| | Predicting Walking at Discharge From Inpatient Rehabilitation After a Traumatic Spinal Cord InjuryPresented in part to the 5th Conference of the Asian Spinal Cord Network, December 2005, Ho Chi Minh City, Vietnam. Abstract Kay ED, Deutsch A, Wuermser LA. Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury. ObjectiveTo investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI). DesignRetrospective study. SettingComprehensive rehabilitation hospital. ParticipantsA total of 343 adult inpatients with traumatic SCI. InterventionsNot applicable. Main Outcome MeasureFIM instrument walking rating of 3 (moderate assistance) or higher at discharge. ResultsSignificantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. ConclusionsAdmission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score ≥3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. WALKING IS A PRIMARY GOAL of patients after spinal cord injury (SCI),1, 2, 3 so it is important to understand what factors affect walking. However, the mode of locomotion (ie, walking or wheelchair use) also has significant implications for discharge planning, so it is useful at rehabilitation admission to predict the ability to walk at inpatient rehabilitation discharge. Many studies4, 5, 6 have investigated walking as a long-term outcome or as a primary means of mobility after an SCI. However, the current trend of a shorter hospital length of stay (LOS) combined with the high cost of durable medical equipment (eg, wheelchairs) and home renovation to improve accessibility makes it important to predict walking even short distances with assistance, especially when further gains are anticipated. Information that predicts walking should help in the development of more accurate prognoses and treatment decisions at the individual level while guiding outcome measurement and policy decisions at the societal level. Developing accurate prognoses is important, because incorrect assumptions or expectations by patients, family members, and/or rehabilitation professionals can have a negative impact on the functional outcome achieved.7 Furthermore, expectations regarding walking are important because interventions have been found to facilitate the recovery of limb function after an SCI.8, 9 The American Spinal Injury Association (ASIA) Impairment Scale10 (AIS) grades of A, B, and C have been considered functionally complete11, 12, 13 and hence comparable, although AIS grades B and C designate injuries that are neurologically incomplete.10 Consistent with the idea that AIS grade A, B, and C injuries are similar, subjects with these injuries have been studied as a single group at admission,11, 14 discharge,11, 12, 13, 14 and follow-up.11 However, New13 reported that 12.5% of adults with a nontraumatic SCI and AIS grade C walked at rehabilitation discharge, although none with AIS grade A or B injuries could walk. Scivoletto et al14 also reported that more people with AIS grade C than A or B injuries at discharge could walk. These data strongly suggest that AIS grade C lesions differ from the other 2 grades, at least with regard to walking at discharge. Patients with AIS grade D injuries are known to be able to walk13, 14, 15 and have been found to have similar FIM motor subscores regardless of the injury level.11, 13 Therefore, injury level may not affect walking in those with AIS grade D injuries. Age is a second factor that deserves investigation with regard to walking after an SCI. Although age has been shown to affect outcomes after SCI,14, 15, 16, 17 it is not known if it specifically affects walking at discharge. This is important because it has been shown that people 50 years and older with a new SCI are more likely to have incomplete tetraplegia14, 18, 19, 20, 21, 22 (eg, AIS grade C or D injuries) and to have worse outcomes.14, 15, 16 The aim of this study was to examine how the AIS grade, level of injury, and age at rehabilitation admission are associated with walking at rehabilitation discharge for adults with traumatic SCI. This knowledge may improve the ability to predict walking at discharge from inpatient rehabilitation. We hypothesized that (1) subjects with AIS grade C injuries are more likely to walk than subjects with AIS grade A or B injuries, (2) more subjects with AIS grade C paraplegia would walk at discharge than those with AIS grade C tetraplegia, (3) subjects with AIS grade D injuries would be more likely to walk than those with AIS grade C injuries, (4) subjects with AIS grade D tetraplegia and AIS grade D paraplegia would have the same expectations of walking, and (5) being 50 years or older at the time of injury would negatively affect walking at discharge. Methods  After approval from the institutional review board at Northwestern University, we reviewed the medical records of patients with a traumatic SCI treated at the Rehabilitation Institute of Chicago (RIC). Data were abstracted from the records of patients who met the inclusion criteria, including patients who were (1) at least 18 years of age at the time of injury, (2) admitted to RIC within 3 months of injury, and (3) inpatients between January 1998 and May 2004. Records were excluded if (1) the patient did not complete inpatient rehabilitation at RIC; (2) the patient had significant physical deficits before the SCI; (3) the patient had a diagnosis of dementia, brain injury, or mental retardation unless the cognitive deficits were documented to be mild; or (4) key data were missing. One author reviewed each patient chart and abstracted age, sex, date of injury, rehabilitation admission date, rehabilitation discharge date, comorbidity diagnoses, admission neurologic level, admission AIS grade, admission FIM instrument scores, and discharge locomotion method(s) (walk, wheelchair, or both), equipment, and FIM locomotion score. The neurologic level, AIS grade,10 and comorbidity diagnoses were gathered from the physicians’ examinations completed within 72 hours of rehabilitation admission using the 1997 ASIA standards.10 When neurologic level was different for the right and left sides, the more caudal level was used to acknowledge the motor abilities present on at least 1 side. FIM mobility data (ie, transfers, locomotion, stairs) and mode(s) of locomotion, assistance needed, and assistive devices were obtained from physical therapy notes. Self-care data (ie, eating, grooming, bathing, dressing upper and lower body, toileting) were obtained from the occupational therapy notes, and bowel and bladder data were obtained from the nursing notes. FIM cognitive scores were taken from speech notes when present or team conference notes when speech evaluations were not present. The primary outcome measure was walking or not walking at the time of rehabilitation discharge. Walking was defined as the ability to provide 50% or more of the effort to walk 45m (150ft)—the definition for a FIM score of 3 (ie, moderate assistance) or higher. Data Analysis We used descriptive statistics to characterize the subjects. Differences in subject characteristics across subgroups, based on level and completeness of injury, were tested with 1-way analysis of variance for continuous variables and chi-square for categoric variables. The Fisher exact test and the chi-square test were used to test whether the percentage of subjects walking at discharge was different across subgroups. We examined the association between AIS grade and walking at discharge (FIM walking level ≥3) using logistic regression while adjusting for onset time and age (hypothesis 3). Logistic regression was also used to examine the association between level of injury and walking at discharge (FIM walking level 3 or higher) while adjusting for onset time and age (hypotheses 2 and 4). Data were analyzed using SPSS,a and α was set at .05 for all analyses. Results Participants Among the 481 records reviewed, 343 (71.3%) met all of the study criteria. Records for 138 patients were excluded because 95 had chronic SCI or were admitted more than 3 months after the SCI, 21 were missing key data, 7 had motor limitations before the SCI, 9 had cognitive deficits before the SCI, and 6 did not complete inpatient rehabilitation at RIC. The subject subgroups included 135 subjects with AIS grade A or B tetraplegia, 84 with AIS grade A or B paraplegia, 44 with AIS grade C tetraplegia, 16 with AIS grade C paraplegia, 50 with AIS grade D tetraplegia, and 14 with AIS grade D paraplegia (table 1). The mean age for all subjects was 42.1 years, 79.9% of subjects were men, the mean time after injury that subjects were admitted to RIC was 24.0 days, and the mean LOS was 60.4 days. The mean age, proportion of men, mean time from injury to rehabilitation admission, mean rehabilitation LOS, admission FIM motor scores, and admission FIM cognitive rating all varied by subgroup (see table 1). Walking Among Subjects With AIS Grade C Injuries by Neurologic Level Injury level was not significantly associated with walking at discharge for subjects with AIS grade C injuries. Table 2 shows that 5 (31.3%) of 16 subjects with AIS grade C paraplegia and 12 (27.3%) of 44 subjects with AIS grade C tetraplegia (P=.756) walked at discharge. A logistic regression model showed that injury level was not associated with walking (P=.946) when data were adjusted for age and onset time. Five (38.5%) of the 13 subjects with AIS grade C tetraplegia and central cord syndrome (CCS) walked at discharge, compared with 7 (22.6%) of 31 of subjects with AIS grade C tetraplegia without CCS (P=.281). The presence of CCS was not associated with walking at discharge with an AIS grade C injury in this sample. Walking Among Subjects With AIS Grade C Versus AIS Grade D Injuries Subjects with AIS grade D injuries at admission were more than twice as likely to walk as subjects with AIS grade C injuries (67.2% vs 28.3%, P<.001). Subjects with AIS grade D injuries tended to need less assistance to walk than those with AIS grade C injuries (see table 3). A logistic regression model showed that admission AIS grade (D vs C) was associated with walking at discharge (P=.001) when data were adjusted for age and onset time. Walking Among Subjects With AIS Grade D Injuries by Neurologic Level Thirty-five (70%) of 50 subjects with AIS grade D tetraplegia and 8 (57.1%) of 14 with AIS grade D paraplegia walked by discharge (see table 2). This association remained nonsignificant when logistic regression was used to adjust for age and onset time. Twelve (66.7%) of 18 subjects with AIS grade D tetraplegia and CCS walked by discharge compared with 22 (68.8%) of 32 subjects with AIS grade D tetraplegia but without CCS. The presence of CCS was not associated with walking at discharge with an AIS grade D injury in this sample. Walking Among Subjects by Age (>50y) Among the subjects with AIS grade C lesions, 33.3% of the subjects younger than 50 years and 25.0% of those 50 years or older (P=.483) walked by discharge (table 4). The difference remained nonsignificant when logistic regression was used to examine the association between age and walking while adjusting for neurologic level and onset time (P=.810). In contrast, among those with AIS grade D lesions significantly more subjects younger than 50 years walked than subjects 50 years of age and older, with 78.8% of younger subjects and 54.8% of older subjects walking by discharge (P=.041). In this sample, older subjects were less likely to walk than younger subjects after an AIS grade D injury but not an AIS grade C injury. Discussion This study examined how AIS grade, level of injury, and age at admission to inpatient rehabilitation are associated with walking at discharge for patients with traumatic SCI treated at 1 rehabilitation facility. Results support the hypotheses that subjects with AIS grade C injuries at admission were more likely to walk than subjects with AIS grade A or B injuries; subjects with AIS grade D injuries were more likely to walk than those with AIS grade C injuries, and subjects with AIS grade D injuries were equally likely to walk at discharge regardless of injury level. However, contrary to the study hypotheses, subjects with AIS grade C injuries were equally likely to walk at discharge regardless of injury level (16 with paraplegia vs 44 with tetraplegia), and being 50 years or older at the time of injury negatively affected walking at discharge for subjects with AIS grade D injuries, but age did not affect walking for subjects with AIS grade C injuries. Comparison of Results With Published Literature Walking after AIS grade C compared with AIS grade A and B injuries Only 2 (0.9%) of the 215 subjects with AIS grade A or B injuries walked at discharge. Both had L3 injuries, 1 AIS grade A and 1 AIS grade B. It is not known if either had improvement in neurologic level, AIS grade, or both before discharge, but both subjects were discharged before spontaneous recovery would have been complete4, 5, 6, 11 and walked with modified independence (one without any orthoses). The finding of only 2 ambulators, 2.4% of subjects with AIS grade A or B paraplegia, is consistent with the 5% of subjects with complete paraplegia who have been reported to walk 1 year postinjury.5, 23 The finding that none of the subjects with AIS grade A or B tetraplegia walked by discharge is consistent with the finding of Waters et al4 that no subject with complete cervical injuries became ambulatory even though 6 of 61 subjects converted to incomplete injuries. Among subjects with AIS grade C injuries, 28.3% walked with moderate assistance or less by discharge. Notably, all had enough muscle control to walk without knee-ankle-foot orthoses (KAFO), suggesting some recovery of antigravity strength. It is not known if any of the subjects had an improvement in AIS grade by discharge, but it has been shown that people with AIS grade C sparing can walk.5, 6, 13, 14, 15 Walking among subjects with AIS grade C injuries The finding that level of injury was not associated with walking for subjects with AIS grade C injuries was not expected. We hypothesized that more subjects with paraplegia would walk because of the presence of unaffected upper-body strength for use with an assistive device(s), an attribute that has been found to be important.6 In addition, most of the subjects with AIS grade C paraplegia in this study had low-level injuries (T10-L3) and hence good trunk and upper-extremity strength. However, despite these advantages, the level of injury did not affect walking in this sample. Although the number of study subjects with AIS grade C paraplegia was small (n=16), the nonsignificant trend of more paraplegic than tetraplegic subjects with AIS grade C injuries walking has been noted for adults with nontraumatic SCI.13 In agreement with New,13 none of the subjects in this study walked with a KAFO. The 27.3% of subjects with AIS grade C tetraplegia at admission who walked by discharge in this study is lower than the 67% reported by Burns et al.15 However, there are key differences in the 2 studies that may contribute to the different findings. First, Burns’s subjects were graded on admission to the emergency department rather than rehabilitation. Because recovery is likely between these time points, subjects graded AIS grade C in the Burns study could have been classified as AIS grade D in the current study. Second, in the Burns study walking was defined as the subject walking a minimum of 15m (50ft) without assistance from another person. The current study used a minimal distance of 45m and no more than moderate assistance. Finally, the Burns data were collected between 1984 and 1993, a time when rehabilitation LOSs were typically longer. The current finding of 27.3% with AIS grade C tetraplegia walking at discharge is consistent with the 38% of subjects with AIS grade C tetraplegia reported to use only ankle-foot orthoses or no orthoses to walk at least limited household distances at the 1-year follow-up.6 However, the populations are not directly comparable, because some of those with AIS grade C injuries in this study may have had AIS grade D injuries by discharge. Despite inconsistencies in the percentage reported to be ambulatory, the finding that adults with AIS grade C injuries at admission can become ambulatory by discharge from inpatient rehabilitation should encourage therapists to include ambulatory preparation activities in these patients’ programs. Comparison of walking as an outcome with AIS grade C versus AIS grade D injuries The finding that subjects with AIS grade D injuries were more likely to walk by discharge than those with AIS grade C injuries is consistent with results from studies of people with traumatic15 and nontraumatic13 SCI. However, the magnitude of the differences varied between studies. Other studies have reported that 1.515 to 6 times13 as many adults with AIS grade D injuries walk at discharge compared with those with AIS grade C injuries; our study results are within this range. Differences may be related to the cause of the injury (traumatic vs nontraumatic) and sample sizes. Studies of FIM motor scores11 and surface electromyography24 also found that AIS grade C and D lesions differed significantly. Walking among subjects with AIS grade D injuries A larger percentage of subjects with AIS grade D tetraplegia walked by discharge than subjects with AIS grade D paraplegia; however, the difference was not statistically significant. This trend was also found in adults with nontraumatic SCI.13 The current study found that 67.2% of subjects with AIS grade D injuries at admission walked by discharge, less than the 100% of subjects with AIS grade D injuries reported by Burns.15 A possible explanation for the different results may be the higher proportion of older subjects in the present study; however, Burns15 did not provide enough detail to make a comparison. Walking among subjects with CCS CCS would result in greater sparing in the muscles of the lower limbs, so it could improve walking in subjects with tetraplegic involvement. However, the presence of CCS was found to not be associated with walking at discharge in subjects with AIS grade C or D injuries. Although the number with AIS grade C and CCS (n=13) or AIS grade D and CCS (n=18) was very small, these data may suggest that subjects with CCS are hampered in their ability to relearn how to walk secondary to being unable to use traditional assistive devices and techniques. Affect of age (>50y) on ability to walk at discharge Age was not associated with walking at discharge for subjects with AIS grade C injuries even when data were adjusted for the level of injury (ie, tetraplegia vs paraplegia) and onset time. However, for subjects with AIS grade D injuries, those 50 years and older at the time of injury walked significantly less often than younger subjects. Furthermore, these results may underestimate the true potential for the younger group, because the younger subjects in this study had a relatively high incidence of secondary injuries (eg, limb fractures) and medical precautions (ie, non–weight-bearing limbs) that limited the ability to walk during their inpatient stays. The oldest subject in the study to walk with an AIS grade D injury was 84 years old, and the oldest to walk with an AIS grade C injury was 81 years old. The findings related to age differ from previous work reported by Burns15 and Scivoletto14 and colleagues. Both studies report that patients under 50 years of age with an AIS grade C injury walked significantly more often than older subjects with an AIS grade C injury, and age did not affect walking after an AIS grade D injury. The differences between those studies and the current study may be explained by 3 factors. First, admission data were collected within 72 hours15 and 56.9±43.9 days14 postinjury rather the average of 24.0±16.4 days in this study, and rehabilitation LOSs were longer in the other studies. Burns15 did not report LOS (from admission to acute until discharge from rehabilitation) but those data came from 1984 to 1993, a time when hospital stays tended to be longer. Scivoletto14 reported a mean LOS of 98.7±68.13 days; considerably longer than the 60.4±32.5–day LOS found here. Second, the populations may have differed. Although Scivoletto had more subjects with nontraumatic than traumatic SCI in the older group and the reverse in the younger group, age data were not reported in the Burns study. Finally, the differences may be explained by the small number of subjects used in each study. None gives conclusive evidence that age reduces or has no affect on walking after an incomplete SCI. Clinical Significance of Findings These results may help clinicians make better predictions about walking by discharge from inpatient rehabilitation and should encourage the inclusion of activities to facilitate walking in adults with AIS grade C injuries. Because there was a significant difference in the percentage of subjects who walked at discharge from inpatient rehabilitation, patients with AIS grade C injuries should not be grouped with those with AIS grade A or B injuries with regard to predicting walking. Given that our study findings differ from previously published work related to age and walking, additional research is warranted. Furthermore, because most subjects were discharged before recovery is complete,5, 6, 11 additional research is needed to investigate if it is more cost-effective to rent rather than purchase equipment until long-term mobility outcomes are determined. Study Limitations Several limitations should be considered when interpreting study results. First, this was a retrospective study limited to data documented in charts. Second, walking status was based on a single FIM item score, although physical therapy notes were reviewed for verification and details about assistive devices and the FIM instrument is a valid25 and reliable25, 26, 27 measure for rehabilitation patients that is widely used for measuring functional status. A third limitation is the absence of discharge AIS grades, which makes the explanation of recovery less certain, because AIS levels may have changed during the rehabilitation stay. Fourth, we had access only to inpatient rehabilitation data, so the number of subjects who eventually walked and their long-term abilities are not known. Although functional gains have been found to be greatest between inpatient rehabilitation admission and discharge, gains can continue, albeit at a slower rate, for the first year after discharge.5, 6, 11 Therefore, prognoses developed from these findings must rely on the AIS level28 at the time of admission, and these outcomes are comparable only with walking ability at discharge from inpatient rehabilitations of comparable times after injury. A fifth limitation is the small sample size from 1 facility, so findings need to be verified with a larger number of subjects. Finally, data were limited to adults with traumatic SCI, so the results may not apply to adults with nontraumatic SCI or to children. Despite the limitations, these findings provide valuable information about mobility that is important for helping rehabilitation team members with referrals, recommendations for appropriate equipment, and patient and family education in preparation for discharge from acute inpatient rehabilitation. Furthermore, knowledge of the walking status at discharge should be helpful for guiding policy decisions regarding the realistic burden of care and equipment needs faced by families with regard to locomotion at discharge. Conclusions This is the first longitudinal study to investigate walking (FIM score ≥3) at discharge from acute inpatient rehabilitation based on subjects’ AIS grades at admission. The study found that (1) patients admitted with AIS grade C injuries should not be considered functionally complete with regard to walking at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. Supplier References 1. 1Ditunno JF, Ditunno PL, Graziani V, et al. Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal Cord. 2000;38:234–243. MEDLINE 2. 2Davies H. Hope as a coping strategy for the spinal cord injured individual. Axone. 1993;15(2):40–46. MEDLINE 3. 3Hussey RW, Stauffer ES. Spinal cord injury: requirements for ambulation. Arch Phys Med Rehabil. 1973;54:544–547. MEDLINE 4. 4Waters RL, Adkins RH, Yakura JS, Sie I. Motor and sensory recovery following complete tetraplegia. Arch Phys Med Rehabil. 1993;74:242–247. 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28. 28Jonsson M, Tollback A, Gonzales H, Borg J. Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury. Spinal Cord. 2000;38:675–679. MEDLINE a Spinal Cord Injury Program, Rehabilitation Institute of Chicago, Chicago, IL b Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL c Department of Physical Medicine and Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago, IL d Acute Spinal Cord Injury Program, Northwestern Memorial Hospital, Chicago, IL.  Correspondence to Anne Deutsch, RN, PhD, CRRN, Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, 345 E Superior St, Onterie Center, Chicago, IL 60611-4496
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprints are not available from the author. PII: S0003-9993(07)00222-5 doi:10.1016/j.apmr.2007.03.013 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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