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NeuroRehabilitation 35 (2014) 341–347 DOI:10.3233/NRE-141111 IOS Press
Predictors of functional outcome in patients with traumatic spinal cord injury after inpatient rehabilitation: In Saudi Arabia Amal B. Abdul-Sattar∗ Department of Rehabilitation and Physical Medicine, Zagazig University, Zagazig, Egypt
Abstract. OBJECTIVE: To identify the possible factors influencing motor functional outcome of patients with traumatic spinal cord injury (T-SCI) after inpatient rehabilitation. METHODS: 90 patients with T-SCI consecutively admitted for inpatient SCI rehabilitation unit was studied. Demographic characteristics, level and completeness of SC injury using American Spinal Injury Association (ASIA) Impairment Scale, disability level using Functional Independence Measure (FIM), psychological state using Hospital Anxiety and Depression Scale (HADS), and SCI-related medical complications were assessed and recorded at admission. The main measure of functional outcome was the motor FIM gain score at discharge. The univariate and multiple linear regression analyses were performed. RESULTS: The Mean admission motor FIM score was 35.3 (20.1), the mean discharge motor FIM score was 65.3 (22.5), and the mean motor FIM gain score was 30.0 (20.9). Univariate analyses indicated that the significant factors influencing motor functional outcome included age, motor FIM score at admission, level and severity of injury, anxiety/depression score, time between injury and admission to rehabilitation, length of stay, destination at discharge, and family caregiver. However, in multiple linear regression analyses, age, destination at discharge, family caregiver were not significant predictors. CONCLUSION: Age was not predictor of motor functional outcome and rehabilitation can be effective in elderly SCI patients. Rehabilitation intervention should begin as soon as possible. The admission motor FIM score, level and severity of injury, interval between onset and admission, anxiety/depression score, and length of stay can be used to predict functional outcomes of rehabilitation in SCI patients. Keywords: Traumatic spinal cord injury, rehabilitation, predictors, functional outcome
1. Introduction Traumatic spinal cord injury (T-SCI) usually leads to permanent clinical impairment and is a life changing event [6] that affects all regions of the world [1]. In Saudi Arabia, the frequency of T-SCI was higher in males and in 16–30 age group. Road traffic accident is the most common cause of injury, and more than 50% of the T-SCI patients stayed in the hospital for less ∗ Address
for correspondence: Amal B. Abdul-Sattar, 16 ElEmam Ali St., Villat el Jamaa., Zagazig, Egypt. Tel.: +2 1122112959; E-mail: [email protected].
than 70 days [2, 3]. Several measures, including AIS grade conversion rates, have been shown to be poorly predictive of future functional capacity [35]. In light of these findings, the International Campaign for Cures of Spinal Cord Injury Paralysis has embraced a more expanded definition of health outcomes by prioritizing the use of neurological and functional assessment tools in future SCI clinical trials [34]. Functional Independence Measure (FIM) instrument has been widely used in the assessment of disability in patients with SCI [19]. Patients with low motor scores on discharge are more dependent and are therefore more likely to be
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
342
A.B. Abdul-Sattar / Predictors of SCI rehabilitation outcome
discharged to a long-term care facility and those with high motor FIM scores on discharge are likely to return to community living on discharge, even though there may be a need for modification to the living environment to support independent living [9, 15, 34]. Function outcomes are influenced by sociodemographic factors [24, 34, 37], level of injury, and severity of the injury [7, 25, 37]. The aim of this study was to study the possible variables that may influence the functional outcome of patients with traumatic spinal cord injury after inpatient rehabilitation in Saudi Arabia and to determine which factors were significantly associated with poor functional outcomes.
2. Patients and methods All patients with traumatic spinal cord injury (SCI) who were referred from acute hospitals after surgical management to Abdel-Latif Jamil rehabilitation hospital, Jeddah, Saudi Arabia between October, 2007 to October, 2010 for active rehabilitation program and fulfilled inclusion criteria were included in this prospective study. Inclusion/Exclusion criteria: Patients on their initial admissions to inpatient rehabilitation for SCI of traumatic origin were included in this study. However, patients with nontraumatic SC lesion, patients with additional central nervous system lesions located outside the spinal cord or peripheral nervous system pathology were excluded. Whenever a patient was discharged or transferred for more than 3 weeks, the readmission was considered a second admission and the patient was excluded. And as a result, 90 patients fulfilled the inclusion criteria for enrolment into this study which was approved by the hospital’s board. Within 48 hours of transfer of the patient to rehabilitation, and after giving informed consent to participate in this study, all patients provided demographic information. The injury variables (etiology, associated injury, SCI-related medical complications, and surgical intervention), were recorded from the patient’s discharge medical report from the acute hospital where the surgical intervention was done. Then each patient underwent: • Full physical examination. • Neurological examinations by a rehabilitation doctor within 48 hours from admission and before discharge. We used the ASIA Impairment Scale [16] to evaluate sensory and motor function and
neurological level. However, because it has been shown that motor evaluation is the best predictor of impairment in patients with SCI [20], we excluded data on sensory function and used only data on motor function in the data analysis. Neurologic level of injury was classified into tetraplegia or paraplegia. The injury was considered incomplete motor whenever subjects showed signs of sacral motor function in the sacral segments [36]. • Assessment of function disability by Functional Independence Measure (FIM). Although FIM was developed for assessment of disability in patients with stroke and to assess the requirements for burden of care, this instrument has been widely used in the assessment of disability in patients with SCI [19]. The FIM consists of 18 items organized under six categories of function: Self care activities, sphincter control, mobility, locomotion, communication and social integration. Each item is scored on a standardized ordinal scale from one (completely dependent) to seven (full independent) for a maximum potential score of 126. This measurement instrument also allows the calculation of motor–FIM subscore derived from 13 items describing physical abilities and cognitive FIM subscore which describing communication and social cognition abilities. The motor-FIM subscore rang from 13 to 91 and cognitive-FIM subscore range from 5 to 35 [12, 18]. In this study, the patients with additional central nervous system lesions located outside the spinal cord that may affect the patient’s cognition were excluded. Therefore, only the FIM motor score was selected. The FIM motor score was calculated within 48 hours of admission and 48 hours before discharge by trained rehabilitation professionals and the main functional outcome measure was the FIM motor change scores (discharge motor FIM score minus admission motor FIM score). • Evaluation by psychiatrist to assess the psychological condition using Hospital Anxiety and Depression Scale (HADS). HADS was specifically designed to avoid false-positives when administered in hospital settings and therefore focuses on psychological and cognitive symptoms, rather than somatic symptoms or sleep and appetite disturbance. HADS is a 14-item self-report questionnaire comprising 4-point Likert-scaled items covering the occurrence of symptoms of anxiety (HADS-A) and depression (HADS-D) over the past 2 weeks. It has seven items assessing
A.B. Abdul-Sattar / Predictors of SCI rehabilitation outcome
depressive symptoms and seven items assessing anxiety symptoms (sum score 0–21 on each subscale). Each question has 4 possible responses. Responses are scored on a scale from 3 to 0. High scores indicate more severe symptoms [38]. The cut-off for depression (HAD-D) and anxiety (HAD-A) is set to ≥8 [31]. The Arabic version was a reliable instrument for detecting states of anxiety and depression in Saudi patients in a primary health care setting [8]. Other variables were taken into account, such as, the time interval between onset of the injury and admission to rehabilitation (TTA), common SCI-related complications that may occur during inpatient rehabilitation (pressure ulcer, urinary tract infection, spasticity, depression, pneumonia, deep venous thrombosis, pulmonary embolism), length of stay in rehabilitation hospital (LOS), and destination at discharge. In this study, for the purpose of statistical analysis and based on previous experience, we chose a cut off age of 50 years [26] and a cutoff TTA interval of 40 days [33]. LOS less than 123 days has been considered short depending on the mean of LOS in this study, the neurological level of injury was dichotomized into paraplegia or tetraplegia, the motor completeness of neurological impairment was dichotomized into motor complete impaired (AIS = A,B) and motor incomplete impaired(AIS = C,D) according to ASIA Impairment Scale, and destination at discharge was dichotomized into home and others (nursing care, other hospital, other rehabilitation). All patients received a comprehensive rehabilitation program, including medical and nursing management, Physiotherapy at least six days a week, and each treatment session lasted 45 to 60 minutes twice a day, occupational therapy was applied six days a week, each treatment session lasted 20–40 minutes twice a day. If necessary, patients had access to individual training for breathing, bowel, and bladder dysfunction, Psychotherapy and medical social work interventions. Sessions of all therapies included not only patients, but their relatives and other patients as well. Weekly multidisciplinary staff meetings were conducted to assess progress, review functional goals and plan further therapies. Family case conferences were conducted to educate family members and plan patients aftercare needs. The decision to discharge a patient at the end of the rehabilitation process was reached when motor FIM scores were stable at two successive determinations, 1 week apart.
343
2.1. Statistical analysis All the possible predictor variables were first examined by means of univariate analysis (t-test) to assess the importance of each of them on the FIM motor change score. The variables were chosen based on clinical judgment and prior literature review and included age, gender, AIS impairment severity, SCI level, the SCI-related complications, Onset-Admission Interval, length of stay, and admission motor FIM scores. The relationship between patient characteristics and clinical factors, on the one hand, and FIM motor gain score on the other was then studied with multivariate linear regression analysis to determine factors with an independent influence on the motor FIM gain score. All the variables were entered simultaneously into the regression model as covariates. The analysis was performed with the use of the forward selection procedure. The adjusted R2 was calculated to assess whether the independent variables were good predictors of the motor FIM gain. Only values of P < 0.05 were considered statistically significant. Analyses were performed with the SPSS version 10.01software (SPSS Inc., Chicago, USA).
3. Results Table 1 details the characteristics of patients with traumatic spinal cord injury at admission to rehabilitation. The mean age at injury was 38.1 years; 82% were males; 66.6% of the patients were married; and the mean time between onset of the T- SCI and admission to rehabilitation (LAT) was 37.7days. On discharge, the mean length of stay was 123 days and 71% discharged to home and 29% discharged to others. SCI-related medical complications, as assessed at admission and occurred during rehabilitation, are represented in Table 2. Urinary tract infections, depression, spasticity, and pressure ulcer were the most frequent, affecting 58.8%, 48.8%, 41.1%, and 36.6% of the patients, respectively. As a whole, a high proportion of the patients, amounting to 70%, showed at least one of medical complications, since SCI until discharge from the rehabilitation hospital. Table 3 lists the means of individual items of motor FIM at admission and discharge. The mean of total motor FIM score improved from 35.3(20.1) at admission to 65.3 (22.5) at discharge and the mean of motor FIM gain was 30.0 (20.9). On univariate analysis of the 90 patients as shown in Tables 4, the significant variables that associated
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Table 1 Characteristics of patients with traumatic spinal cord injury on admission to rehabilitation Variables Age at injury (years), means (SD) 38.1 (18.3) Gender, no (%) Male 74 (82.2) Female 16 (17.8) Marital status, no (%) Married 60 (66.6) Unmarried (Single, Divorced, widowed) 30 (33.3) Educational level, no (%)
NeuroRehabilitation 35 (2014) 341–347 DOI:10.3233/NRE-141111 IOS Press
Predictors of functional outcome in patients with traumatic spinal cord injury after inpatient rehabilitation: In Saudi Arabia Amal B. Abdul-Sattar∗ Department of Rehabilitation and Physical Medicine, Zagazig University, Zagazig, Egypt
Abstract. OBJECTIVE: To identify the possible factors influencing motor functional outcome of patients with traumatic spinal cord injury (T-SCI) after inpatient rehabilitation. METHODS: 90 patients with T-SCI consecutively admitted for inpatient SCI rehabilitation unit was studied. Demographic characteristics, level and completeness of SC injury using American Spinal Injury Association (ASIA) Impairment Scale, disability level using Functional Independence Measure (FIM), psychological state using Hospital Anxiety and Depression Scale (HADS), and SCI-related medical complications were assessed and recorded at admission. The main measure of functional outcome was the motor FIM gain score at discharge. The univariate and multiple linear regression analyses were performed. RESULTS: The Mean admission motor FIM score was 35.3 (20.1), the mean discharge motor FIM score was 65.3 (22.5), and the mean motor FIM gain score was 30.0 (20.9). Univariate analyses indicated that the significant factors influencing motor functional outcome included age, motor FIM score at admission, level and severity of injury, anxiety/depression score, time between injury and admission to rehabilitation, length of stay, destination at discharge, and family caregiver. However, in multiple linear regression analyses, age, destination at discharge, family caregiver were not significant predictors. CONCLUSION: Age was not predictor of motor functional outcome and rehabilitation can be effective in elderly SCI patients. Rehabilitation intervention should begin as soon as possible. The admission motor FIM score, level and severity of injury, interval between onset and admission, anxiety/depression score, and length of stay can be used to predict functional outcomes of rehabilitation in SCI patients. Keywords: Traumatic spinal cord injury, rehabilitation, predictors, functional outcome
1. Introduction Traumatic spinal cord injury (T-SCI) usually leads to permanent clinical impairment and is a life changing event [6] that affects all regions of the world [1]. In Saudi Arabia, the frequency of T-SCI was higher in males and in 16–30 age group. Road traffic accident is the most common cause of injury, and more than 50% of the T-SCI patients stayed in the hospital for less ∗ Address
for correspondence: Amal B. Abdul-Sattar, 16 ElEmam Ali St., Villat el Jamaa., Zagazig, Egypt. Tel.: +2 1122112959; E-mail: [email protected].
than 70 days [2, 3]. Several measures, including AIS grade conversion rates, have been shown to be poorly predictive of future functional capacity [35]. In light of these findings, the International Campaign for Cures of Spinal Cord Injury Paralysis has embraced a more expanded definition of health outcomes by prioritizing the use of neurological and functional assessment tools in future SCI clinical trials [34]. Functional Independence Measure (FIM) instrument has been widely used in the assessment of disability in patients with SCI [19]. Patients with low motor scores on discharge are more dependent and are therefore more likely to be
1053-8135/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
342
A.B. Abdul-Sattar / Predictors of SCI rehabilitation outcome
discharged to a long-term care facility and those with high motor FIM scores on discharge are likely to return to community living on discharge, even though there may be a need for modification to the living environment to support independent living [9, 15, 34]. Function outcomes are influenced by sociodemographic factors [24, 34, 37], level of injury, and severity of the injury [7, 25, 37]. The aim of this study was to study the possible variables that may influence the functional outcome of patients with traumatic spinal cord injury after inpatient rehabilitation in Saudi Arabia and to determine which factors were significantly associated with poor functional outcomes.
2. Patients and methods All patients with traumatic spinal cord injury (SCI) who were referred from acute hospitals after surgical management to Abdel-Latif Jamil rehabilitation hospital, Jeddah, Saudi Arabia between October, 2007 to October, 2010 for active rehabilitation program and fulfilled inclusion criteria were included in this prospective study. Inclusion/Exclusion criteria: Patients on their initial admissions to inpatient rehabilitation for SCI of traumatic origin were included in this study. However, patients with nontraumatic SC lesion, patients with additional central nervous system lesions located outside the spinal cord or peripheral nervous system pathology were excluded. Whenever a patient was discharged or transferred for more than 3 weeks, the readmission was considered a second admission and the patient was excluded. And as a result, 90 patients fulfilled the inclusion criteria for enrolment into this study which was approved by the hospital’s board. Within 48 hours of transfer of the patient to rehabilitation, and after giving informed consent to participate in this study, all patients provided demographic information. The injury variables (etiology, associated injury, SCI-related medical complications, and surgical intervention), were recorded from the patient’s discharge medical report from the acute hospital where the surgical intervention was done. Then each patient underwent: • Full physical examination. • Neurological examinations by a rehabilitation doctor within 48 hours from admission and before discharge. We used the ASIA Impairment Scale [16] to evaluate sensory and motor function and
neurological level. However, because it has been shown that motor evaluation is the best predictor of impairment in patients with SCI [20], we excluded data on sensory function and used only data on motor function in the data analysis. Neurologic level of injury was classified into tetraplegia or paraplegia. The injury was considered incomplete motor whenever subjects showed signs of sacral motor function in the sacral segments [36]. • Assessment of function disability by Functional Independence Measure (FIM). Although FIM was developed for assessment of disability in patients with stroke and to assess the requirements for burden of care, this instrument has been widely used in the assessment of disability in patients with SCI [19]. The FIM consists of 18 items organized under six categories of function: Self care activities, sphincter control, mobility, locomotion, communication and social integration. Each item is scored on a standardized ordinal scale from one (completely dependent) to seven (full independent) for a maximum potential score of 126. This measurement instrument also allows the calculation of motor–FIM subscore derived from 13 items describing physical abilities and cognitive FIM subscore which describing communication and social cognition abilities. The motor-FIM subscore rang from 13 to 91 and cognitive-FIM subscore range from 5 to 35 [12, 18]. In this study, the patients with additional central nervous system lesions located outside the spinal cord that may affect the patient’s cognition were excluded. Therefore, only the FIM motor score was selected. The FIM motor score was calculated within 48 hours of admission and 48 hours before discharge by trained rehabilitation professionals and the main functional outcome measure was the FIM motor change scores (discharge motor FIM score minus admission motor FIM score). • Evaluation by psychiatrist to assess the psychological condition using Hospital Anxiety and Depression Scale (HADS). HADS was specifically designed to avoid false-positives when administered in hospital settings and therefore focuses on psychological and cognitive symptoms, rather than somatic symptoms or sleep and appetite disturbance. HADS is a 14-item self-report questionnaire comprising 4-point Likert-scaled items covering the occurrence of symptoms of anxiety (HADS-A) and depression (HADS-D) over the past 2 weeks. It has seven items assessing
A.B. Abdul-Sattar / Predictors of SCI rehabilitation outcome
depressive symptoms and seven items assessing anxiety symptoms (sum score 0–21 on each subscale). Each question has 4 possible responses. Responses are scored on a scale from 3 to 0. High scores indicate more severe symptoms [38]. The cut-off for depression (HAD-D) and anxiety (HAD-A) is set to ≥8 [31]. The Arabic version was a reliable instrument for detecting states of anxiety and depression in Saudi patients in a primary health care setting [8]. Other variables were taken into account, such as, the time interval between onset of the injury and admission to rehabilitation (TTA), common SCI-related complications that may occur during inpatient rehabilitation (pressure ulcer, urinary tract infection, spasticity, depression, pneumonia, deep venous thrombosis, pulmonary embolism), length of stay in rehabilitation hospital (LOS), and destination at discharge. In this study, for the purpose of statistical analysis and based on previous experience, we chose a cut off age of 50 years [26] and a cutoff TTA interval of 40 days [33]. LOS less than 123 days has been considered short depending on the mean of LOS in this study, the neurological level of injury was dichotomized into paraplegia or tetraplegia, the motor completeness of neurological impairment was dichotomized into motor complete impaired (AIS = A,B) and motor incomplete impaired(AIS = C,D) according to ASIA Impairment Scale, and destination at discharge was dichotomized into home and others (nursing care, other hospital, other rehabilitation). All patients received a comprehensive rehabilitation program, including medical and nursing management, Physiotherapy at least six days a week, and each treatment session lasted 45 to 60 minutes twice a day, occupational therapy was applied six days a week, each treatment session lasted 20–40 minutes twice a day. If necessary, patients had access to individual training for breathing, bowel, and bladder dysfunction, Psychotherapy and medical social work interventions. Sessions of all therapies included not only patients, but their relatives and other patients as well. Weekly multidisciplinary staff meetings were conducted to assess progress, review functional goals and plan further therapies. Family case conferences were conducted to educate family members and plan patients aftercare needs. The decision to discharge a patient at the end of the rehabilitation process was reached when motor FIM scores were stable at two successive determinations, 1 week apart.
343
2.1. Statistical analysis All the possible predictor variables were first examined by means of univariate analysis (t-test) to assess the importance of each of them on the FIM motor change score. The variables were chosen based on clinical judgment and prior literature review and included age, gender, AIS impairment severity, SCI level, the SCI-related complications, Onset-Admission Interval, length of stay, and admission motor FIM scores. The relationship between patient characteristics and clinical factors, on the one hand, and FIM motor gain score on the other was then studied with multivariate linear regression analysis to determine factors with an independent influence on the motor FIM gain score. All the variables were entered simultaneously into the regression model as covariates. The analysis was performed with the use of the forward selection procedure. The adjusted R2 was calculated to assess whether the independent variables were good predictors of the motor FIM gain. Only values of P < 0.05 were considered statistically significant. Analyses were performed with the SPSS version 10.01software (SPSS Inc., Chicago, USA).
3. Results Table 1 details the characteristics of patients with traumatic spinal cord injury at admission to rehabilitation. The mean age at injury was 38.1 years; 82% were males; 66.6% of the patients were married; and the mean time between onset of the T- SCI and admission to rehabilitation (LAT) was 37.7days. On discharge, the mean length of stay was 123 days and 71% discharged to home and 29% discharged to others. SCI-related medical complications, as assessed at admission and occurred during rehabilitation, are represented in Table 2. Urinary tract infections, depression, spasticity, and pressure ulcer were the most frequent, affecting 58.8%, 48.8%, 41.1%, and 36.6% of the patients, respectively. As a whole, a high proportion of the patients, amounting to 70%, showed at least one of medical complications, since SCI until discharge from the rehabilitation hospital. Table 3 lists the means of individual items of motor FIM at admission and discharge. The mean of total motor FIM score improved from 35.3(20.1) at admission to 65.3 (22.5) at discharge and the mean of motor FIM gain was 30.0 (20.9). On univariate analysis of the 90 patients as shown in Tables 4, the significant variables that associated
344
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Table 1 Characteristics of patients with traumatic spinal cord injury on admission to rehabilitation Variables Age at injury (years), means (SD) 38.1 (18.3) Gender, no (%) Male 74 (82.2) Female 16 (17.8) Marital status, no (%) Married 60 (66.6) Unmarried (Single, Divorced, widowed) 30 (33.3) Educational level, no (%)
