2001 DA
data.

5-31
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
5. Questionnaire results; Lamb and Chan
activity measure: showed perceived
improvement of functional activities
significantly lower in 2001 (p=<0.001).
QIF scores of current functional
independence was significantly better
(p=0.004). Additional Burwood
questionnaire showed levels of
satisfaction, perceived expectation,
gratification and opportunity
enhancement were maintained over
time (p=0.281).
Population: Age: 21-59 years (av. 29 1. Elbow Function: 10/16 elbows (10
years); Gender: 38 male; 3 female; patients): full extension; 2/16 elbows
Complete injuries. Av. Follow up after 20 degree flexion contracture; 4/16 15
operation: 6 months- 25 years; Tetraplegia degrees of extension lag. All 10
Treatment: Surgery patients considered the procedure
Outcome Measures: Elbow strength; beneficial.
Hand function (assessment checklist 2. Hand Function: 48 hands (assessed
developed); ADL (developed checklist) only 27 patients). 5 rated as excellent;
28 rated good; 11 rated as fair; 4
graded as poor. No patient had any
impairment of hand function after
Lamb & Chan 1983; UK operation.
Downs & Black score=14 3. ADL: 29 patients assessed. No one
Case Series considered their functional capability
N=41 deteriorated after operation. Most
significant improvement in basic
activities such as washing, eating and
using the toilet, hold glasses and cups,
wash limbs and brush hair, turn on
taps, improve bladder compression,
insertion of suppositories, change from
complete reliance on other for self-
care, more mobile, 7 able to drive a
car. Improvement in UL function
facilitated development of personal
interests.
Population: Age at time of injury-mean 1. No statistical analysis provided-
30yrs, age at time of operation-mean37yrs, gestural ability improved in more than
time between injury and surgery 7-356 80% of the patients and functional gain
Walreads et al. 2003;
months, injury level C5-C8 was important in more than half.
Belgium
Treatment: Upper limb surgery 2. 43 procedures; Atypical procedures (2)
Downs & Black score=12
Outcome measures: Functional testing. good: 2; Moberg procedures (18)
Case Series
good: 17; poor: 1; Deltoid/triceps (12)
N=25
good: 7; fair 3; poor 2; Additional
procedures (11) good: 7; fair: 3; poor:
1.
Population: Age: av. age at first operation 1. Subjective Assessment: obtained for
27 years (5-55 years); Gender: 51 males, 6 86% of the patients, av. Follow up of
females; Level of Injury: 00:4; 01: 6; 02: 4; 37 months (range 5-86 months); 70%
Mohammed et al. 1992
03: 6; 0X: 3; Cu3: 6; Cu 4: 24; Cu 5: 10; Cu reported good or excellent results;
New Zealand
6: 3; Cu X: 3; Tetraplegia 22% fair; 8% poor.
Downs & Black score=12
Treatment: Surgery 2. Simultaneous surgery for key-grip and
Case Series
Outcome Measures: Subject assessment hook grip strength 96% good or
N=57
of ADL by questionnaire; Objective excellent results.
assessment of key pinch (Preston Pinch 3. Objective Results: over 70% of
Meter); Hook-grip strength (modified patients, av. follow up of 32 months;

5-32
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Sphygmomanometer); Elbow extension: Key Pinch 52/68 cases (76%); av.
MRC grading system strength was 2.1 kg. Hook grip
measured in 42/58 cases (72%),
thumb included av. strength was 42
mmHg; thumb excluded 29 mmHg.
4. Elbow extension measured in 71% of
patients, obtained grade 3 or 4
strength.
Population: age at time of surgery 15- 1. One hundred forty two transfers were
Freehafer et al. 1984;
61yrs, time since injury to surgery 1-17yrs, performed on 68 subjects.
USA
tetraplegics, 2. No upper limbs were made worse.
Downs & Black score=12
Treatment: Surgical reconstruction 3. Four remained unimproved, all others
Case Series
Outcome Measures: Comparison of the that had tendon transfers improved.
N=68
post surgical with the pre surgical condition
Population: Age: born between 1918- 1. Elbow Extension: 30 elbows in 23
1962; Gender: 7 female, 36 male; Level of patients; (23/30 with free tendon
Injury: 0:1 9 pts; 0:2 2 pts; 0Cu:1 4 pts; graft;7/30 Castro-Sierra and Lopez-
0Cu:2 13 pts; 0Cu:3 9 pts; 0Cu:4 5 pts; Pita method); 5/23 with free tendon
0Cu:6 1 pt. re-examined 1-14 yrs after the graft 1/23 full ext.; 8/23 lack ext.
last operation. against gravity of max. 60; 10/23 lack
Treatment: Surgery even more ext.; 6/7 ext. deficit greater
Outcome Measures: Questionnaire of 55 than 60.
ADL tasks; opinion of the effect of surgery 2. Key Grip: 50 hands/40 patients;
Ejeskar & Dahllof 1988; to perform these ADL tasks; elbow Strength 0-3.5 kg (av. 0.7 kg); 15 case
Sweden extension (evaluation of extension deficit or had minimum of 1.0 kg.
Downs & Black score=11 holding a sand bag in hand); key grip pinch 3. Finger Flexion: 14 hand/13 patients
Case Series (Preston Pinch Guage); finger flexion (ECRL to profundi II-V); grip 0-0.27 kP
N=43 (Martin Vigorimeter) (av. 0.13 kP); 5/14 minimum strength
1.0 kg.
4. 4 patients reported no improvement (1
severe spasticity, 2 BR muscle
transferred to wrist; 1 operation on
weaker hand); 4/43 could not state
how much they had improved, 35/43
average improved capacity to perform
23/55 ADL tasks; 3/43 patients a
functional deterioration.
Population: Neurological levels C5-C8. 1. Opponens transfers were done 180
Treatment: Surgical reconstruction. times; transfers for finger flexion-161
Freehafer 1998; USA Outcome Measures: Not specified times; posterior deltoid transfers-59
Downs & Black score=10 times; transfers for wrist extension-17
Case Series times.
N=285 2. 13 out of 285 stated that they were no
better, and no patient said they were
worse.
Population: level of injury OCu 1,2,3 No statistically significant findings reported
Treatment: Reconstruction of key grip and Subjective client reports.
active elbow extension.
Hentz et al. 1983; USA
Outcome Measures: interview and/or
Downs & Black score=4
questionnaire (self-care, communication,
Case Series
mobility), objective measurements - pre +
Initial N=30; Final N=23
post op strength, ROM wrist + elbow
extension, strength of key pinch, range of
passive wrist flexion + functional testing

5-33
Summary Table 5.18 Multiple Reconstructions
Author N Intervention Main Outcome(s)
BR to FPL or BR and
24 patients tenodesis FPL +ve key-pinch and hook grip
Rothwell et al. 2003
(48 reconstructions) ECRL to FDP +ve ADL and functional use
PD to Triceps
PD to Triceps
Biceps to Triceps
Hand Grip: ECRL to
FDP
+ve elbow extension and function
BR to FPL
-ve elbow extension (biceps to
41 patients Key-Pinch: FPL
Lamb and Chan 1983 triceps)
(57 reconstructions) tenodesis or FPL
+ve hook grip and key pinch and
tenodesis plus ECRL to
ADL and functional use
FDP
Other: EPB to ECU,
FCR to FDS, APB to
EDM
PD to Triceps +ve elbow extension
25 patients
Walreads et al. 2003 ECRL to FDS +ve key grip and grasp
(43 procedures)
BR to FDS +ve ADL and functional use
PD to Triceps
Key-Pinch: BR or PT to
57 patients ECRL; FPL tenodesis + hook grip strength
Mohammed et al. 1992
(97 transfers) and IP stabilization +ve ADL and functional use
Hook Grip: BR or ECRL
to FDP
+ve key-pinch and grip strength
68 patients Variation of all
Freehafer et al. 1984 +ve elbow extension
(142 transfers) procedures
+ve ADL and functional use
PD to Triceps
-ve elbow extension
43 patients Tenodesis FPL, thumb
Ejeskar and Dahllof 1988 +ve key-grip and finger flexion
(94 transfers) IP joint stabilization
+ve ADL and functional use
ECRL to Profundus iv
Opponens transfer: 180
times
Transfers to finger
285 patients Review of surgical procedures and
Freehafer 1998 flexors: 161 times
(417 transfers) recommendations.
PD to Triceps: 59 times
Transfers for wrist
extension: 17 times
PD to Triceps or Biceps
to Triceps
30 patients +ve satisfaction with surgery
Hentz et al. 1983 FPL tenodesis
(40 limbs) +ve pinch and grip strength
BR to ECRB
EPL and EPB tenodesis
+ positive outcome, = no difference, - negative outcome

Discussion

In reviewing the identified studies as a whole, the operative interventions on the tetraplegic hand
and upper limb bring definite gains in pinch force, cylindrical grasp, and the ability to reach
above shoulder height that result in an improvement in ADL function and quality of life for the
individual with tetraplegia. Despite the level of evidence (grade 4) the subjective acceptance
among patients who have had reconstructive surgery is high. One of the reported downsides of
surgery is the high complication rate (infection, torn attachments) and the extended period of
time post surgery for rehabilitation and increased need for personal care (Meiners et al. 2002).

5-34
Many Spinal Cord Injury Centres do not offer or have access to reconstructive surgery or
neuroprothesis interventions. It is also debated whether the overall cost of surgery or use of
neuroprostheses is more beneficial to the client, as the client has to relearn new movement
strategies in order to perform activities of daily living (ADL) (van Truijl et al. 2002).

Conclusion

There is level 4 evidence from multiple studies that support the use of reconstructive
surgery for the tetraplegic upper limb for the improvement of ADL and quality of life.

Reconstructive surgery appears to improve pinch, grip and elbow extension functions that
improve both ADL performance and quality of life in tetraplegia.

5.8 Neuroprostheses

A neuroprostheses for grasping is a device designed to improve or restore the grasping, holding
and reaching functions in individuals with stroke and SCI (Baker et al. (1993); Cornwall et al.
2004). The neuroprostheses applies functional electrical stimulation (FES) in which paralyzed
muscles are electrically stimulated to produce movement (Shimada et al. 1996A). The FES
uses bursts of short electrical pulses (pulse widths 0-250 mSec and pulse amplitude 0-150 mA)
to generate muscle contraction by stimulating motoneurons or reflex pathways. The key
element for achieving synergistic activity of muscles that results with reaching and grasping is
the appropriate sequencing of bursts of electrical pulses. For continuous contraction of the arm
and hand muscles (tetranization), a FES system has to deliver at least 16 stimulation pulses per
second to elicit action potentials (AP) in the motor nerve, causing the corresponding muscles to
contract. FES enables the patients with high spinal cord injury to reconstruct grasp movements
such as palmar and lateral grasps of the upper extremity (Shimada et al. 2003). The palmar
grasp is used to hold bigger and heavier objects such as cans and bottles and the lateral grasp
is used to hold smaller and thinner objects such as keys, paper and CDs (Popovic et al. 2002).
It has been reported to be useful in improving ADL functions (Shimada et al. 1996A; Popovic et
al. 2001). FES is also applied to generate elbow extension by stimulating the triceps brachii in
combination with voluntary biceps contraction used to augment reaching (Grill and Peckham
1998; Popovic et al. 1998). Elbow and shoulder FES systems have not been developed into
practical clinical devices.

The motor nerves can be stimulated using surface (transcutaneous), percutananeous or


implanted electrodes (Mortimer 1981). Transcutaneous stimulation is performed with self-
adhesive or non-adhesive electrodes that are placed on the subject’s skin in the vicinity of the
motor point of the muscle that needs to be stimulated (Baker et al. 1993; Mortimer et al. 1981).
Percutaneous and fully implanted electrodes are placed close to the entry point of the motor
nerve to the muscle which should be stimulated, either epimysial or intramuscular (Cameron et
al. 1997; Hoshimiya and Handa 1989).

Individuals with C5-C7 complete SCI and with no major degree of motoneuron or nerve root
damage of the stimulated muscles benefit the most from neuroprosthesis. The use of an
implanted FES system can only be applied once the patient reaches stable neurological status,
which usually occurs two or more years post SCI. The use of surface FES systems can be
introduced during the early rehabilitation period, as the patient does not have to be
neurologically stable.

5-35
Gorman et al. (1997) and Cornwall and Hausman (2004) have presented guidelines for patient
selection for consideration of for an implantable neuroprosthesis. They are as follows:
• Anatomic: Stable tetraplegia with C5 or C6 motor level with international classification
motor scores of 0, 1, 2 or an impairment scale level of A, B, C (ASIA)
• Physiologic: Presence of adequate ROM in joints of the shoulder, arm, forearm, wrist
and hand
• Medical: Free of overwhelming medical problems
• Psychosocial factors: Sufficient motivation to learn its use and use it
• Adequate caregiver and/or family support
• One year post injury, plateau of functional recovery.
• Need for sufficient vision to provide visual feedback during training and use sufficient
cognitive ability

Contraindications to neuroprothesis use include:


• Cardiac disease
• Arrhythmias
• Pace makers
• Chronic systemic infections
• Diabetes
• Immune disease

5.8.1 Types of Neuroprostheses

There are several existing neuroprostheses and these include implanted FES systems such as
the Freehand System and the NEC FESMate System and surface stimulation electrode systems
such as the Handmaster NMS-1, Bionic Glove, ETHZ-ParaCare Neuroprosthesis and systems
developed by Rebersek and Vodonik and Popovic et al.

5.8.1.1 Freehand System

The Freehand System from Cleveland, OH, USA is an implantable neuroprothesis intended to
restore hand function in C5 and C6 level tetraplegics. The Freehand system can stimulate eight
different muscles in order to produce a useful grip and key pinch in tetraplegic individuals. It is
the only FDA approved (1997) implantable upper extremity neuroprothesis. The system consists
of a surgically implanted receiver/stimulator unit and electrodes with an external controller and
power supply/microprocessor. It was first implanted in 1986 (Cornwall and Hausman 2004).

The NeuroControl Freehand System consists of an active receiver/stimulator that is placed in


the chest wall and has eight leads that come from the receiver/stimulator and pass under the
skin to a connector site in the upper arm. At this point they are joined to epimyseal electrode
leads that are passed under the skin from the forearm and hand. Power and control signals
from the unit are passed through the skin to the receiver/stimulator from a skin-mounted coil.
The patient controls the device by movement of the opposite shoulder that uses a skin surface
mounted position detector. The lateral grasp is generated by first flexing the fingers to provide
opposition, which is followed by thumb flexion. Palmar grasp is generated by first forming the
opposition between the thumb and palm, followed by simultaneous flexion of both the thumb
and fingers. Stimulating the flexor digitorum superficialis and profundus muscles performs
finger flexion and finger extension is obtained by stimulating the extensor communis digitorum.
Stimulation of the thumb thenar’s muscle or median nerve produces thumb flexion. Hand
opening and closure strength are proportional to the distance moved by the shoulder. Both

5-36
palmar and lateral grasps are possible by pressing a button on the shoulder controller. Taylor et
al. (2002) and Keith et al. (1996) reported that most clients with require several surgical
procedures are needed for each client for optimal use of the device. The most common
surgeries performed are brachioradialis to extensor carpi radialis for voluntary wrist extension
and posterior deltoid to triceps for elbow extension (Taylor et al. 2002; Keith et al. 1996). The
1st generation of the Freehand System is no longer available from NeuroControl Corporation.
There are devices still available on a selective basis in several centres (Cornwall et al. 2004).

Table 5.19 Freehand System


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender m=26, f=8; Age: 13- 1. General Satisfaction: 87% were
53 yrs; Age at implantation: 16-57yrs; positive agree or strongly agree, 97%
Tetraplegia; One year post survey, would recommend neuroprosthesis to
including 6 months of home use others, 90% were satisfied with
Treatment: Implemented with a hand neuroprosthesis, 90% stated
neuroprosthesis that provides grasp and neuroprosthesis was reliable, 87%
release would have surgery again, 80% felt the
Outcome Measures: Functional neuroprosthesis met their
Evaluations: standardized test of grasp and expectations, & 77% would pay for the
release, measurements of pinch strength neuroprosthesis if they had the money
and range of motion & satisfaction survey 2. Life Impact: 88% responses were
positive for life impact; 90% stated
neuroprosthesis improved their quality
of life; 87% positive impact on their life
(90% reported did not make a negative
impact); 83% provided a benefit ADL;
87% responses regarding changes in
ADL were positive; 93% participants
could perform ADL easier; 93% could
perform ADL such as painting and
shaving; 90% had increased
confidence when performing ADL;
Wuolle et al. 1999; USA
83% could perform ADL more
Downs & Black score=22
normally; 73% could perform ADL
Case Series
faster
Initial N=42; Final N=30
3. Independence: 81% of responses
were positive; 87% reported they were
able to function more independently;
83% used less adaptive equipment;
87% required less assistance from
others; 67% felt more comfortable out
in the community alone
4. Occupation: 57% of responses to
occupation questions were positive
5. Appearance: 87% felt their hand
appearance was unchanged or
improved
6. Usage: used prosthesis median of 5.5
days/week - ranged from 15
participants (44%) who donned the
neuroprosthesis 7 days per week to 5
participants (15%) who used it less
than 1 day/week; 24/34 participants
(71%) used it 4 or more days/week;
range of usage C4/C5, C5/C5, C6/C6
levels was the same (0 to 7
days/week) C5/C6 group - used it

5-37
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
most regularly 4 to 7 days/week with
most participants 8/10 reporting daily
use
7. Activities: most frequently reported
activities included eating, drinking,
shaving, brushing teeth, brushing hair,
writing, operating a computer, playing
games
8. Quality of Life: 18/34 positive
comments; 1/34 responded neutrally;
1/34 responded negatively
9. Improvements: Additional stimulus
channels, an implanted command
source, smaller, lighter external control
unit - easier to don, improve hand and
arm function, make device operable if
user is confined to bed
Participants: gender m=42, f=9, age at 1. When the neuroprosthesis was
implant 16-57yrs, level of injury C5=C6, activated all participants increased
time from injury 4.6yrs (median), follow-up- their pinch force in lateral pinch
3-13.9yrs (p<0.001) and some increased their
Treatment: Participants were trained to pinch force in palmar grasp (p<0.001).
Peckham et al. 2001;
use the neuroprosthesis and to use it for 2. 98% of participants moved at least 1
USA/UK/Australia
functional activities. Once they were object with the neuroprosthesis
Downs & Black score=16
satisfied with their ability to perform daily (p<0.001) and 37 improved by moving
Cohort
activities or when they reached a plateau in at least 3 more objects (p<0.001).
Initial N=51; Final N=50
proficiency then rehab was complete. 3. Disability was reduced in 49 of 50
Outcome Measures: Pinch strength, participants as measured by the ADL
active ROM, Grasp-Release Test, Activities abilities or ADL assessment tools.
of Daily Living (ADL) Abilities Test, ADL
Assessment Test, user satisfaction survey.
Population: Age: 31-48 No statistical results reported
Gender: m=7: f=1; Level: C4-6 1. Care-all users had come from outside
Time Since Injury: 43-430 months; Time agencies (mean 11.5 h a day, range 3-
Since Surgery: 8-53 months 24 hrs); 4 users had additional care
Treatment: Interviews- reviewing use of from family members (mean 3.4 h a
Neuro Control Freehand System day, range 2-5 hrs); no users claimed
Outcome Measures: Amount of Care & that care given by family members had
The System decreased
2. System-donning external components
5-10 min; most users reported no
significant problems fitting the external
Taylor et al. 2001; UK equipment; 2 users had problems
2001 locating the coil; 3 locating the
Downs & Black score=16 shoulder controller; 1 had persistent
Case Series problems maintaining the position
Initial N=9; Final N=8 through the day d/t the adhesive tape
used becoming detached (4 reported
this as an occasional problem); 4
users had problems with skin allergy to
the tape or double sided adhesive
rings; 2 users reported that the system
made transfers more difficult; 3 users
never stopped using the system d/t
system failure; some problems with
equipment reliability; no change in
paid caregiver time; 6 users felt more

5-38
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
confident when using the system; 7 felt
their quality of life had improved
Population: Level of injury C5-C6. 1. Variation in elbow moment across
Treatment: Epimysial or intramuscular subjects significantly greater than the
electrodes were implanted on the triceps. variance within subjects (ANOVA p<
Following surgery standard stimulation 0.001).
exercise regimens were followed. 2. 10/11 elbows tested elbow moment
Outcome Measures: elbow extension generated by triceps stimulation at
moments at different elbow positions, different elbow angles, elbow moment
performance in controllable workspace weakest with elbow in more extended
experiments, comparison to an alternative position (30 degrees flexion) and
method of providing elbow extension in peaked with elbow at 90 flexion,
these individuals (posterior deltoid to significant ANOVA p<0.001.
triceps tendon transfer) 3. Elbow moment generated by triceps
stimulation at 90 and 120 degrees
elbow flexion was significantly greater
Memberg et al. 2003; than elbow moment produced by
USA tendon transfer (ANOVA p<0.05), no
Downs & Black score=14 difference between elbow extension
Case Series methods at 30 degrees elbow flexion.
N=22 4. Triceps stimulation and posterior
deltoid together provided a greater
elbow moment than each method
separately, difference significant at
each elbow position p<0.05, except at
90 degrees.
5. Quantitative workspace assessment
done on 5 arms, more successful with
triceps stimulation, significant for each
subject, chi square p<.05).
6. Average acquisition time with triceps
stimulation less than without
stimulation 4/5 arms (3.2-6.4 seconds)
and significant in 3/5 arms (unpaired t-
test p<0.01) and not for one p=0.076.
Population: Tetraplegia; Age:16-55 1. 7/9 use Freehand System daily
Treatment: The patients, using an external 2. Provided an active grip of some
stimulator, built up the muscles strength in strength which allowed many
the hand and forearm, to ensure the functional activities
Hobby et al. 2001; UK
muscles were in good condition at the time 3. Increase in self confidence
Downs & Black score=14
of surgery 4. Over 80% of their selected ADL goals
Cohort
Outcome Measures: Grip Strength, ADL - user preferred to be independent with
N=9
their Freehand system than use
previous method or have activity
performed by caregiver

Population: Age: 28-57 years; Time from 1. Pinch force ranged from 8 to 25 N,
injury to insertion of implant: 2 years 2 with stimulation and greater than
months to 9 years; Clinically complete at tenodesis grasp alone; all
C5 or C6; Chronicity: 2 years 2 months to 9 demonstrated functional grasp
Kilgore et al. 1997; USA years patterns and were able to manipulate
Downs & Black score=13 Treatment: Implanted neuroprosthesis. at least 3 more objects with the
Case Series Outcome Measures: Grasp force; Grasp- neuroprosthesis; had increased
N=5 Release Test; Tests of ADL (functional independence and were able to use
independence); Usage Survey the neuroprosthesis at home on a
regular basis; the implanted stimulator
proved to be safe and reliable.

5-39
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: age-16-18yrs, level CC6, >1yr 1. 40 electrodes implanted, 37 continued
post injury. to work, all implant stimulators have
Treatment: Surgery functioned without problems with
Mulcahey et al. 1997;
Outcome Measures: Grasp Release Test follow up ranging between 16 and 25
USA
& ADL Test before and after months
Downs & Black score=13
implementation of the implanted FES hand 2. Grasp Release Test-lateral pinch and
Pre-post
system palmar grasp forces - Wilcoxon test,
N=5
FES forces were significantly greater
than tenodesis forces for both grasps
(P=0.043)
Population: age-mean 38.4yrs, gender 1. Grasp release test results: increase in
m=7, f=1, level-C4-C6, time since injury- the types of tasks that subjects could
mean 10.1 yrs. perform (pre n=1.4) and post
Treatment: no-it was assessment of the implantation (n= 5.1 p=0.011).
Freehand System 2. One year post implantation the types
Outcome Measures: Grasp Release Test, of tasks performed was 5.5 p=0.027,
Taylor et al. 2002; UK
Grip Strength, Activities of Daily Living, without the system it was 1.2
Downs & Black score=12
Sensory ability (static 2 pt discrimination) (p=0.028).
Case Series
3. Number of repetitions increased post
N=9
implantation from 12.7 to 37.4
(p=0.028) and with out the implant
post-implantation (20.2, p=0.046).
4. At one year number of repetitions was
increase to 50.5, p=0.046 with the
system and without 24.3, p=0.28.
Population: age-13-19yrs, gender m=5, 1. No predicted difference between
level of injury C5-C6, # of mths in study 12- electrodes in intrinsic and extrinsic
38, time since injury 3-72mths muscles (P=0.93)
Treatment: Intramuscular electrodes were 2. Significant differences were predicted
implanted in the upper extremity muscles between exit sites (P=0.016) + across
Smith et al. 1994; USA Outcome measures: The Breslow Test - a muscle groups (P=0.047)
Downs & Black score=12 non-parametric linear rank test used to 3. Survival likelihoods poorer for
Case Series compare survival chances across electrodes exiting dorsally
N=5 subgroups 4. At 90 days after implant survivals
95% confidence limit used to reject the null probabilities of the finger + thumb
hypothesis extensors + thumb abductors (P=0.8)
were smaller than that of thumb
adductor + flexor muscle groups
(P>0.9)
Population: Age 23-48yrs, level of injury- No statistical analysis was complete.
C5-C6 1. Passive elbow extension was within
Treatment: Participants were implanted normal limits.
with an upper extremity neuroprothesis 2. With stimulated triceps subjects
including a triceps’ electrode to provide attained full elbow extension; without it
stimulated elbow extension. Participants full range was not met
Bryden et al. 2000; USA
exercised triceps 4-6 hr/session using a
Downs & Black socre=12
programmed electrical stimulation exercise
Case Series
regimen that includes breaks. Participants
N=4
exercised either nightly or every other
night-whatever was best for maintaining an
optimal amount of strength
Outcome Measures: 5 overhead reaching
tasks, amount of assistance required to
complete the task & survey of home use.
Smith et al. 1996; USA Population: age-13-19yrs, gender m=3, FNS vs. Tenodesis
Downs & Black score=11 f=2, level of injury C5, time since injury 3 – 1. With FNS and tenodesis each case of
Case Series 72mths. improved performance in later
N=5 Treatment: FNS vs. Tenodesis sessions was significantly better as

5-40
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Outcome Measures: CWRU Hand System compared to the initial session.
(Case Western Reserve University), Grasp (p<0.05).
and Release Test 2. The average grasp forces with FNS
increased; the range was from 8.9N
(SD+5.2) to 22.5N (SD+8.6) and the
palmar grasp forces increases from
2.1N (SD+2.9) to 11.1N (SD+6.0).
Population: Age-13-16years, tetraplegia, 1. No statistical results are reported.
injury to surgery 4-16 weeks. 2. No perioperative complications
Treatment: The following muscles were reported.
implanted with intramuscular electrodes: 3. Subjects began Freehand System use
Extensor digitorum profundus, extensor between 2 = 5 days after implantation
pollicis longus, flexor pollicis longus, 4. Muscle Strength-no subject gained
adductor pollicis, and opponens pollicis for significant strength in any key muscle
each subject. on their freehand limb
Mulcahey et al. 2004; Outcome Measures: Muscle Strength- 5. Pinch Force-with Freehand System -
USA Pinch Force & Hand Function, each subject realized significant
Downs & Black score=6 Performance of ADL, Satisfaction with + improvement in pinch force
Case Series without the Freehand System (COPM), 6. Upper Extremity Capacity-first 11
N=4 Upper Extremity Capacity, Quadriplegic questions - no difference with or
Index of Function without Freehand-last set of questions
Freehand System improved scores
7. Quadriplegic Index of Function-all
subjects increased their level of
independence
8. Freehand System Open-ended
Questions-all subjects would repeat
implantation

SummaryTable5. 20 Implanted Neuroprostheses (Freehand System and CWRU)


Author N Intervention Main Outcome(s)
+ve satisfaction (87%)
+ve life impact (90%)
+ve ADL (87%)
+ve independence (81%)
Implanted Freehand System and
Wuolle et al. 1999 34 +ve occupation (74%)
31 had adjunctive surgeries
+ve appearance
+ve usage (5.5 d/week median)
+ve activities
+ve QOL
+ve lateral pinch
+ve palmar grasp
51 implanted Implanted Neuroprosthesis and +ve Grasp Release Test
Peckham et al. 2001
(50 evaluated) adjunctive surgeries +ve satisfaction
= no change in ability and long
term stability and function
= no change in level of personal
care assistance
Taylor et al. 2001 8 Implantation of Freehand System
-ve system failure
+ve ADL and functional use
5/11 Implanted Freehand System
6/11 CWRU
6/11 tendon transfer surgery for
+ve elbow extension
Memberg et al. 2003 10 elbow extension
+ve workspace assessment
4 arms triceps electrode
11 triceps electrodes/10 UL

5-41
Author N Intervention Main Outcome(s)
+ve ADL and functional use (80%)
+ve lateral grasp
+ve palmar grasp
Implanted Freehand System and +ve 5 finger grasp
Hobby et al. 2001 9
adjunctive surgeries -ve several electrode failures;
stimulator failure; medical
complications
7/9 use device daily
+ve Grasp Release Test
Taylor et al. 2002 9 Implantation of Freehand System +ve Grip Strength
+ve ADL Assessment
+ve pinch force
Implanted Neuroprosthesis and +ve grasp strength
Kilgore et al. 1997 5
adjunctive surgeries +ve Grasp Release Test
+ve ADL and functional use
Implanted Freehand System and +ve Grasp Release Test
Mulcahey et al. 1997 5
adjunctive surgeries +ve ADL and functional use
Smith et al. 1994 5 Implanted Neuroprosthesis -ve electrode failure
+ve elbow function (strength,
4 Implantation of Freehand System
Bryden et al. 2000 ROM)
(5 limbs) with electrode to triceps
+ve ADL and functional use
+ve unilateral grasp and release
Smith et al. 1996 5 Implanted Neuroprosthesis
abilities with FNS
= UE strength
+ve ADL: QIF scores
Mulcahey et al. 2004 4 Implanted Freehand System +ve Satisfaction: COPM
+ve lateral and palmar pinch
= UE capacity: UEC
+ positive outcome, = no difference, - negative outcome

5.8.1.2 HandMaster-NMS-1

The Handmaster developed by Nathan et al., and produced by Neuromuscular Electrical


Stimulator Systems, Ra’anana, Israel. It has been FDA approved for use with stroke patients. It
is predominantly used as an exercise tool for stroke subjects and is commercially available in a
limited number of countries (Popovic et al. 2001). The Handmaster has three surface
stimulation channels used to generate grasping function in tetraplegic and stroke subjects. One
channel is used to stimulate extensor digitorum communis muscle at the volar side of the
forearm. The second channel stimulates the flexor digitorium superficialis and profundus
muscles. The third stimulation channel generates thumb opposition. The system is controlled
with a push button that triggers the hand opening and closing functions. The system is easy to
don and doff. However, it does have some limitations in its design. The system is limited by not
enough sufficient flexibility to vary the position of the electrodes for stimulation of the finger
flexors for grasp; it is a stiff orthosis that fixes the wrist joint angle and prevents full supination of
the forearm (Popovic et al. 2001).

Table 5. 21 Handmaster-NMS-1
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: Gender m=7, level of injury No statistical results reported.
Alon & McBride 2003
C5-C6, 6mths post injury 1. All were 100% successful in using the
USA
Treatment: Subjects practiced with the handmaster in the studied ADL and
Downs & Black score=12
neuroprothesis daily to regain grasp, hold, grasp (hold and release) tasks.
Case Series
and release ability and to restore selected 2. Improvements were noted in strength
N=7
functions of 1 of the 2 paralyzed hands. (.57 ± 98N to 16.5 ± 4.4N, finger linear

5-42
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Subjects were observed 2 to 3 times motion (0.0cm to 8.4 ± 3.2cm) and
weekly for 3 wee Fugi-Meyer scores (p<0.05)
Outcome Measures: Hand function was
evaluated by a series of upper limb
measures: 3 ADL tasks, 3 hand impairment
measures, 2 grasp and release tests.
Population: Gender: m=8, f=2; Age range: No statistical results were reported.
20 to 65; Level of injury: C4 to C6; 1. 6 people left the study for various
Snoek et al. 2000;
Classification: 3-Cu n=3, 1-O n=5, 2-O n=1, reasons (>50%). Over all the 4
Netherlands
0-O n=1; Fitted hand: Right n=6, Left n=4 remaining were able to perform
Downs & Black score=8
Treatment: Training for use of Handmaster several tasks with the Handmaster that
Case Series
Outcome Measures: not specified they were not able to without it ( e.g.:
Initial N=10; Final N=4
3/4 were able to put the splint on
independently)

Summary Table 5. 22: Handmaster-NMS-1


Author N Intervention Main Outcome(s)
+ve ADL use
+ve Grasp Release Test
Alon and McBride 2003 7 NESS Handmaster
+ve grip strength
= finger motion
10 patients -ve poor compliance, only 4 completed
Snoek et al. 2000 Handmaster
(7 at end) the training period
+ positive outcome, = no difference, - negative outcome

5.8.1.3 Bionic Glove

Developed by Prochazka and colleagues at the University of Alberta the Bionic Glove improves
hand function in people with SCI. This device uses three channels of electrical stimulation to
stimulate finger flexors, extensors and thumb flexors. The control signal comes from a wrist
position tranducer mounted in the garment. The actual functioning of the device can be
described as greatly augmenting tenodesis (Prochazka et al. 1997; Popovic et al. 2005).

The Bionic Glove is designed to enhance the tenodesis grasp in subjects that have a voluntary
control over the wrist (flexion and extension). Stimulates finger flexors and extensors during
tenodesis grasp, enhances strength of grasp. The Bionic Glove is available at the University of
Alberta, Alberta, Canada and used primarily for clinical evaluation. A modified version of this
device will be called Tetron (Popovic et al. 2002).

Overall acceptance rate for long-term use is reported in 30% of potential users. Functions of
power grasp and handling of big objects were significally improved (Popovic et al. 2002). There
have been several identified concerns with the device that include damage to the stimulator
located on the forearm that is frequently damaged through accidental contact during functional
activities and the transducer mechanism is delicate and has to be replaced frequently (Popovic
et al. 2001).

Table 5.23 Bionic Glove


Author Year; Country
Score
Methods Outcome
Level
Total Sample Size
Popovic et al. 1999; Population: 12 people with SCI at C5-7 1. QIF: mean was 19.0 +/- 6.5 at the

5-43
Author Year; Country
Score
Methods Outcome
Level
Total Sample Size
Yugoslavia who had used the device 6 months or more beginning; at the end 28.4 +/- 5.2,
Downs & Black score=13 Age: 26.5 +/- 8.3 years (18-38 yr) improvement of 49.5%.
Case Series 10 complete; 1 central cord; 1 Brown- 2. FIM: 63.8 +/- 10.4 at the beginning;
N=12 Sequard 79.0 +/- 8.9 after 6 months. When 3
Time post injury; 2+ years: 7; 1+ year: 3; 6 clients excluded who had 120 points
months+: 1; 3 months: 1 on FIM scores were beginning 44.4 +/-
Treatment: Taught how to use the device 13.5 and 64.8 +/- 16.6 after 6 months
Outcome Measures (increase of 20.4 points/46%).
Quadriplegia Index of Function; Functional 3. Functional task completion: 6 subjects
Independence Measure; Upper Extremity continued to use the device. Average
Function Test; Goniometric Measurements was .745 or 75% of the functions were
performed better after 6 months of
use. 6/12 (50%) did not continue to
use the device C6-C7 individuals may
find the device beneficial enough to
use it as an assistive device.
4. Technical improvements specifically
cosmetics, positioning of the
electrodes, donning/doffing.
5. Best candidates are individuals with
complete C6-C7 tetraplegia;
6. FIM score between 25-50 (up to 75),
QIF between 0-13 (up to 27), are
motivated to use it, can demonstrate
efficient grasp.
Population: Gender m=8, f=1, age-22- 1. Mean peak force of tenodesis grasp in
42yrs, level of injury-C6-C7, time post the nine subjects increased from 2.6 N
Prochazka et al. 1997; injury-16mths-22yrs. ± 3.8 N (passive) to 11.3 N ± 7.4 N
Canada Treatment: Use of bionic glove (glove active), significant than Fp (P=
Downs & Black score=12 Outcome Measures: Mean peak force of 0.0064, t-test), and significant at end
Case Series tenodesis grasp, qualitative ratings of of 5th grasp 6.8 N ± 4.2 N, P= 0.0064,
N=9 manual tasks. Mann-Whitney rank sum test.
2. Most manual tasks improved
significantly with the use of the glove

Summary Table 5.24 Bionic Glove


Author N Intervention Main Outcome(s)
+ve QIF
Popovic et al. 1999 12 Bionic Glove +ve FIM
+ve UE Function Test
+ve grasp
Prochazka et al. 1997 9 Bionic Glove
+ve compliance (60%)
+ positive outcome,= no difference, - negative outcome

5.8.1.4 ETHZ-ParaCare System

The ETHZ-Para Care System was developed collaboratively between ParaCare, the University
Hospital Zurich, the Rehabilitation Engineering Group at Swiss Federal Institute of Technology
Zurich and Compex SA, Switzerland. The system was designed to improve grasping and
walking function in SCI and stroke patients. Surface stimulation FES system is programmable,
4 stimulation channels, can be interfaced with any sensor or sensory system. The system
provides both palmar and lateral grasps. The device has some reported disadvantage that
includes a lengthy time to don and doff the device (7-10 minutes) and it is not commercially
available. The next generation of the device will be called the Compex Motion (Popovic et al.
2001; Popovic et al. 2005). The Compex Motion device is currently available in clinical trials

5-44
with approximately 80 units available. The Compex Motion stimulator was designed to serve as
a hardware platform for the development of diverse FES systems that apply transcutaneous
(surface) stimulation technology. One of the main designs in this system is that it is easily
programmable (Popovic et al. 2005).

Table 5.25 ETHZ ParaCare and Compex Motion Systems


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: gender m=9, f=2, age 15- No statistical results.
70yrs, level of injury C5-C7, ASIA A-D, Case Reports.
FES applied 1-67 mths post injury 1. Cervical SCI patients can benefit from
Treatment: FES was carried out with a transcutaneous FES of hand muscles
stationary stimulation system and 2 during rehabilitation with respect to
Mangold et al. 2005; portable systems (ETHZ-Paracare FES muscle strengthening, facilitation of
Switzerland system, and Complex Motion) voluntary muscle activity and
Downs & Black socre=10 Outcome Measures: videos of functional improvements of ADL functions
Case Series tasks: hand function tests, self-designed 2. Surface FES system is more flexible in
N=11 functional tests, f/u query-assessment of its application and does not need
muscle strength surgical procedures
3. High flexibility in electrode placement,
stimulation programmes, and FES
control devices is required in order to
adapt the system to individual needs

Summary Table 5.26: ETHZ ParaCare and Compex Motion Systems


Author N Intervention Main Outcome(s)
+ve Training Programme
ETHZ-ParaCare FES System +ve Functional exercises in therapy
Mangold et al. 2005 11
and Compex Motion = ADL function in rehab centre
-ve ADL use at home
+ positive outcome, = no difference, - negative outcome

5.8.2 Other Surface or Percutaneous Neuroprosthesis Systems

5.8.2.1 NEC-FES System

The Sendai FES team in corporation with NEC Inc. 1994 developed the NEC-FES System. The
system is to restore both grasping and walking abilities. It is an implanted FES system with 16
stimulation channels. It is used almost exclusively for research purposes and is not available
outside Japan.

5.8.2.2 Neuroprosthesis developed by Rebersek and Vodovik (1973)

This is one of the first FES systems developed for grasping three decades ago. The device has
three stimulation channels (2 stimulation electrodes per channel) that are used to generate the
grasping function by stimulating finger flexors and extensors and thumb flexors. The user can
control the stimulation intensity via different sensory interfaces such as EMG sensor, sliding
resistor and pressure sensors. The main reported disadvantages of the system are the long
donning and doffing times and the selectivity of stimulation is low. This device is not
commercially available (Popovic et al. 2001).

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5.8.2.3 Belgrade Grasping-Reaching System (BGS)

The BGS as proposed by Popovic et al. (1998) is a neuroprosthesis device designed for
grasping and it also provides a reaching function. The device has four stimulation channels
(three for generating grasping function and fourth to stimulate triceps brachii muscle for elbow
extension). The grasping function is controlled via a push button that triggers hand opening and
closing. The motion of grasp is performed in three phases; prehension that forms the correct
aperature of the hand, a relaxation phase that allows the hand to get into good contact with the
object and closure of the hand by opposing either the palm and the thumb or side of index finger
and thumb. The act of hand release is completed in two stages; opening of the hand and
resting. Measuring the subject’s shoulder velocity with a goniometer and then generating a
synergistic elbow motion by stimulation of the triceps brachii muscle achieves the reaching
function of the upper limb. It is reported that the BGS system requires more time to place
electrodes compared to Handmaster system, and it is not commercially available (Popovic et al.
2002).

5.8.3 Reported Benefits of Neuroprosthesis Use

There have been many documented and reported benefits of neuroprosthesis use with the
spinal cord injured person. The training required to use the device leads to short and long-term
changes within the central nervous system (Popovic et al. 2002). A neuroprosthesis can be
used as a neurorehabilitation system that promotes recovery and better hand function in
incomplete SCI and stroke subjects or as a permanent orthotic device for complete cervical
lesion SCI subjects to augment the grasp and manipulation functions required for typical ADLs.

5.8.4 Clinical Results of Neuroprosthesis Use

The following are the reported clinical results of neuroprosthesis use;


• Clinical trials show improvement in grasping functions in stroke and SCI subjects
• FES technology facilitates a comfortable and secure grasp that allows the individual to
hold and manipulate various objects
• All except the Bionic Glove were able to facilitate both palmar (power) grasp and lateral
(fine) grasp
• The Handmaster-NMS-1, the BGS system, and the ETHZ-ParaCare neuroprostheses
have been applied successfully as rehabilitation tools to restore grasping function in SCI
individuals instead of being used as permanent orthotic systems
• To control the neuroprosthesis, subjects are using either an on-off type of switch or have
to apply simple analog sensors to generate desired control commands
• There is a delay of 1-2 seconds from time command is issued and moment that grasp is
executed which restricts the speed that an individual can grasp and release objects
• Neuroprosthesis for grasping can only be used for slower grasping tasks
• The most widely used and accepted neuroprostheses for grasping are the Freehand
System and the Handmaster-NMS-1 and all of the other neuroprostheses mentioned are
mainly used in experimental trials for research purposes

5.8.5 Challenges in Neuroprosthesis Use

There are several reported challenges in neuroprosthesis use:


• There is a general perception within the clinical community that neuroprosthesis
technology is not fully matured and the application of its use is labour intensive

5-46
• Patients and families have over expectations from assistive systems as aspirations and
results do not match
• Acceptance of the device depends on the specific needs of the client
• Complicated by variety of age and lifestyle factors represented in patients with UE
paralysis
• Complacent (feel comfortable, safe and happy with home and workplace adaptation and
with attendant care)
• Waiting for cure (refuse any other intervention)
• Afraid of technology
• Degree of cognitive interaction they require – high levels of attention to their
neuroprosthesis may interfere with social interaction
• Impact in clinical applications is limited
• Reasons for poor acceptance is can be technical, cultural and psychological
• FES technology requires intensive maintenance and skilled technician
• Found to be effective in hospitals with strong engineering support
• Attempts to simplify neuroprosthesis systems and reduce the system’s donning and
doffing time resulted in less technical support needed but the devices then failed to
address the needs of a wider population
• Inadequate reliability of use (breakage of wires, electrode failure, accidental damage)
• The grasping functions are robotic quality of stimulated motions and in order to design a
more dexterous hand motion it would require a more complicated system
• Overall cosmetics of the device
• Implanted neuroprosthesis require additional surgery and it is recommended that tendon
transfers be performed to augment the system
• Extensive training is required to learn how to use the device, which is expensive in terms
of staffing and resources
• Efforts to increase reliability of system components, data on long-term reliability not yet
available
• Simple systems for powered tenodesis grip for individual with lesions at C6 or lower
have not been fully explored in deference to volitional tendon transfer surgery (Popovic
et al. 2002; Triolo et al. 1996)

Discussion

The use of neuroprosthesis whether implanted or surface electrodes appear to benefit persons
with C5-C7 level tetraplegia. The studies consistently demonstrate improvements in pinch
(lateral and palmar), grip strength, and ADL functioning and general satisfaction with the use of
the device, although the study subject numbers are relatively small. Ongoing compliancy and
use of the devices on a long-term basis continue to be problematic. Reasons for discontinuing
the use of the device are with length of time and the amount of assistance required to don and
doff the device, and if using the device can provide enough of a difference in overall level of
functioning. The studies also consistently report both mechanical/electrode failure and adverse
medical complications. Many of the devices are only available in specialized rehabilitation
centres where access to rehabilitation engineering is available. In addition, many of the devices
continue to be only available in clinical trials. The overall cost to use the device continues to be
great when factors such as cost of the device, the extensive training period required and staff to
support the programme.

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Conclusion

There is level 4 evidence from multiple studies that support the use of neuroprostheses
for persons with C5-C6 complete tetraplegia in the improvement of pinch and grip
strength and ADL functioning. However, many devices are only available in clinical trials
in specialized rehabilitation centres and the overall cost of the device continues to be
expensive.

The use of neuroprostheses appears to have a positive impact on pinch and grip strength and
ADL functions in C5-C6 complete tetraplegia, however, access to the devices are limited and
continue to be expensive in use.

5.9 Summary

The treatment and management of the upper limb in persons with a spinal cord injury can be
rewarding yet very challenging. Secondary complications related to repetitive strain injury, pain
and hypertonicity in addition to aging presents numerous challenges for both the injured
individual and the clinician. In reviewing the critical evidence of treatment interventions it was
surprising that there was few studies on the effectiveness of traditional interventions such as
strengthening, exercise, splinting and management of hypertonicity. The majority of research
for the upper limb has been focused on reconstructive surgery and the use of neuroprosthesis.
Advancements in understanding the mechanisms related to spinal cord injury has led to
restorative treatment interventions especially in the management of the incomplete SCI person.

This chapter outlined the importance in the prevention of upper limb dysfunction and the impact
of an injury in one’s overall level of basic independence in the areas of self-care and mobility.
Further research and consensus is needed in how we assess and document upper limb function
especially hand function in an effort to establish objective, reliable and measurable outcomes.
Other areas for further research have been identified throughout the chapter.

There is level 1 evidence based on one RCT that physical capacity continues to improve
after 1- year post discharge.

There is level 2 evidence based on one pre/post study that neuromuscular stimulation-
assisted ergometry alone and in conjunction with voluntary arm crank exercise was an
effective strengthening intervention for chronically injured individuals.

There is level 2 evidence based on one study that muscle strength continues to improve
up to 15 months post hospital discharge for both tetraplegic and paraplegic individuals.

There is level 4 evidence based on one study that neuromuscular stimulation-assisted


exercise improves muscle strength over conventional therapy.

There is level 1 evidence (from 2 RCTs) that augmented feedback is not effective in
improving upper limb function in tetraplegia.

There is level 4 evidence that intrathecal baclofen may be an effective treatment for
upper extremity hypertonia of spinal cord origin.

5-48
There is level 1 evidence from one RCT that showed that massed practice (repetitive
activity) and somatosensory stimulation (median nerve stimulation) demonstrated
significant improvement in grip and pinch strength required for functional activity use.

There is level 2 evidence from a before/after study that showed that rTMs treatment in
individuals with chronic stable ISCI may produce reductions in corticospinal inhibition
that resulted in clinical and functional changes for several weeks after treatment.

There is level 2 evidence from one RCT that showed that the use of concomitant
auricular and electrical acupuncture therapy may improve the neurological and
functional recovery of acutely injured spinal cord individuals.

There is level 2 evidence based on one RCT that wearing a thumb opponens splint will
improve pinch strength and functional use of the hand.

There is level 1 evidence based on two RCTs that a shoulder exercise and stretching
protocol reduces the intensity of shoulder pain post SCI.

There is level 2 evidence that general acupuncture is no more effective than Trager
therapy in reducing post-SCI upper limb pain.

There is level 4 evidence from multiple studies that support the use of reconstructive
surgery for the tetraplegic upper limb for the improvement of ADL and quality of life.

There is level 4 evidence from multiple studies that support the use of neuroprostheses
for persons with C5-C6 complete tetraplegia in the improvement of pinch and grip
strength and ADL functioning. However, many devices are only available in clinical trials
in specialized rehabilitation centres and the overall cost of the device continues to be
expensive.

5-49
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CHAPTER SIX
Lower Limb Rehabilitation
Following Spinal Cord Injury

Tania Lam, PhD, PT


Dalton L Wolfe, PhD
Jane TC Hsieh, MSc
Maura W Whittaker, PT
Janice J Eng, BSc (PT/OT), PhD
Key Points

Patterned Electrical Stimulation (PES) programs are beneficial in preventing and


restoring lower limb muscle atrophy as well as improving lower limb muscle strength
and endurance.

Functional Electrical Stimulation (FES)-assisted exercise programs are beneficial in


preventing and restoring lower limb muscle atrophy as well as improving lower limb
muscle strength and endurance.

For patients less than 6 months post-SCI, body weight supported treadmill training has
equivalent effects on gait outcomes to conventional rehabilitation consisting of
overground mobility practice.

Body weight-support gait training strategies can improve gait outcomes in chronic,
incomplete SCI, but no body weight-support strategy (overground, treadmill, with FES)
is more effective.

There is little evidence that any pharmacological agent is significantly beneficial in


directly improving ambulation in individuals with SCI.

FES-assisted walking can enable walking or enhance walking speed in incomplete SCI
or complete (T4-T11) SCI. Regular use of FES in gait training or activities of daily
living can lead to improvement in walking even when the stimulator is not in use.

There is limited evidence that bracing alone does not enable significant gains in
functional ambulation for people with complete SCI. The advantages of bracing
appear largely restricted to the general health and well-being benefits related to
practice of standing and the ability to ambulate short-distances in the home or indoor
settings. The benefits of bracing-alone on functional ambulation are primarily with
people with incomplete spinal lesions.

There is limited evidence that a combined approach of bracing and FES results in
additional benefit to functional ambulation in paraplegic patients with complete SCI.

Locomotor training programs are beneficial in improving lower limb muscle strength
although in acute SCI similar strength benefits can be obtained with conventional
rehabilitation. The real benefit of locomotor training on muscle strength may be
realized when it is combined with conventional therapy. This should be further
explored in acute, incomplete SCI where better functional outcomes may be realized
with the combination of therapies.
Table of Contents

6.1 Introduction ......................................................................................................................6-1

6.2 Electrical Stimulation to Enhance Lower Limb Muscle Function........................................6-2


6.2.1 Patterned Electrical Stimulation (PES) ...........................................................................6-2
6.2.2 Functional Electrical Stimulation .....................................................................................6-4

6.3 Gait Retraining to Achieve Functional Measures of Overground Ambulatory


Capacity ............................................................................................................................6-7
6.3.1 Body-weight supported treadmill training (BWSTT) ........................................................6-8
6.3.1.1 BWSTT in Acute/Sub-acute SCI ..................................................................................6-8
6.3.1.2 BWSTT in Chronic SCI ..............................................................................................6-10
6.3.2 Special Case Report: Spinal Cord Stimulation Combined with BWSTT .......................6-12
6.3.3 Pharmacological Interventions......................................................................................6-12
6.3.4 Functional Electrical Stimulation (FES).........................................................................6-15
6.3.5 Orthoses/Braces ...........................................................................................................6-18
6.3.5.1 Bracing alone in SCI ..................................................................................................6-18
6.3.5.2 Bracing Combined with FES in SCI ...........................................................................6-22
6.3.6 Enhancing Strength Following Locomotor Training ......................................................6-24

6.4 Summary...........................................................................................................................6-26

References..............................................................................................................................6-29

This review has been prepared based on the scientific and professional information available in 2005. The SCIRE
information (print, CD or web site www.icord.org/scire) is provided for informational and educational purposes only. If
you have or suspect you have a health problem, you should consult your health care provider. The SCIRE editors,
contributors and supporting partners shall not be liable for any damages, claims, liabilities, costs or obligations arising
from the use or misuse of this material.

Lam T, Wolfe DL, Hsieh JTC, Whittaker M, Eng JJ (2006). Lower Limb Rehabilitation Following Spinal Cord Injury.
In: Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Aubut J, Abramson C, Hsieh JTC, Connolly S, editors.
Spinal Cord Injury Rehabilitation Evidence. Vancouver, p 6.1-6.34.

www.icord.org/scire
Lower Limb Rehabilitation
Following Spinal Cord Injury

6.1 Introduction

The rehabilitation of lower extremity function after spinal cord injury has generally focused on
the recovery of mobility. In individuals with paraplegia, the recovery of trunk stability and walking
function are cited as the highest priorities after sexual and bladder/bowel function. Among
people with tetraplegia, the return of arm/hand function is by far the greatest concern, but trunk
stability and walking movement do appear among their priorities (Anderson 2004). Indeed, the
basic capacity to stand upright and interact with others at eye-level is an important ability that
many able-bodied individuals take for granted.
Improvements in emergency and acute medical care for spinal cord injury have translated into
improved survival rates in people who suffer such trauma (Frankel et al. 1998; O'Connor 2005).
Concomitant with this change is also the finding that there is a trend towards less severe
lesions, increasing the number of incomplete spinal cord injuries (Tator et al. 1993). The chance
that a person can be ambulatory following a spinal cord injury is greatly increased when the
severity of the spinal lesion is less (Burns et al. 1997; Curt & Dietz 1997). Thus, with the trend
towards increased survival rates and decreased lesion severity, there is an increasing need for
ambulatory rehabilitation treatments to maximize function and mobility for people with spinal
cord injury.
Conventional rehabilitation strategies for enhancing lower limb function after spinal cord injury
have focused on range of motion and stretching, active exercises, electrical stimulation to
strengthen functioning musculature, and functional training in daily mobility tasks (e.g.
transferring, bed mobility, sitting).
After SCI, it is well established that muscles experience deconditioning, especially those
denervated following complete SCI. The most visible effect of deconditioning is muscle atrophy,
characterized by a reduction in size of individual muscle fibers (Castro et al. 1999a; Castro et al.
1999b). Deconditioning is also associated with a complex cascade of biochemical events and
alterations over time in muscle composition such as changes to muscle fiber type (Stewart et al.
2004; Round et al. 1993). Functionally, these changes are manifest as loss of strength and
endurance of muscular contractions and have been targets for various interventions. Muscular
contractions have the added potential of improving the well known loss of bone density following
SCI. It should be noted that there might be additional benefits to enhancing muscle structure
and function in addition to the immediate functional consequences of enhancing strength and
endurance. For example, Anderson (2004) noted that future treatments developed for chronic
SCI may require the reversal of muscle atrophy in order for benefits of the treatment to be
detectable. Others have noted the potential health benefits (e.g., reduction in secondary
conditions) that may be associated with reducing muscle atrophy and enhancing muscular
strength and endurance (Shields & Dudley-Javoroski 2006). Various rehabilitation techniques
have been focused on reducing or reversing these detrimental changes to the muscles of the
lower limb following SCI.
Standing and overground ambulation training are also important components of conventional
rehabilitation using various bracing and assistive devices such as walkers (O'Sullivan & Schmitz
1994; Somers 1992). In the last several years, we have also seen exciting advances in
technology applications for facilitating or augmenting gait rehabilitation strategies, such as

6-1
robotic devices for treadmill gait retraining (Colombo et al. 2001; Hesse et al. 2004) and the
introduction of microstimulators for activating paralyzed muscles (Weber et al. 2004).

6.2 Electrical Stimulation to Enhance Lower Limb Muscle Function

A variety of electrical stimulation techniques have been employed to enhance lower limb muscle
structure and function in people with SCI. These typically involve delivering a series of electrical
pulse trains to the muscle (or nerve supplying the muscle) over time such that it simulates the
“normal” exercise experience. Specific stimulation parameters (i.e., pulse width, train duration,
between train interval, method of application) and other exercise-related variables (i.e.,
frequency, duration, intensity, program length) may each be varied to attain an optimal training
stimulus. Given the number and variety of these factors, it is not surprising that there is
considerable heterogeneity among the specific electrical stimulation interventions that have
been investigated to date. In the present review we focus on two strategies: patterned electrical
stimulation (PES) and functional electrical stimulation (FES). Whereas both methods typically
employ cyclical patterns of electrical stimulation that simulate natural muscular activity, FES is
directed towards the attainment of purposeful movement such as cycling or walking. PES, on
the other hand, is focused on producing muscle contractions that may be used to generate
muscle force such as in an isometric condition. In some applications, PES techniques have
been used as a training stimulus to prepare muscles for a subsequent FES training condition
(e.g., Kern et al. 2005; Hjeltnes & Lannem 1990). In situations where increased muscle torque
and endurance are primary goals to improve function, for example in the quadriceps in an
incomplete SCI, the outcomes of these experimental studies have direct clinical relevance.

6.2.1 Patterned Electrical Stimulation (PES)

Table 6.1 PES Studies Examining Muscle Function and Morphology


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 26 subjects within 15 weeks 1. Lean body mass increased with
SCI, traumatic, motor complete, thoracic or FES-cycling at all regions and
cervical SCI, mean ages from 25.0 to 28.2 declined for control and PES group.
years, 67.5-80% males. 2. With respect to total body lean
Baldi et al. 1998; USA Treatment: Random assignment to 3-6 mass, lower limb lean mass and
PEDro=5 months of 1. FES-assisted cycle ergometry gluteal lean mass, controls lost an
RCT (n=8), 30 min, 3X/week; 2. PES-assisted average of 6.1%, 10.1%, 12.4%
N=26 isometric exercise group (n=8) (same after 3 months and 9.5%, 21.4%,
muscle groups as FES group) for 1 hr, 26.8% after 6 months.
5X/week and 3. control group (n=9) with no
stimulation.
Outcome Measures: lean body mass
lower lim .
Population: 7 men with complete SCI Compared to the untrained side, stimulated
(ASIA class A), C5-T10, ≥ 6 weeks post- limb had:
injury, ages 21-43. 1. ↑ strength (↑ peak stimulated ankle
Treatment: PES exercise to unilateral torque and higher torque-time
Shields et al. 2006; USA ankle plantarflexion (untrained leg served integrals (p<0.05).
Downs & Black score=17 as a control). Four 4 min exercise bouts, 5 2. More resistant to fatigue (↑muscle
Prospective Controlled days/week for 1.87-3.05 years.
Trial fatigue indexes), (p<0.05).
Outcome Measures: Stimulated ankle
N=7 3. Increased twitch difference
torque and soleus twitch profiles at
(indicative of force generating
baseline and every 6 months up to 3 years.
capacity) (p<0.05), especially with
successive stimulation trains.
4. Greater trabecular bone mineral

6-2
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
density at some sites but not
others.

Population: 4 subjects with SCI; Frankel A 1. No group statistics done. At least 2


(3 chronic T7-T12; 1 with recent injury at subjects had ↑ knee extension
T5); age range 20-36; 3 females, 1 male; 3 torque, ↑ muscular endurance, ↑
months-5 years post-injury. thigh circumference, ↑ elevated CK
Hjeltnes & Lannem 1990;
Treatment: PES, 4 weeks, 2x/day, 5- (indicator of muscle injury) on
Norway
10mins, isokinetic resistance to quadriceps occasion. The more acute subject
Downs & Black score=11
muscles followed by 4 weeks, 30 min, stopped training due to muscle
Pre-post
2X/day, 4-5X/day of integrated training of spasms.
N=4
rising and standing. 2. One subject progressed to the
Outcome Measures: Knee extension planned stage of FNS-assisted
torque, thigh circumference, creatine ambulation training.
kinase collected monthly.
Population: 5 male patients, complete 1. No group statistical analysis
paraplegia (T5-L2), 19 to 68 years of age, performed, limited by heterogeneity
3-60 months post-injury. across subjects.
Kayaga et al. 1996; Treatment: Subcutaneous PES to various 2. All cross-sectional muscle areas
Japan lower limb nerves and muscles for 6 except gluteus maximus increased
Downs & Black score=9 months. Applied at 10 min, 3X/day and (p<0.05 to <0.001).
Pre-post gradually increased to 60 min, 3X/day at 10 3. Muscle torques generally increased
N=5 weeks. after PES.
Outcome Measures: Muscle cross- 4. Manual muscle tests generally
sectional area (CT scan), manual muscle increased (p<0.001) for muscles
test, stimulated muscle torque. initially assessed as poor-minus or
greater.

Discussion

In general, all studies reviewed involving PES produced beneficial results on muscle functions
such as strength and endurance or muscle structure such as increased muscle size (i.e.,
reduced muscle atrophy). The study with the strongest design was conducted by Shields and
Dudley-Javorski (2006), who employed an experimental non-RCT design to examine the effect
of long-term (up to 3 years) PES exercise to unilateral ankle plantarflexor muscles with the
untrained leg serving as a control. This study examined 7 ASIA class A males with relatively
recent injuries (~6 weeks post-injury). Peak stimulated ankle torque (i.e, non-voluntary) was
found to be significantly greater in the stimulated leg as compared to the untrained leg. Trained
limbs also generated significantly higher torque-time integrals than untrained limbs (p<0.05).
Pre-post study designs of PES-assisted exercise also found increased stimulated muscle forces
or torques following training although the subjects involved in these studies were generally more
chronic (Kagaya et al. 1996; Hjeltnes & Lannem 1990). In addition, Bajd et al. (1999) showed
increases in voluntary and stimulated isometric knee joint torques in 4 of 7 subjects with
incomplete SCI (2 months to 8 years post-injury) with a 5th subject showing an increase in the
stimulated response only.
In addition to enhancing muscle bulk, most interventions are focused on improving muscle
function, most notably strength and endurance, but also contractile speed and muscle fatigue.
PES-assisted exercise, in particular, has been studied and shown to benefit the property of
strength in the lower limb. All but one (i.e., Bajd et al. 1999) of the studies assessing outcome
measures associated with strength evaluated this in individuals with complete or motor
complete SCI (Shields & Dudley-Javoroski 2006; Kagaya et al. 1996; Hjeltnes & Lannem 1990).

6-3
Shields and Dudley-Javorski (2006), also demonstrated a beneficial effect with their protocol of
PES-assisted exercise to the plantarflexors in more recently injured individuals with ASIA A SCI.

Conclusion

There is level 2 evidence that a program of PES-assisted isometric exercise reduces the
degree of lower limb muscle atrophy in individuals with recent (~10 weeks post-injury)
motor complete SCI, but not to the same extent as a comparable program of FES-
assisted cycling exercise.
There is level 4 evidence that programs of PES-assisted exercise partially reverses the
lower limb muscle atrophy found in individuals with long-standing (>1 year post-injury)
motor complete SCI.
There is level 2 evidence that a program of PES-assisted exercise increases lower limb
strength and muscular endurance.

PES programs are beneficial in preventing and restoring lower limb muscle atrophy as well as
improving lower limb muscle strength and endurance.

6.2.2 Functional Electrical Stimulation

Table 6.2 FES Studies Examining Muscle function and Morphology


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 26 subjects within 15 weeks 1. Lean body mass increased with
SCI, traumatic, motor complete, thoracic or FES-cycling at all regions and
cervical SCI, mean ages from 25.0 to 28.2 declined for control and PES group.
years, 67.5-80% males. 2. Controls lost an average of 6.1%,
Baldi et al. 1998; USA Treatment: Random assignment to 3-6 10.1%, 12.4% after 3 months and
PEDro=5 months of 1. FES-assisted cycle ergometry 9.5%, 21.4%, 26.8% after 6 months
RCT (n=8), 30 min, 3X/week; 2. PES-assisted in total body lean mass, lower limb
N=26 isometric exercise group (n=8) (same lean mass and gluteal lean mass,
muscle groups as FES group) for 1 hr, respectively.
5X/week and 3. control group (n=9) with no
stimulation.
Outcome Measures: lower limb lean body
mass.
Population: 9 subjects (1 female, 8 1. Overall mean fiber diameter of
males), aged 20-49, complete traumatic trained group was increased vs
conus cauda equina lesions, at least .8 untrained group (p<0.001) and also
years post-injury. had similar values to normal
Kern et al. 2005; Austria Treatment: Progressive PES to FES sedentary adults.
Downs & Black score=14 program for quadriceps to FES-assisted 2. Proportion of total cross-sectional
Pre-post standing (n=4 trained ≥ 2.4 years); area covered by muscle fibers
N=9 untrained controls (n=5). increased with training whereas the
Outcome Measures: Muscle biopsy of area covered by adipocytes and
vastus lateralis (mean fiber diameter, % connective tissue significantly
area covered by muscle fibers, adipocytes, decreased.
connective tissue).

6-4
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 6 tetraplegic, 4 paraplegic, 1. Total collagen content (as indicated
complete, aged 27-45, 5 sedentary by hydroxyproline concentration)
controls, age 30-39. was increased with first training
Treatment: 18-month FES-assisted cycling period (p=0.05) and second training
Koskinen et al. 2000; ergometry (First training period: 30 min, period (p=0.05) and even more so
Finland 3X/week, 1 year; Second training compared to able-bodied controls.
Downs & Black score=14 period:1X/week, 6 months). No difference in Type IV collagen
Pre-post Outcome Measures: Muscle morphology content between groups.
N=15 and protein measurement (type IV 2. This result combined with the
collagen, total collagen, muscle proteins). changes seen with the other
muscle proteins suggest
accelerated type IV collagen
turnover in skeletal muscle.
Population: 7 male subjects with motor- 1. ↑ Work output as training
complete spinal lesions, aged 28-61, (5 progressed (p=0.019).
ASIA A, 2 ASIA B), C5-T8, from 1-27 years 2. More fatigue-resistant: ↓ force
post-injury. decrement during quadriceps
Gerrits et al. 2000; UK Treatment: FES leg cycle ergometry fatiguing stimulations (p=0.012).
Downs & Black score=16 training, 3 - 30 minutes sessions/week for 6 3. No change in contractile speed
Pre-post weeks. (using maximal rate of rise force),
N=7 Outcome Measures: Thigh girth, work ↓ mean ½ Rt (p=0.014) and the
output, contractile speed and fatigue degree of fusion diminished
resistance characteristics, including half (p=0.006).
relaxation time (½ Rt) and degree of fusion 4. ↓ Force responses at low
of electrically stimulated isometric stimulation frequencies.
contractions. 5. No change in thigh circumference.
Population: 13 males, ASIA class A, aged 1. ↑ cross-sectional area including:
24-46, C5-L1, 2-19 years post-injury. rectus femoris, sartorius, adductor
Treatment: A 3-phase, FES-assisted cycle magnus-hamstrings, vastus
ergometry exercise program leading to lateralis, vastus medialis-
FES-induced cycling for 30 minutes. intermedius (all p ≤ .025). No
Average program was 2.3X/week for 52.8 change in cross-sectional area of
Scremin et al. 1999; USA weeks. adductor longus and gracilis
Downs & Black score=16 Outcome Measures: CT-scan of legs to muscles.
Pre-post assess muscle cross-sectional area and 2. No correlations between total
N=13 proportion of muscle and adipose tissue number of sessions and magnitude
collected (pre-test, midpoint and post-test). of muscle hypertrophy.
3. There were significant increases in
the muscle/adipose tissue ratio
(p<0.05), muscle tissue in the thigh
and leg (p<0.05) but no changes in
the adipose tissue.
Population: 6 subjects with complete 1. Total work performed increased
paraplegia (T4-T12) at least 8 years post- (p<0.05) after training.
injury, 5 males, 1 female, age 28-43. 2. Paralysed vastus lateralis muscle
Treatment: FES leg cycle ergometry was altered with ↑ type IIA fibres, ↓
Crameri et al. 2002; training, 3 - 30 min/week for 10 weeks. type IIX fibres ↓ MHC IIx and ↑
Denmark Outcome Measures: Incremental exercise MHC IIA (p<0.05).
Downs & Black score=14 leg test to muscle fatigue (total work 3. Total mean fibre cross-sectional
Pre-post output), histological assessment, myosin area increase of 129%, ↑ cross-
N=6 heavy chain (contractile protein) (MHC), sectional area of type IIA and IIX
citrate synthase (a mitochondrial enzyme) fibres (p<0.05).
and hexokinase (enzyme needed to 4. ↑ Number of capillaries surrounding
produce muscle glycogen). each fibre (p<0.05).
5. ↑ Citrate synthase and hexokinase
activity (p<0.05).

6-5
Discussion

In general, all studies reviewed involving FES produced beneficial results on muscle functions
such as strength and endurance or muscle structure such as increased muscle size (i.e.,
reduced muscle atrophy). FES may have additional benefits over PES alone. In particular, the
study by Baldi et al. (1998) should be highlighted as it was the only randomized, controlled trial
(n=26) which compared FES (cycle ergometry exercise), PES (isometric exercise) and an
untrained control group. These investigators assessed lean body mass in 3 distinct body areas
(i.e., total body, lower limb, gluteal) as a marker of muscle atrophy in recently injured (˜10
weeks) individuals with motor complete SCI. Their results demonstrate that the FES-assisted
cycling program is effective in reducing atrophy and resulted in relative increases in lean body
mass in all areas after 3 and 6 months of participation. The PES-assisted isometric exercise
group also reduced muscle atrophy but had intermediate results between FES and no treatment
(their control group actually loss lean mass).
Reversal of muscle atrophy also appears feasible in more longstanding complete or motor-
complete SCI (i.e, > 2 years post-injury) SCI as shown by increases in muscle cross-sectional
area and the muscle/adipose tissue ratio using FES-cycling (Crameri et al. 2002; Scremin et al.
1999). However, controlled trials in chronic SCI are lacking.
Note that PES is often used to strengthen the atrophied muscles to some extent prior to FES
(Kern et al. 2005) and in some cases, FES is not possible unless PES is first used. Kern et al.
(2005) used a progressive PES - FES program for quadriceps building eventually leading to
FES-assisted standing in people with longstanding complete cauda equina injuries (>1.2 years
post-injury). These investigators demonstrated increases to the overall mean fiber diameter and
the proportion of total cross-sectional area covered by muscle fibers with training as compared
to an untrained group. However, the feasibility of providing life-long stimulation therapy to
subjects with denervation injuries is uncertain.
There was one null finding associated with muscle atrophy in that Gerrits et al. (2000) employed
a relatively shorter program of 6 weeks of FES-assisted cycling exercise in people with
longstanding motor complete SCI (> 1 year post-injury) and found no change in muscle size.
These non-significant results might be due to the measure of thigh circumference which may not
have been sufficiently sensitive to change, especially with the short intervention period and the
absence of a control group for comparison purposes.
In addition to improving muscle properties, FES-cycling can improve work output and endurance
(Crameri et al. 2002; Gerrits et al. 2000). For example, Gerrits et al. (2000) used a short (6
weeks) pre-post trial of FES-assisted cycling intervention in people with motor complete SCI
and found an increase resistance to fatigue in the quadriceps muscle and greater work output.
Some mechanistic investigations have been conducted which help to explain some of these
adaptations to muscle morphology and function with ongoing electrical stimulation exercise
programs. For example, using FES-assisted cycling, Koskinen et al. (2000) demonstrated an
increase in total collagen content as well as up- and down-regulation of proteins consistent with
muscle-building activity. Others have noted an adaptive response to FES-assisted cycling
exercise that serves to limit or alter the shift in the oxidative properties or fibre type composition
of muscles that typically occurs following SCI (Crameri et al. 2002)

6-6
Conclusion

There is level 2 evidence that a program of FES-assisted cycling exercise prevents and
reverses lower limb muscle atrophy in individuals with recent (~10 weeks post-injury)
motor complete SCI and to a greater extent than PES.
There is level 4 evidence that programs of FES partially reverses the lower limb muscle
atrophy found in individuals with long-standing (>1 year post-injury) motor complete SCI.
There is level 4 evidence that a program of FES-assisted cycle exercise increases lower
limb muscular endurance.

FES-assisted exercise programs are beneficial in preventing and restoring lower limb muscle
atrophy as well as improving lower limb muscle strength and endurance.

6.3 Gait Retraining to Achieve Functional Measures of Overground Ambulatory Capacity

There are several approaches to measure overground functional ambulation, as opposed to


neurophysiological or biomechanical measures of gait. These include objective measures of
walking speed or distance, or the use of qualitative functional scales or categories to describe
ambulatory capacity.
Walking speed is typically calculated from the time required for the subject to walk over 10 m
(10-m walk test, or 10MWT). Walking speed has also been calculated by measuring the total
distance traversed over a 2-minute period (Field-Fote 2001; Field-Fote et al. 2005).
Walking endurance is typically assessed by measuring the total distance traversed within 6
minutes (6-minute walk test, or 6MWT). This test was developed to assess fitness capacity in
patients with cardiopulmonary illnesses, but is now also often used to assess walking
endurance in patients with spinal cord injury e.g. (Hornby et al. 2005; Thomas & Gorassini 2005;
Wirz et al. 2005; Dobkin et al. 2006). Recently, both the 10MWT and the 6MWT have been
shown to be valid and reliable measures for assessing walking function in ambulatory
individuals with SCI (Van Hedel et al. 2005).
Ambulatory capacity may also be qualitatively described by the type of ambulatory aid used
during overground walking. The Walking Index for Spinal Cord Injury (WISCI) (Ditunno et al.
2000) and its current revision (the WISCI-II) (Dittuno & Dittuno 2001) is a 20-point scale that
measures the level of assistance and type of ambulatory aid required to walk 10-m. A score of 0
corresponds to an inability to stand or walk with assistance while the maximum score of 20 is
given when the subject can ambulate 10m without any personal or physical assistance (Dittuno
& Dittuno 2001). This measure has been shown to be a valid measure of ambulatory capacity in
patients with SCI (Ditunno et al. 2000).
There are other functional ambulatory scales in use by various investigators to describe walking
capacity in people with SCI. The Wernig Scale of Ambulatory Capacity (Wernig et al. 1995;
Wernig et al. 1998; Hicks et al. 2005; Effing et al. 2006) classifies people according to the
amount and type of assistance required to walk 5 steps, with classification levels ranging from
no walking capability to free walking for more than 5 steps. The Garrett Scale of Walking
classifies subjects according to their functional ambulatory status, ranging from a physiological
walker (hospital ambulation) to unlimited community ambulator (Scivoletto et al. 2000; Protas et
al. 2001).

6-7
6.3.1 Body-weight Supported Treadmill Training (BWSTT)

It has been more than a decade now since it was first demonstrated that body-weight supported
treadmill training (BWSTT) in animals can enhance locomotor activity after spinal cord
transection (Barbeau & Rossignol 1987; Edgerton et al. 1991). In this approach, partial body
weight support is provided by a harness suspended from the ceiling or a frame while limb
stepping movements are assisted by a moving treadmill belt. Since then, BWSTT strategies has
been introduced as a promising approach to improve ambulatory function in people with spinal
cord injury (Barbeau & Blunt 1991). This area of research has raised much excitement and
interest among rehabilitation specialists and neuroscientists.
In this review, we focus on the BWSTT intervention studies that report functional ambulation
outcome measures (such as walking speed). These studies tend to focus on individuals with
incomplete SCI lesions. There are a few studies reporting the effects of treadmill training on the
locomotor pattern in people with complete SCI lesions (Dietz et al. 1994; Dietz et al. 1995;
Wernig et al. 1995; Dietz et al. 1998; Wirz et al. 2001; Dietz & Muller 2004; Grasso et al. 2004).
While there is modulation of muscle (EMG) activity during body weight support treadmill-
assisted stepping in individuals with complete SCI lesions, there has not been any evidence for
functional ambulatory gains in this sub-population.
In people with incomplete SCI, much motor recovery already occurs within the first 2 months
post-injury; the rate of further recovery then decelerates over the next 3 to 6 months (Burns &
Ditunno 2001). However, it is possible for motor function to continue to improve up to 2 years
post-injury. For ease of interpretation, the studies reviewed in this section separate those that
investigated subjects <6 months post-injury (“acute/sub-acute”) from those that studied subjects
who were >6 months post-injury (“chronic”). In studies that used both types of subjects, the
results were divided by subject chronicity. In addition, only results from studies with more than 3
subjects of a given chronicity were included. Therefore, some studies that investigated both
chronic and acute SCI subjects may appear only in Table 6.4 because they had >3 chronic
subjects, but <3 acute subjects (e.g. Thomas & Gorassini 2005).

6.3.1.1 BWSTT in Acute/Sub-acute SCI

Table 6.3 Studies Using BWSTT in Acute/sub-acute SCI (<6 months post-injury)
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 117 men and women 1. No difference in Functional
(completed study), age 16-69 years, ASIA Independence Measure Locomotor
B-D; up to 8 weeks post-injury. Scale (ASIA B & C) or walking
Treatments: BWSTT (manual) vs. speed (ASIA C & D) between
conventional rehabilitation with overground groups.
mobility training. BWSTT group also 2. ASIA C & D subjects in both groups
Dobkin et al. 2006; USA practiced overground walking. Gait training improved walking function. No
PEDro=7 was 5X/week, 9-12 weeks, 30-45 improvement in walking function in
RCT min/session. Follow-up at 3 and 6 months the ASIA B subjects with either
N=117 post-training. intervention, except in subjects who
Outcome measures: primary: Locomotor improved to ASIA C within 8 weeks
Scale of the Functional Independence after injury.
Measure (ASIA B & C, n=108), walking

speed (ASIA C & D, n=72); secondary:


6MWT, WISCI.
Wernig et al. 1995; Population: Study 1: 0-4.5 months post 1. Study 1 (BWSTT): 7 initially non-
Germany injury. Study 2: 2-30 weeks post-injury. ambulatory tetraplegic subjects

6-8
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Downs & Black score=9 Treatment: Study 1: BWSTT (manual, no progressed to walk with assistance
Case Control parameters presented) (n=12). Study 2: or with rollator. Five subjects
N=97 BWSTT (n=45), 2-22 weeks versus progressed from walking with aids
conventional rehab (n=40) (historical to walking independently.
controls). 2. Study 2: Of the non-ambulatory
Outcome measures: Wernig Scale of subjects, 33/36 progressed to
Ambulatory Capacity. walking with aids or independently
after BWSTT, but only 12/24
improved to functional walking with
conventional rehab.
Population: 41 subjects, incomplete, 3-16 1. 29/37 initially non-ambulatory
Wernig et al. 1998; weeks post-injury. subjects improved to walking with
Germany Treatment: BWSTT (manual). 30-60 min, aids.
Downs & Black score=12 5X/week, 3-22 weeks. 2. Follow-up (6 months to 6 years
Pre-post Outcome measures: Wernig Scale of post-training): 15 subjects showed
N=41 Ambulatory Capacity. continued improvement, 26 had no
change in ambulatory status

Discussion

For acute/sub-acute (< 6 months) incomplete SCI, there were 3 studies (n>3) reporting the
effects of locomotor training in subjects with using functional measures of ambulatory capacity
(Table 6.3). The general finding across these studies is that BWSTT with manual assistance
beginning during the acute/sub-acute post-injury period provides improvements in ambulatory
capacity in people with incomplete SCI. The studies of Wernig (Wernig et al. 1995; Wernig et al.
1998) showed that 87% (87/98) of their incomplete SCI subjects achieved improvements in
functional ambulation with BWSTT in the acute phases of injury. The lack of ambulatory change
in 13 subjects may be related to severe flaccid paralysis, high cervical lesion, or proprioceptive
disturbances (Wernig et al. 1995).
Although lower levels of study design (non-randomized, non-blinded) suggest that BWSTT in
acute/sub-acute SCI yields better outcomes than conventional rehabilitation (Wernig et al.
1995), there exists strong evidence from a single-blind RCT (Dobkin et al. 2006) (n=146) that
there are no differences in effects between BWSTT and overground mobility practice (standard
of care) in incomplete SCI during inpatient rehabilitation for walking speed or distance. In both
groups, improvements in walking function were particularly notable in subjects with ASIA C
(92%) or D (100%). Among the subjects who were initially classified as ASIA B, those who
improved to ASIA C within 8 weeks post-injury showed improved walking function. In addition,
subjects who entered the trial earlier (< 4 weeks post-injury) had faster walking speeds and
endurance post-training. This was particularly the case for subjects who improved in their ASIA
classification within 4 to 6 weeks post-injury.
The fact that both subjects in both treatment groups were provided with task-specific locomotor
training (on a treadmill or overground) may account for the lack of any difference in functional
outcomes observed (Dietz 2006). Both groups experienced similar durations of body loading
during therapy, either as a function of practicing standing or walking between parallel bars or
ambulatory aids overground, or practicing upright locomotion with body weight support and a
treadmill (Dobkin et al. 2006). In the older study that reported improved outcomes with BWSTT
compared to conventional rehabilitation (Wernig et al. 1995), the ‘conventional’ rehabilitation
was not well defined. The disparate results between these two sets of data may be accounted
for by the shift in recent years towards more intensive and task-specific rehabilitation therapy.

6-9
Conclusion

There is level 2 evidence using historical controls that BWSTT is effective in improving
ambulatory function. However, stronger evidence from one level 1RCT demonstrates
that BWSTT has equivalent effects to conventional rehabilitation consisting of
overground mobility practice for gait outcomes in acute/sub-acute SCI.

For patients less than 6 months post-SCI, body weight supported treadmill training has
equivalent effects on gait outcomes to conventional rehabilitation consisting of
overground mobility practice.

6.3.1.2 BWSTT in Chronic SCI

Table 6.4 Studies Using BWSTT in Chronic SCI (>1 year post-injury)
Author Year; Country
Score
Methods Outcome
Level
Total Sample Size
Population: 27 men and women, age 21- 1. No difference in outcome
64 years, incomplete, C3-T10. between groups, but a trend
Treatment: Randomized to 4 gait training towards better improvement in
strategies, 45-50 min, 5X/week, 12 weeks: groups who received FES (groups
Field-Fote et al. 2005;
1) BWSTT (manual leg movement) (n=7); 2 & 3).
USA
2) BWSTT+FES (common peroneal nerve) 2. Subjects with slower initial walking
PEDro=6
(n=7); 3) overground body weight support speed (< 0.1 m/s) had greater
RCT
walking+FES (n=7); 4) Lokomat (robotic percent increase in walking speed
N= 27
gait device with body weight support) compared to those with faster initial
(n=6). walking speeds.
Outcome measures: walking speed and
distance, step length, step symmetry.
Population: 44 subjects with para and 1. Study 1: 25/33 initially non-
tetraplegia. BWSTT (manual leg ambulatory could walk after
movement). BWSTT. At 6 months post-training,
Wernig et al. 1995;
Treatment: Study 1: 30-60 min, 5X/week, 18/21 ambulatory patients
Germany
3-20 weeks. Study 2: 29/44 subjects of maintained abilities.
Downs & Black score=9
study 1 compared with 24 chronic subjects 2. Study 2: 14/18 initially non-
Case Control
who underwent conventional rehab ambulatory subjects could walk
N=68
(historical controls). after BWSTT, compared with only
Outcome measures: Wernig Walking 1/14 in the conventional rehab
Capacity Scale. group.
Population: 14 men and women, age 20- 1. 6/14 subjects improved in walking
Hicks et al. 2005; 53 years, ASIA B (n=2) & C (n=12), C4-L1. capacity, but only 3 maintained
Canada Treatment: BWSTT (robotic). Up to 45 improvements at 8 months post-
Downs & Black score=18 min, 3X/week, 144 sessions (12 months). training.
Pre-post Outcome measures: Walking Capacity 2. 3/10 initially non-ambulatory
N=14 Scale (Wernig). subjects could walk (with
assistance) post-training.
Population: 20 men and women, age 16- 1. No statistical change in WISCI II.
Wirz et al. 2005; 64 years (mean 40, SD 14), ASIA C (n=9) 2. Among initially-ambulatory
Switzerland & D (n=11), C3-L1. subjects, there was an overall
Downs & Black score=17 Treatment: BWSTT (robotic). Up to 45 significant increase in 10MWT and
Pre-post min, 3-5X/week, 8 weeks. 6MWT.
N=20 Outcome measures: WISCI II, 10MWT,
6MWT.
Field-Fote 2001; USA Population: 19 men and women, mean 1. Significant increase in walking
Downs & Black score=15 age 31.7 (SD 9.4) years, ASIA C, para- speed (median: 77%).
Pre-post and tetraplegia.

6-10
Author Year; Country
Score
Methods Outcome
Level
Total Sample Size
N=19 Treatment: BWSTT + common peroneal
nerve FES. Up to 90 min, 3X/week, 12
weeks.
Outcome measures: gait speed.
Population: 14 men and women, age 18- 1. All subjects showed increase in
Field-Fote & Tepavac 50 years, ASIA C, C4-T7. walking speed (ranging from 0.01
2002; USA Treatment: BWSTT + common peroneal to 0.2 m/s increase).
Downs & Black score=13 nerve FES. Up to 90 min, 3X/week, 12 Subjects with slower walking
Pre-post weeks. speeds showed the greater %
N=14 Outcome measures: overground gait improvement.
speed.
Population: 6 men and women, age 29-78 1. Significant improvement in WISCI II
Thomas & Gorassini (mean 54.4, SD 14.8) years, ASIA C (n=4) score, 6MWT, and 10MWT and
2005; Canada & D (n=2), C5-L1. improvements correlated with the
Downs & Black score=12 Treatment: BWSTT (manual). Up to 60 increase in corticospinal
Pre-post min, 3-5X/week, 10-23 weeks. connectivity.
N=6 Outcome measures: 10MWT, 6MWT,
WISCI II.
Population: 35 men and women, age 19- 1. 20/25 initially non-ambulatory
70, C4-T12. improved to walking with aids.
Wernig et al. 1998; Treatment: BWSTT (manual). 30-60 min, 2. 2/10 ambulatory patients improved
Germany 5X/week, 8-20 weeks. functional class, but all improved
Downs & Black score=12 Outcome measures: Wernig Walking speed and endurance.
Pre-post Capacity Scale. 3. At follow-up (0.5-6.5 years later) all
N=35 ambulatory patients remained
ambulatory, with changes only in
functional class.

Discussion

Across 8 studies, there was a total of 158 chronic incomplete subjects (C3-L1) enrolled in some
form of body-weight supported gait retraining therapy. Gait retraining strategies were typically
performed with a treadmill and the assistance of therapists or the Lokomat, which is a robotic
gait device. The training protocols ranged from 30 to 90 minutes per day, occurred 3 to 5
times/week and lasted for 8 weeks to 12 months. All studies (and 82% of all subjects) reported
overall improvements in functional walking ability.
Subjects with initially-slower walking speeds (< 0.10 m/s walking speed) tend to make the most
improvements in locomotor function. Subjects with initially high walking capacity (> 0.10 m/s gait
speed) or severely impaired, initially non-ambulatory subjects tend to show little improvement
after gait retraining (Wernig et al. 1995; Wernig et al. 1998). Note that a large percent
improvement from an initially low walking speed can be a result of the mathematics. Of greater
clinical utility is an understanding of how gains in walking speed translate to everyday function.
For people with paraplegia, it has been suggested that an overground walking speed of at least
0.9 m/s is necessary for community ambulation (Cerny et al. 1980). None of the studies showed
attainment of walking speeds greater than 0.5 m/s. Nevertheless, even modest gains in walking
speed after treadmill training have been reported to translate into meaningful enhancements in
daily function (Field-Fote et al. 2005).
BWSTT with FES of the common peroneal nerve results in improvements in overground walking
speed in chronic incomplete SCI (Field-Fote 2001; Field-Fote & Tepavac 2002). However, there
is only a non-significant trend for better outcomes when electrical stimulation was combined with

6-11
treadmill or overground body weight support gait training in chronic SCI subjects compared with
locomotor training alone (Field-Fote et al. 2005).

Conclusion

There is Level 4 evidence from pre-test/post-test studies that BWSTT is effective for
improving ambulatory function in people with chronic, incomplete SCI. There is Level 1
evidence from 1 RCT that different strategies for implementing body weight support gait
retraining all yield similar ambulatory outcomes in people with chronic, incomplete SCI. It
is recommended that therapists may choose a body weight support gait retraining
strategy based on available resources (Field-Fote et al. 2005).

Body weight-support gait training strategies can improve gait outcomes in chronic, incomplete
SCI, but no body weight-support strategy (overground, treadmill, with FES) is more effective.

6.3.2 Special Case Report: Spinal Cord Stimulation Combined with BWSTT

There are 2 published reports (Herman et al. 2002; Carhart et al. 2004) describing the effects of
epidural spinal cord stimulation combined with gait training in a single subject (male with
incomplete tetraplegia, 43 years old, injury level C5-C6, ASIA C, 3.5 years post-injury). The
subject first underwent 12 weeks of BWSTT that resulted in some significant improvements in
treadmill gait parameters although overground ambulation remained limited. Subsequently, the
subject underwent surgical implantation of an epidural stimulation system placed over the T10-
T12 vertebral level. BWSTT and overground gait training in combination with epidural
stimulation commenced after surgical healing. The combination of epidural spinal cord
stimulation with gait training resulted in a substantial improvement in treadmill gait parameters
as well as in overground ambulation. The subject reported a decreased sense of effort, a
doubling in walking speed, and increased walking endurance when assisted by spinal cord
stimulation. This was associated with improved community and indoor functional ambulation.
Obviously, controlled trials of this specific intervention are required before spinal cord
stimulation combined with locomotor training can be recommended as a useful rehabilitation
strategy. Nevertheless, this special case report highlights one of the innovative and exciting
possibilities of technology.

6.3.3 Pharmacological Interventions

Drugs such as clonidine (a noradrenergic agonist), cyproheptadine (a serotonergic antagonist),


baclofen (GABA agonist), GM-1 ganglioside and 4-aminopyridine have been used in association
with attempts to improve ambulation in individuals with SCI. The results from animal studies
indicate that such drugs may act on the receptors in the spinal cord which facilitate interaction
with a locomotor central pattern generator (spinal circuits which produce coordinated locomotor
movement) (Barbeau et al. 1990; Chau et al. 1995; Rosssignol et al. 1996). Although not
conclusive, there is some evidence that similar “central pattern generator” circuits exist in
humans (Calancie et al. 1994; Illis 1995; Bussel et al. 1988; Bussel et al.1996a, 1996b) and
provide the rationale for clinical use of these drugs.

6-12
Table 6.5 Studies of Pharmacological Interventions for Enhancing Locomotion in SCI
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: SCI, chronic, ambulatory 1. Some positive effects for both
(ASIA D). placebo and 4-AP treatment when
Treatment: Double-blind, placebo- compared to baseline, but no
Deforge et al. 2004;
controlled, crossover design: 4- changes between groups were not
Canada
Aminopyridine (4-AP): 1 week of up- significant.
PEDro=10
titration prior to 2 weeks of 10 mg 4x/day
RCT
stable dosing of 4-AP (n=15) versus
N=29
Placebo (n=14) and then switch conditions.
Outcome measures: Isometric muscle
force, gait analysis.
Population: chronic, incomplete. 1. No significant differences were
Van der Bruggen et al. Treatment: Double-blind, placebo- found between groups, period,
2001; Netherlands controlled, crossover design: 4 weeks of cross over design, or treatment
PEDro=10 15-45 mg, immediate-release 4- effects.
RCT Aminopyridine capsules or Placebo. 2
N=20 week washout between conditions.
Outcome measure: walking speed.
Population: chronic paraplegia, complete 1. 1/3 ambulatory patients had
and incomplete. marked improvement in locomotor
Treatment: Double-blind, placebo- function resulting from Clonidine
controlled, crossover design: Two periods compared to Placebo.
of 4 weeks of medication (Clonidine or 2. Spasticity
Stewart et al. 1991; Placebo, randomly assigned) separated by (#Improvement/deterioration/no-
Canada a 2 week washout period. change resulting from Clonidine):
PEDro=8 Outcome measures: Kinematic measures Ankle reflexes 5/2/2, Knee reflexes
RCT during body weight support gait, spasticity, 5/0/2, spasticity visual analog scale
N=9 adverse effects. 6/1/2, Daily spasms 2/0/2, Daily
clonus 4/0/1.
3. Side effects of clonidine (8/9
patients): dry eyes and mouth,
lethargy, mild hypotension and
constipation.
Population: Chronic. 1. Irrespective of treatment order,
Treatment: Double-blind, placebo- GM-1 resulted in ↑motor scores,
Walker & Harris 1993;
controlled crossover study design: walking distance, ↑ walking
USA
Intravenous GM-1 ganglioside (Sygen®), 6 velocity.
PEDro=8
days per week. 6 month physical therapy
RCT
preceding 4 months of trial.
N=9
Outcome measures: Motor Score Walking
distance and velocity.
Population: spastic paraparesis of spinal 1. Descriptive results only.
origin, motor incomplete. 2. Compared to control,
Treatment: Randomized, double-blind Cyproheptadine resulted in 1) gait
Wainberg 1990; Canada cross-over design: Oral Cyproheptadine changes (↓ forward trunk flexion but
PEDro=7 (n=8) or placebo tablets (n=7) over 3 no change in EMG,↑ walking
RCT weeks (1 week each at 2mg, 4mg and 8mg speed, ↓ %stance time,↓ %double
N=15 5x/day) with a 1 week washout in between. support duration; 2) ↓ spasticity: all
Outcome measures: Kinematic and leg subjects reported a decrease in the
muscle activity (EMG) during gait, spasm severity and frequency of
severity, spasticity diary. involuntary movements.
Population: sub-acute to chronic (0.5-16 1. Only 5/8 ambulatory subjects could
Remy-Neris et al. 1999; years post injury). stand up and walk after 60 ug
France clonidine dose (2 showed
Treatment: Intrathecal Clonidine 60μg test
Downs & Black score=15 improvements).
dose (n=11) followed by 3 doses (15 to 90
Pre-post
μg) and a placebo injection (n=4). 2. One subject showed ↑ overground
N=11 speed (P>0.03), ↑ stride length
Outcome measures: Ashworth spasticity

6-13
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
scores, H-reflex, ambulation parameters, (P>0.0009) but not cycle duration
flexion reflexes. and higher doses impaired gait.
3. ↓ Ashworth score in all subjects. No
change seen in H-reflex. Flexion
reflex not enhanced with low doses.
Population: male, chronic, 6 tetraplegics, 1. Improvements in gait velocity (↑ by
3 paraplegics. 36% from 24.1 ± 16.5 m/min to
Treatment: 4-Aminopyridine (single 10mg 32.7 ± 22.9 m/min; (p ≤ 0.04); in
Segal & Brunneman;
immediate-release capsule). stride length (↑ from 0.9 ± 0.3
1998; USA
Comparison of means at baseline and at meters to 1.0 ± 0.3 meters, p≤
Downs & Black score=14
intervals over 24-hour follow-up. 0.02); ↑ cadence and gait cycle
Pre-post
Outcome measures: Ambulation duration, but not significant.
N=9
parameters. 2. Gait changes began 6 hours after
drug administered and persisted
the 24 hour follow-up.
Population: chronic, incomplete, 1. 7/12 subjects had evaluations of all
traumatic. 3 drugs; adverse effects for 4/5
Treatment: 3 different oral tablets in order subjects prevented completion of
of convenience: Clonidine (≤0.25 mg/day) all conditions. The greatest effects
or Cyproheptadine (≤24 mg/day) or in more severely disabled subjects.
Baclofen (≤80mg/day): each drug trial had 2. Cyprohyeptadine resulted in↓need
Norman et al. 1998; incremental increase to maximum dose for assistance, ↑ in maximum
Canada and stable dosing over 3 weeks followed treadmill speed and ↓ clonus.
Downs & Black score=13 by incremental decrease from maximum Clonidine resulted in ↑maximal
Pre-post dose and washout over 2 weeks. treadmill speed and a generally
N=12 Outcome measures: Surface EMG and more upright posture. Baclofen
kinematic gait analysis during treadmill resulted in minor changes in
walking. No statistical analysis. walking. Maximal treadmill speed
increases and other changes were
often retained following washout of
drugs.

Discussion

The interactions of these pharmacological interventions are complex and appear to affect
walking ability and spasticity to varying effects. The studies on clonidine (oral or intrathecal),
cyproheptadine and baclofen demonstrate improvements in various aspects of gait (i.e. walking
speed, posture, spasticity), but no improvements led to significant functional improvements in
walking. Norman et al. (1998) found the greatest improvements in more severely disabled
subjects and in many cases, the drug effects were retained following washout of drugs.
Bradycardia and hypotension, common side-effects of oral clonidine can be ameliorated with
intrathecal injection of clonidine (150-450µg) (Filos et. al. 1994). The combined effect of
different drugs has not been well explored. One very small study (not tabled due to its small
sample size of 2 subjects) (Fung et al. 1990) showed that a combination of Clonidine,
Cyproheptadine and treadmill training improved SCI locomotion in 2 subjects.
Conflicting evidence exists on the use of GM-1 ganglioside for neurologic recovery for walking in
SCI. The small RCT conducted by Walker and Harris in 1993 (N=9) concluded that the use of
GM-1 ganglioside improved motor scores, walking distance and walking speed in chronic SCI
subjects. A recent large scale multicenter RCT (n=760) (Geisler et al 2001) suggested that
although GM-1 treatment may have accelerated initial SCI recovery (at 8 weeks), it did not
improve the final extent of recovery (26 weeks). However, walking ability was not assessed
given the subjects who ranged from ASIA A to D.

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The effects of immediate release, 4-aminopyridine capsules on ambulation are conflicting with 2
RCTs suggesting no benefit (vander Bruggen et al. 2001, n=20; Deforge et al. 2004, n=15).
However, the van der Bruggen et al. (2001) hypothesis was not directed solely at exploring the
effects on walking and therefore the heterogenous nature of the subject groups may have
confounded the ambulation results. Furthermore, differences in intervention (i.e. 10mg single
dose, 15-45mg/day over 4 weeks in the Deforge et al. study versus 10mg 4X/day for 8 days in
the Van der Bruggen et al study and the lack of consistent clinically relevant outcome measures
complicates the interpretation of the available evidence.

Conclusion

In summary, level 1 evidence describes limited and indirect improvements in aspects of


walking (i.e. spasticity, speed and posture) but do not translate into significant functional
walking gains as a result of clonidine and cyproheptadine. Limited and non-functional
improvements in walking as a result of baclofen are only supported by level 4 evidence.
Conflicting evidence provides little guidance with respect to the use of GM-1 and 4-
aminopyridine for the improvement of ambulation in spinal cord injury. Scientifically
robust studies with consistent clinically relevant outcome measures are needed for
pharmacological intervention studies of ambulation after spinal cord injury.

There is little evidence that any pharmacological agent is significantly beneficial in directly
improving ambulation in individuals with SCI.

6.3.4 Functional Electrical Stimulation (FES)

The idea of compensating for paralyzed function using electrical stimulation was introduced as
early as the 1960s (Liberson et al. 1961). Functional electrical stimulation of the common
peroneal nerve was found to be effective in assisting foot clearance during the swing phase
(Liberson et al. 1961). There has also been a report of attempts to stimulate the ankle
plantarflexor muscles to assist push-off at the end of stance and enhance the initiation of the
swing phase in subjects with incomplete SCI (Bajd et al. 1999). Approaches that focus on swing
phase activity are more suitable for less severely disabled individuals who have adequate
balance to support their stance leg during gait. There are also more complex systems that
involve several channels of stimulation that support proper extension as well as foot clearance
during swing (e.g. Sigmedics 2000). These are more suitable for patients who require
assistance in standing as well as gait, such as those with neurologically complete SCI. FES
systems such as the Parastep or ALT-2 provide stimulation of thigh extensor muscles
(quadriceps, gluteal muscles) to support extension and standing, as well as stimulation of the
common peroneal nerve to assist with swing phase movements. FES may also be combined
with bracing to counter trunk and hip instability (Solomonow et al. 1997a).
One of the limitations of surface FES is possible skin irritation, discomfort under the electrodes,
or difficulties with proper positioning of the electrodes. With improvements in electronics
technology, FES systems are becoming smaller and more amenable for everyday use. In
addition, some patients have opted for implanted FES systems that may be inserted without
surgery. These systems offer a more precise delivery of stimulation, enabling greater muscle
selectivity, and the ability to access deeper muscles, such as the hip flexors (Kobetic et al.

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1997). Percutaneous electrodes, which are inserted through the skin with a hypodermic needle,
offer one possibility to circumvent complications with surface electrodes (Marsolais & Kobetic
1986; Kobetic et al. 1997). However, there may be complications due to infection or irritation at
the site of insertion, and electrode movement or breakage (Agarwal et al. 2003). More recently,
there was a case study reporting positive effects with a BION microstimulator in an incomplete
tetraplegic subject with drop-foot (Weber et al. 2004). Thus, preliminary reports of the use of
such innovative FES technology are promising, but further study is warranted to determine the
long-term stability and efficacy of such implanted systems.

Table 6.6 Studies Using Functional Electrical Stimulation to Improve Locomotor Function
Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 15 men and women, age 16- 1. 13 subjects completed training. All
47 years, T3-T11, Frankel A, B (n=1), and could ambulate independently with
C (n=1), 6-240 months post-injury (some the Parastep system after ~14
Brissot et al. 2000; same subjects as Gallien et al. (1995). sessions.
France Treatment: Surface FES: Parastep® 6 2. The mean walking distance without
Downs & Black score=17 channels (bilateral common peroneal a rest was 52.8 m (SD 69 m; range:
Post-test nerve, quadriceps, glutei/lumbar muscles), 1-350 m). The mean speed was
N=15 mean of 20 sessions. 0.15 m/s (SD 0.14 m/s; range:
Outcome measures: ambulatory status, 0.03-0.4 m/s). 5/10 patients with a
walking distance and speed (with FES). 3 year follow-up continued to use
the system at home.
Population: 14 (but only 10 subjects 1. Mean increase of 0.10 m/s in
analyzed), age 25-49 years, C3-L1, walking speed (over the first year of
incomplete, 1.8-19.1 years post-injury. FES-use (measured with and
Ladouceur & Barbeau;
Treatment: Surface FES: bilateral or without FES).
2000a; Canada
unilateral common peroneal nerve, home
Downs & Black score=16
use as much as possible ~1 year (26 and
Pre-post
56 weeks), 2 subjects also had bilateral
N=14
quadriceps.
Outcome measures: temporal gait
measures.
Population: 16 men and women, mean 1. Most subjects improved endurance
age 28.4 (SD 6.6) years, T4-T11, and gait speed. Longest distance
complete, 0.7-9.0 years post-injury. walked with FES was between 12
Klose et al. 1997; USA Treatment: Surface FES: Parastep®I: 6 to 1707 m (mean: 334 m; SD 402
Downs & Black score=15 channels (bilateral common peroneal m).
Pre-post nerve, quadriceps, glutei). 3X/week, 32
N=16 sessions (once subjects had sufficient
strength to stand).
Outcome measures: walking distance and
speed (with FES).
Population: 6 men and women, age 20-40 1. Significant mean increase in stride
years, C3-L1, Frankel C & D, 2 to 18 years length, but not speed or cadence.
post-injury. 2. 3 to 4 subjects had significant
Granat et al. 1993;
Treatment: Surface FES: quadriceps, hip individual increases in gait speed,
Scotland
abductors, hamstrings, erector spinae, stride length and cadence.
Downs & Black score=14
common peroneal nerve,
Pre-post
home program >30 min, 5X/week, 3
N=6
months.
Outcome measures: walking speed, stride
length, cadence.

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Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size
Population: 14 (but only 10 subjects 1. All subjects showed an
analyzed), age 25-49 years, C3-L1, improvement in functional mobility.
incomplete, 1.8-19.1 years post-injury 7/14 subjects showed improvement
(same subjects as in Ladouceur & Barbeau based on type of ambulatory
Ladouceur & Barbeau
2000a). device.
2000b; Canada
Treatment: Surface FES: bilateral or 2. When walking with FES, 13/14
Downs & Black score=14
unilateral common peroneal nerve, 2 subjects improved gait speed.
Pre-post
subjects also had bilateral quadriceps, Ambulatory improvements were still
N=14
home use as much as possible ~1 year. evident when the FES was turned
Outcome measures: temporal gait off during walking in12/14 subjects,
measures. suggesting a training, or carryover,
effect with long-term FES-use.
Population: 31, mean age 36 (SD 2) 1. Overall improvement in gait speed
years, injury level above lumbar levels, which persisted even when
incomplete, mean 6 (SD 1) years post- subjects walked without FES.
Wieler et al. 1999; injury, 4 centres. 2. Mean increase in speed was 0.14
Canada Treatment: Surface FES: common m/s (SE: 0.03 m/s) (although mixed
Downs & Black score=13 peroneal nerve; some subjects also stroke and SCI results). Greatest %
Pre-post received FES to hamstrings, quadriceps, improvements particularly for the
N=31 gluteus medius, duration of FES ranged initially slow walkers.
from 3 months to over 3 years.
Outcome measures: walking speed, stride
length, cycle time.
Population: 13 men and women, age 17- 1. Independent ambulatory distances
42 years, T4-T10, complete, 5-240 months 2 to 350m (mean 73.25 m, SD 102
Gallien et al. 1995;
post-injury. m) and speed 0.2 to 0.6 m/s (mean:
France
Treatment: Surface FES: Parastep®: 6 0.2 m/s, SD 0.1 m/s).
Downs & Black score=6
channels (bilateral common peroneal 2. Poorer performances were
Post-test
nerve, quadriceps, glutei). observed in more chronic subjects.
N=13
Outcome measures: walking distance and
speed (with FES).
Population: age 20-44 years, C2-T10, 1. All subjects improved gait speed
incomplete, 2.5-10 years post-injury. when FES was on (mean change
Stein et al. 1993; Canada Treatment: Surface, percutaneous, or was 4 m/min), particularly
Downs & Black score=6 implanted FES of common peroneal nerve, significant for more disabled
Pre-post and sometimes quadriceps, glutei, and subjects.
N=10 psoas.
Outcome measures: speed, gait
parameters

Discussion

To date, there are no randomized controlled or blinded assessments of the efficacy of any form
of FES to improve mobility after SCI. Results from the experimental pre-test/post-test studies
reviewed here show that almost all the participants showed improvements in gait parameters
(walking speed or distance) when FES was used. This is not surprising, given that the FES
could compensate for weakened or paralyzed muscle function during gait. Of greater interest is
the finding of carryover effects after FES training. After completion of an FES-training program,
improvements in gait function persisted even when the stimulator was turned off (Wieler et al.
1999; Ladouceur & Barbeau 2000; Johnston et al. 2003). This suggests that neuroplastic
changes may have taken place in response to regular use of FES during walking. Indeed, it has
been shown in non-disabled human subjects that the combination of treadmill walking and FES
led to an acute increase in corticospinal excitability that persists even after the cessation of FES

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(Kido Thompson & Stein 2004). Improved muscle strength and conditioning after regular use of
FES could also contribute to carryover effects in walking function (Granat et al. 1993).
Although laboratory studies advocate the efficacy of FES systems for improving ambulatory
function in patients with SCI, the effectiveness of any technology is only as good as its
acceptance by the intended users. Wieler et al (Wieler et al. 1999) reported that the majority of
their subjects found they could use the FES device easily on a regular basis and that they
walked better with the FES. Those who reported difficulties reported problems with finding the
proper stimulation site or technical difficulties with the leads, switches, or electrodes. There
have also been reports of musculoskeletal complications such as ankle sprain, calcaneum
fracture, back pain, or falls with FES use (Gallien et al. 1995; Brissot et al. 2000). Some of these
complications may have been associated with commencement of upright exercise (gait) after a
period of being non-ambulatory. Anecdotal reports found in several studies suggest that most
subjects mainly use FES indoors or at home, for short distance walking, to prevent
complications due to prolonged immobilization, and to enhance physical fitness rather than
functional community ambulation (Gallien et al. 1995; Klose et al. 1997; Brissot et al. 2000).
Subjects who do use FES outdoors for community ambulation tend to be the less severely
impaired (Granat et al. 1993; Brissot et al. 2000).
The functional benefits derived from FES are also quite variable. For instance, Stein et al. (Stein
et al. 1993) report that most subjects showed a modest improvement in gait speed (average: 4
m/min), which was more significant for the more severely disabled subjects. Higher-functioning
subjects felt that this small benefit in gait speed did not warrant the daily use of FES. In contrast,
(Ladouceur & Barbeau 2000) reported that there was a tendency for the subjects with initially
faster gait speed to have greater absolute improvements. Thus, outcomes from FES-use also
seem to be quite variable in terms of walking speed (Stein et al. 1993; Ladouceur & Barbeau
2000) or distance (Klose et al. 1997).

Conclusion

There is Level 4 evidence that FES-assisted walking can enhance walking speed and
distance in complete and incomplete SCI. There is also Level 4 evidence from 3
independent laboratories that regular use of FES in gait training or activities of daily
living leads to persistent improvement in walking function that is observed even when
the stimulator is not in use.

FES-assisted walking can enable walking or enhance walking speed in incomplete SCI or
complete (T4-T11) SCI. Regular use of FES in gait training or activities of daily living can lead
to improvement in walking even when the stimulator is not in use.

6.3.5 Orthoses/Braces

6.3.5.1 Bracing alone in SCI

There are several available devices used for bracing the legs in order to support standing and
walking function, particularly for people with complete SCI. These range from single-joint
bracing (e.g. ankle-foot orthosis), usually for individuals with low, incomplete spinal lesions, to
whole-leg/long-leg braces that extend from the lower back to the ankle. Among the most
common long-leg braces studied in the literature are the purely mechanical Parawalker (Rose

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1979) or the Reciprocating Gait Orthosis (RGO) (Douglas et al. 1983). These devices may also
be combined with FES to augment gait function and efficiency (Nene and Patrick 1990; Yang et
al. 1996; Marsolais et al. 2000). These devices must be used with a walking aid (e.g. crutches
or walker) for functional ambulation.

Table 6.7 Studies of Bracing Interventions in SCI


Author Year; Country
Score
Methods Outcome
Research Design
Total Sample Size