Association Between Time to Rehabilitation and Outcomes After Traumatic Spinal Cord Injury



      To examine the relations between time to rehabilitation after spinal cord injury (SCI) and rehabilitation outcomes at discharge and 1-year postinjury.


      Retrospective cohort study.


      Facilities designated as Spinal Cord Injury Model Systems.


      Patients (N=3937) experiencing traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a model system within 24 hours of injury.


      Not applicable.

      Main Outcome Measures

      Rasch-transformed FIM motor score at discharge and 1-year postinjury, discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores at 1-year postinjury.


      After accounting for health status, a 10% increase in time to rehabilitation was associated with a 1.50 lower FIM motor score at discharge (95% confidence interval [CI], −2.43 to −0.58; P=.001) and a 3.92 lower CHART Physical Independence score at 1-year postinjury (95% CI, −7.66 to −0.19; P=.04). Compared to the mean FIM motor score (37.5) and mean CHART Physical Independence score (74.7), the above-mentioned values represent relative declines of 4.0% and 5.3%, respectively. There was no association between time to rehabilitation and discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.


      Earlier rehabilitation after traumatic SCI may improve patients' functional status at discharge.


      List of abbreviations:

      AIS (ASIA Impairment Scale), CHART (Craig Handicap Assessment and Reporting Technique), CI (confidence interval), LOS (length of stay), OLS (ordinary least squares), SCI (spinal cord injury), SCIMS (Spinal Cord Injury Model Systems)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • National Spinal Cord Injury Statistical Center
        Spinal cord injury facts and figures at a glance.
        Univ of Alabama at Birmingham, Birmingham2013
        • Jain N.B.
        • Ayers G.D.
        • Peterson E.N.
        • et al.
        Traumatic spinal cord injury in the United States, 1993-2012.
        JAMA. 2015; 313: 2236-2243
        • Eastwood E.A.
        • Hagglund K.J.
        • Ragnarsson K.T.
        • Gordon W.A.
        • Marino R.J.
        Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990-1997.
        Arch Phys Med Rehabil. 1999; 80: 1457-1463
        • Whiteneck G.
        • Gassaway J.
        • Dijkers M.
        • et al.
        The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation.
        J Spinal Cord Med. 2011; 34: 133-148
        • Emerich L.
        • Parsons K.C.
        • Stein A.
        Competent care for persons with spinal cord injury and dysfunction in acute inpatient rehabilitation.
        Top Spinal Cord Inj Rehabil. 2012; 18: 149-166
        • DeVivo M.J.
        • Kartus P.L.
        • Stover S.L.
        • Fine P.R.
        Benefits of early admission to an organised spinal cord injury care system.
        Paraplegia. 1990; 28: 545-555
        • Behrman A.L.
        • Bowden M.G.
        • Nair P.M.
        Neuroplasticity after spinal cord injury and training: an emerging paradigm shift in rehabilitation and walking recovery.
        Phys Ther. 2006; 86: 1406-1425
        • Consortium for Spinal Cord Medicine
        Outcomes following traumatic spinal cord injury: clinical practice guidelines for health-care professionals.
        J Spinal Cord Med. 2000; 23: 289-316
        • O'Brien S.R.
        • Xue Y.
        • Ingersoll G.
        • Kelly A.
        Shorter length of stay is associated with worse functional outcomes for Medicare beneficiaries with stroke.
        Phys Ther. 2013; 93: 1592-1602
        • Salter K.
        • Jutai J.
        • Hartley M.
        • et al.
        Impact of early vs delayed admission to rehabilitation on functional outcomes in persons with stroke.
        J Rehabil Med. 2006; 38: 113-117
        • Needham D.M.
        Mobilizing patients in the intensive care unit: improving neuromuscular weakness and physical function.
        JAMA. 2008; 300: 1685-1690
        • Needham D.M.
        • Korupolu R.
        • Zanni J.M.
        • et al.
        Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project.
        Arch Phys Med Rehabil. 2010; 91: 536-542
        • Lippert-Gruner M.
        • Maegele M.
        • Pokorny J.
        • et al.
        Early rehabilitation model shows positive effects on neural degeneration and recovery from neuromotor deficits following traumatic brain injury.
        Physiol Res. 2007; 56: 359-368
        • Krakauer J.W.
        • Carmichael S.T.
        • Corbett D.
        • Wittenberg G.F.
        Getting neurorehabilitation right: what can be learned from animal models?.
        Neurorehabil Neural Repair. 2012; 26: 923-931
        • Sumida M.
        • Fujimoto M.
        • Tokuhiro A.
        • Tominaga T.
        • Magara A.
        • Uchida R.
        Early rehabilitation effect for traumatic spinal cord injury.
        Arch Phys Med Rehabil. 2001; 82: 391-395
        • Scivoletto G.
        • Morganti B.
        • Molinari M.
        Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study.
        Arch Phys Med Rehabil. 2005; 86: 512-516
        • New P.W.
        • Townson A.
        • Scivoletto G.
        • et al.
        International comparison of the organisation of rehabilitation services and systems of care for patients with spinal cord injury.
        Spinal Cord. 2013; 51: 33-39
        • DeVivo M.J.
        • Go B.K.
        • Jackson A.B.
        Overview of the National Spinal Cord Injury Statistical Center database.
        J Spinal Cord Med. 2002; 25: 335-338
        • Cao Y.
        • Massaro J.F.
        • Krause J.S.
        • Chen Y.
        • Devivo M.J.
        Suicide mortality after spinal cord injury in the United States: injury cohorts analysis.
        Arch Phys Med Rehabil. 2014; 95: 230-235
        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The Functional Independence Measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Bode R.K.
        • Heinemann A.W.
        • Kozlowski A.J.
        • Pretz C.R.
        Self-scoring templates for motor and cognitive subscales of the FIM instrument for persons with spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 676-679.e5
        • Walker N.
        • Mellick D.
        • Brooks C.A.
        • Whiteneck G.G.
        Measuring participation across impairment groups using the Craig Handicap Assessment Reporting Technique.
        Am J Phys Med Rehabil. 2003; 82: 936-941
        • Newhouse J.P.
        • McClellan M.
        Econometrics in outcomes research: the use of instrumental variables.
        Annu Rev Public Health. 1998; 19: 17-34
        • The Center for the Evaluative Clinical Sciences at Dartmouth Medical School
        The Dartmouth atlas of health care.
        American Hospital Publishing, Inc., Chicago1998
        • McWilliams J.M.
        • Landon B.E.
        • Chernew M.E.
        • Zaslavsky A.M.
        Changes in patients' experiences in Medicare Accountable Care Organizations.
        N Engl J Med. 2014; 371: 1715-1724
        • Skinner J.
        • Staiger D.
        • Fisher E.S.
        Looking back, moving forward.
        N Engl J Med. 2010; 362: 569-574
        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • Gottlieb D.J.
        • Lucas F.L.
        • Pinder E.L.
        The implications of regional variations in Medicare spending, Part 1: the content, quality, and accessibility of care.
        Ann Intern Med. 2003; 138: 273-287
        • Skinner J.
        Causes and consequences of regional variations in health care.
        in: Pauly M.V. McGuire T.G. Barros P.P. Handbook of health economics. North Holland, Amsterdam2012: 45-93
        • Teno J.M.
        • Gozalo P.L.
        • Bynum J.P.
        • et al.
        Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009.
        JAMA. 2013; 309: 470-477
        • Nicholas L.H.
        • Langa K.M.
        • Iwashyna T.J.
        • Weir D.R.
        Regional variation in the association between advance directives and end-of-life Medicare expenditures.
        JAMA. 2011; 306: 1447-1453
        • Periyakoil V.S.
        • Neri E.
        • Fong A.
        • Kraemer H.
        Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives.
        PLoS One. 2014; 9: e98246
        • Hadley J.
        • Waidmann T.
        • Zuckerman S.
        • Berenson R.A.
        Medical spending and the health of the elderly.
        Health Serv Res. 2011; 46: 1333-1361
        • Kaestner R.
        • Silber J.H.
        Evidence on the efficacy of inpatient spending on Medicare patients.
        Milbank Q. 2010; 88: 560-594
        • Skinner J.
        • Fisher E.S.
        • Wennberg J.
        The efficiency of Medicare.
        in: Wise D.A. Analyses in the economics of aging. Univ of Chicago Pr, Chicago2005
        • Whiteneck G.
        • Gassaway J.
        • Dijkers M.P.
        • Heinemann A.W.
        • Kreider S.E.
        Relationship of patient characteristics and rehabilitation services to outcomes following spinal cord injury: the SCIRehab project.
        J Spinal Cord Med. 2012; 35: 484-502
        • Colin Cameron A.
        • Miller D.L.
        A practitioner's guide to cluster-robust inference.
        J Hum Resour. 2015; 50: 317-372
        • Wong H.
        • Wu R.C.
        • Tomlinson G.
        • et al.
        How much do operational processes affect hospital inpatient discharge rates?.
        J Public Health (Oxf). 2009; 31: 546-553
        • Varnava A.M.
        • Sedgwick J.E.
        • Deaner A.
        • Ranjadayalan K.
        • Timmis A.D.
        Restricted weekend service inappropriately delays discharge after acute myocardial infarction.
        Heart. 2002; 87: 216-219
        • Bartel A.P.
        • Chan C.W.
        • Kim S.-H.
        Should hospitals keep their patients longer? The role of inpatient and outpatient care in reducing readmissions.
        National Bureau of Economic Research, Cambridge2014 (NBER Working Paper Series No. 20499)
        • Wooldridge J.M.
        Econometric analysis of cross section and panel data.
        2nd ed. MIT Pr, Cambridge2010
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale1988
        • Staiger D.
        • Stock J.H.
        Instrumental variables regression with weak instruments.
        Econometrica. 1997; 65: 557-586
        • Horn S.D.
        • Smout R.J.
        • DeJong G.
        • et al.
        Association of various comorbidity measures with spinal cord injury rehabilitation outcomes.
        Arch Phys Med Rehabil. 2013; 94: S75-S86
        • Heinemann A.W.
        State-of-the-science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. an introduction.
        Arch Phys Med Rehabil. 2007; 88: 1478-1481
        • Kane R.L.
        Assessing the effectiveness of postacute care rehabilitation.
        Arch Phys Med Rehabil. 2007; 88: 1500-1504
        • Whiteneck G.
        • Gassaway J.
        • Dijkers M.
        • Jha A.
        New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab project.
        J Spinal Cord Med. 2009; 32: 251-259
        • Herzer K.R.
        • Gonzalez-Fernandez M.
        Impact of earlier rehabilitation on outcomes following spinal cord injury.
        PM R. 2015; 7: S106-S107
        • Hoyer E.H.
        • Brotman D.J.
        • Chan K.S.
        • Needham D.M.
        Barriers to early mobility of hospitalized general medicine patients: survey development and results.
        Am J Phys Med Rehabil. 2015; 94: 304-312
        • Kane R.L.
        Finding the right level of posthospital care: “we didn't realize there was any other option for him”.
        JAMA. 2011; 305: 284-293
        • Covinsky K.E.
        • Pierluissi E.
        • Johnston C.B.
        Hospitalization-associated disability: “she was probably able to ambulate, but I'm not sure”.
        JAMA. 2011; 306: 1782-1793
        • Mechanic R.
        • Tompkins C.
        Lessons learned preparing for Medicare bundled payments.
        N Engl J Med. 2012; 367: 1873-1875
        • Pronovost P.J.
        • Berenholtz S.M.
        • Needham D.M.
        Translating evidence into practice: a model for large scale knowledge translation.
        BMJ. 2008; 337: a1714
        • Klein K.
        • Mulkey M.
        • Bena J.F.
        • Albert N.M.
        Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study.
        Crit Care Med. 2015; 43: 865-873
        • Herzer K.R.
        • Niessen L.
        • Constenla D.O.
        • Ward Jr., W.J.
        • Pronovost P.J.
        Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA.
        BMJ Open. 2014; 4: e006065
        • Herzer K.R.
        • Gonzalez-Fernandez M.
        Presentation abstracts.
        J Spinal Cord Med. 2014; 37: 432-447
        • Fisher E.S.
        • Wennberg J.E.
        Health care quality, geographic variations, and the challenge of supply-sensitive care.
        Perspect Biol Med. 2003; 46: 69-79