Advertisement

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy

Published:October 11, 2021DOI:https://doi.org/10.1016/j.apmr.2021.07.815

      Abstract

      Objective

      To characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy.

      Design

      Observational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services.

      Setting

      Rehabilitation and community wellness facilities at 4 SCI Model Systems centers.

      Participants

      Eligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training.

      Interventions

      Outpatient physical therapy or community wellness services for locomotor/gait training.

      Main Outcome Measures

      SCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference.

      Results

      After controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group.

      Conclusions

      Locomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants’ preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.

      Keywords

      List of abbreviations:

      AIS (American Spinal Injury Association Impairment Scale), CI (credible interval), OR (odds ratio), PT (physical therapy), SCI (spinal cord injury), SCI-FI (Spinal Cord Injury-Functional Index), SCI-QOL (Spinal Cord Injury-Quality of Life)
      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:

      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

      References

        • Emerich L
        • Parsons KC
        • 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
        • Boninger ML
        • Field-Fote EC
        • Kirshblum SC
        • et al.
        Research progress from the SCI Model Systems (SCIMS): an interactive discussion on future directions.
        J Spinal Cord Med. 2018; 41: 216-222
        • Backus D
        • Gassaway J
        • Smout RJ
        • et al.
        Relation between inpatient and postdischarge services and outcomes 1 year postinjury in people with traumatic spinal cord injury.
        Arch Phys Med Rehabil. 2013; 94: S165-S174
        • Kogos S
        • DeVivo M
        • Richards S.
        Recent trends in spinal cord injury rehabilitation practices and outcomes.
        Top Spinal Cord Inj Rehabil. 2004; 10: 49-57
        • Whiteneck G
        • Gassaway J.
        The SCIRehab project: what rehabilitation interventions are most strongly associated with positive outcomes after spinal cord injury?.
        J Spinal Cord Med. 2012; 35: 482-483
        • Whiteneck GG
        • Gassaway J
        • Dijkers MP
        • et al.
        Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study.
        Arch Phys Med Rehabil. 2011; 92: 361-368
        • Martini L
        • Maus U
        • Bokel A
        • et al.
        Utilization of outpatient physical and occupational therapy in people with spinal cord injury in Germany: results of the German Spinal Cord Injury Survey.
        Am J Phys Med Rehabil. 2020; 99: 532-539
        • National Spinal Cord Injury Statistical Center
        Spinal Cord Injury Facts and Figures at a Glance.
        University of Alabama at Birmingham, 2020 (Available at) (Accessed August 20)
        • Field-Fote EC.
        Spinal cord control of movement: implications for locomotor rehabilitation following spinal cord injury.
        Phys Ther. 2000; 80: 477-484
        • Simmons OL
        • Kressler J
        • Nash MS.
        Reference fitness values in the untrained spinal cord injury population.
        Arch Phys Med Rehabil. 2014; 95: 2272-2278
        • Berlowitz DJ
        • Wadsworth B
        • Ross J.
        Respiratory problems and management in people with spinal cord injury.
        Breathe (Sheff). 2016; 12: 328-340
        • Clark JM
        • Findlay DM.
        Musculoskeletal health in the context of spinal cord injury.
        Curr Osteoporos Rep. 2017; 15: 433-442
        • Haider IT
        • Lobos SM
        • Simonian N
        • Schnitzer TJ
        • Edwards WB.
        Bone fragility after spinal cord injury: reductions in stiffness and bone mineral at the distal femur and proximal tibia as a function of time.
        Osteoporos Int. 2018; 29: 2703-2715
        • Gibbs JC
        • Gagnon DH
        • Bergquist AJ
        • et al.
        Rehabilitation Interventions to modify endocrine-metabolic disease risk in Individuals with chronic spinal cord injury living in the Community (RIISC): a systematic review and scoping perspective.
        J Spinal Cord Med. 2017; 40: 733-747
        • Ginis KA
        • Arbour-Nicitopoulos KP
        • Latimer AE
        • et al.
        Leisure time physical activity in a population-based sample of people with spinal cord injury part II: activity types, intensities, and durations.
        Arch Phys Med Rehabil. 2010; 91: 729-733
        • Ginis KA
        • Latimer AE
        • Arbour-Nicitopoulos KP
        • et al.
        Leisure time physical activity in a population-based sample of people with spinal cord injury part I: demographic and injury-related correlates.
        Arch Phys Med Rehabil. 2010; 91: 722-728
        • Jensen MP
        • Hoffman AJ
        • Cardenas DD.
        Chronic pain in individuals with spinal cord injury: a survey and longitudinal study.
        Spinal Cord. 2005; 43: 704-712
        • Dorsett P
        • Geraghty T
        • Sinnott A
        • Hope Acland R.
        coping and psychosocial adjustment after spinal cord injury.
        Spinal Cord Ser Cases. 2017; 3: 17046
        • Dittuno PL
        • Ditunno Jr., JF
        Walking index for spinal cord injury (WISCI II): scale revision.
        Spinal Cord. 2001; 39: 654-656
        • Calhoun CL
        • Schottler J
        • Vogel LC.
        Recommendations for mobility in children with spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2013; 19: 142-151
        • Alamro RA
        • Chisholm AE
        • Williams AMM
        • Carpenter MG
        • Lam T.
        Overground walking with a robotic exoskeleton elicits trunk muscle activity in people with high-thoracic motor-complete spinal cord injury.
        J Neuroeng Rehabil. 2018; 15: 109
        • Baron R
        • Kneissel M.
        WNT signaling in bone homeostasis and disease: from human mutations to treatments.
        Nat Med. 2013; 19: 179-192
        • Hicks AL.
        Locomotor training in people with spinal cord injury: is this exercise?.
        Spinal Cord. 2021; 59: 9-16
        • Harkema SJ
        • Hillyer J
        • Schmidt-Read M
        • Ardolino E
        • Sisto SA
        • Behrman AL.
        Locomotor training: as a treatment of spinal cord injury and in the progression of neurologic rehabilitation.
        Arch Phys Med Rehabil. 2012; 93: 1588-1597
        • Fleerkotte BM
        • Koopman B
        • Buurke JH
        • van Asseldonk EH
        • van der Kooij H
        • Rietman JS.
        The effect of impedance-controlled robotic gait training on walking ability and quality in individuals with chronic incomplete spinal cord injury: an explorative study.
        J Neuroeng Rehabil. 2014; 11: 26
        • Schrade SO
        • Datwyler K
        • Stucheli M
        • et al.
        Development of VariLeg, an exoskeleton with variable stiffness actuation: first results and user evaluation from the CYBATHLON 2016.
        J Neuroeng Rehabil. 2018; 15: 18
        • Molteni F
        • Gasperini G
        • Cannaviello G
        • Guanziroli E.
        Exoskeleton and end-effector robots for upper and lower limbs rehabilitation: narrative review.
        PM R. 2018; 10: S174-S188
        • Aguirre-Guemez AV
        • Perez-Sanpablo AI
        • Quinzanos-Fresnedo J
        • Perez-Zavala R
        • Barrera-Ortiz A.
        Walking speed is not the best outcome to evaluate the effect of robotic assisted gait training in people with motor incomplete Spinal Cord Injury: a systematic review with meta-analysis.
        J Spinal Cord Med. 2019; 42: 142-154
        • Fang CY
        • Tsai JL
        • Li GS
        • Lien AS
        • Chang YJ.
        Effects of robot-assisted gait training in individuals with spinal cord injury: a meta-analysis.
        Biomed Res Int. 2020; 20202102785
        • Miller LE
        • Zimmermann AK
        • Herbert WG.
        Clinical effectiveness and safety of powered exoskeleton-assisted walking in patients with spinal cord injury: systematic review with meta-analysis.
        Med Devices (Auckl). 2016; 9: 455-466
        • Heinemann AW
        • Jayaraman A
        • Mummidisetty CK
        • et al.
        Experience of robotic exoskeleton use at four spinal cord injury model systems centers.
        J Neurol Phys Ther. 2018; 42: 256-267
        • Sale P
        • Russo EF
        • Scarton A
        • Calabro RS
        • Masiero S
        • Filoni S.
        Training for mobility with exoskeleton robot in spinal cord injury patients: a pilot study.
        Eur J Phys Rehabil Med. 2018; 54: 745-751
        • Chang SH
        • Afzal T
        • Group TSCE
        • Berliner J
        • Francisco GE.
        Exoskeleton-assisted gait training to improve gait in individuals with spinal cord injury: a pilot randomized study.
        Pilot Feasibility Stud. 2018; 4: 62
        • Cahill A
        • Ginley OM
        • Bertrand C
        • Lennon O.
        Gym-based exoskeleton walking: a preliminary exploration of non-ambulatory end-user perspectives.
        Disabil Health J. 2018; 11: 478-485
        • Arbour-Nicitopoulos KP
        • Martin Ginis KA
        • Latimer-Cheung AE
        • et al.
        Development of an evidence-informed leisure time physical activity resource for adults with spinal cord injury: the SCI Get Fit Toolkit.
        Spinal Cord. 2013; 51: 491-500
        • Hicks AL
        • Martin Ginis KA
        • Pelletier CA
        • Ditor DS
        • Foulon B
        • Wolfe DL
        The effects of exercise training on physical capacity, strength, body composition and functional performance among adults with spinal cord injury: a systematic review.
        Spinal Cord. 2011; 49: 1103-1127
        • Hicks AL
        • Martin KA
        • Ditor DS
        • et al.
        Long-term exercise training in persons with spinal cord injury: effects on strength, arm ergometry performance and psychological well-being.
        Spinal Cord. 2003; 41: 34-43
        • Gagnon DH
        • Vermette M
        • Duclos C
        • Aubertin-Leheudre M
        • Ahmed S
        • Kairy D.
        Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton.
        Disabil Rehabil Assist Technol. 2019; 14: 138-145
        • Mehta S
        • Janzen S
        • McIntyre A
        • Iruthayarajah J
        • Loh E
        • Teasell R.
        Are comorbid pain and depressive symptoms associated with rehabilitation of individuals with spinal cord injury?.
        Top Spinal Cord Inj Rehabil. 2018; 24: 37-43
        • Pinto D
        • Garnier M
        • Barbas J
        • et al.
        Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems.
        J Neuroeng Rehabil. 2020; 17: 4
        • Shirota C
        • Balasubramanian S
        • Melendez-Calderon A.
        Technology-aided assessments of sensorimotor function: current use, barriers and future directions in the view of different stakeholders.
        J Neuroeng Rehabil. 2019; 16: 53
        • Mathews KJ.
        Patient self-rationing, a health system problem.
        Virtual Mentor. 2012; 14: 835-838
        • Horn SD
        • Gassaway J.
        Practice-based evidence study design for comparative effectiveness research.
        Med Care. 2007; 45: S50-S57
        • Roberts TT
        • Leonard GR
        • Cepela DJ.
        Classifications In brief: American Spinal Injury Association (ASIA) impairment scale.
        Clin Orthop Relat Res. 2017; 475: 1499-1504
        • Sinha R
        • Slavin MD
        • Kisala PA
        • Ni P
        • Tulsky DS
        • Jette AM.
        Functional ability level development and validation: providing clinical meaning for Spinal Cord Injury Functional Index scores.
        Arch Phys Med Rehabil. 2015; 96: 1448-1457
        • Tulsky DS
        • Kisala PA
        • Tate DG
        • Spungen AM
        • Kirshblum SC.
        Development and psychometric characteristics of the SCI-QOL Bladder Management Difficulties and Bowel Management Difficulties item banks and short forms and the SCI-QOL Bladder Complications scale.
        J Spinal Cord Med. 2015; 38: 288-302
        • Cohen ML
        • Kisala PA
        • Dyson-Hudson TA
        • Tulsky DS.
        Measuring pain phenomena after spinal cord injury: development and psychometric properties of the SCI-QOL Pain Interference and Pain Behavior assessment tools.
        J Spinal Cord Med. 2018; 41: 267-280
        • Bürkner P-C.
        brms: An R package for Bayesian multilevel models using Stan.
        J. Stat. Softw. 2017; 80
      1. R Foundation for Statistical Computing. R Core Team. R: A language and environment for statistical computing. Available at: https://www.R-project.org. Accessed December 1, 2020.

        • Carpenter B
        • Gelman A
        • Hoffman MD
        • et al.
        Stan: A probabilistic programming language.
        J Stat Softw. 2017; 76
        • Baig SA.
        Bayesian inference: an introduction to hypothesis testing using Bayes factors.
        Nicotine Tob Res. 2020; 22: 1244-1246
        • Adamina M
        • Tomlinson G
        • Guller U.
        Bayesian statistics in oncology: a guide for the clinical investigator.
        Cancer. 2009; 115: 5371-5381
        • Hespanhol L
        • Vallio CS
        • Costa LM
        • Saragiotto BT.
        Understanding and interpreting confidence and credible intervals around effect estimates.
        Braz J Phys Ther. 2019; 23: 290-301
        • Efron B.
        Why isn't everyone a Bayesian?.
        Am Stat. 1986; 40
        • Matthews RAJ.
        Why should clinicians care about Bayesian methods?.
        J Stat Plan Inference. 2001; 94: 43-58
        • Wagenmakers E-J
        • Lee M
        • Lodewyckx T
        • Iverson GJ.
        Bayesian Versus Frequentist Inference.
        in: Hoijtink H Klugkist I Boelen PA Bayesian Evaluation of Informative Hypotheses. Springer, New York, New York2008: 181-207
        • Huo Y
        • de la Torre J
        • Mun EY
        • et al.
        A hierarchical multi-unidimensional IRT approach for analyzing sparse, multi-group data for integrative data analysis.
        Psychometrika. 2015; 80: 834-855
        • Kruschke JK.
        What to believe: Bayesian methods for data analysis.
        Trends Cogn Sci. 2010; 14: 293-300
        • Pires MC
        • Colosimo EA
        • Silva AA.
        Survival Weibull regression model for mismeasured outcomes.
        Commun Stat Theory Methods. 2017; 47: 601-614
        • Ying GS
        • Heitjan DF.
        Weibull prediction of event times in clinical trials.
        Pharm Stat. 2008; 7: 107-120
        • Zhang Z.
        Parametric regression model for survival data: Weibull regression model as an example.
        Ann Transl Med. 2016; 4: 484
        • Gelman A
        • Hill J.
        Data Analysis Using Regression and Multilevel/Hierarchical Models (Analytical Methods for Social Research).
        Cambridge University Press, Cambridge2006
        • Agresti A.
        An Introduction to Categorical Data Analysis.
        2nd ed. Wiley-Interscience, Hoboken2007
        • van Ravenzwaaij D
        • Cassey P
        • Brown SD
        A simple introduction to Markov Chain Monte-Carlo sampling.
        Psychon Bull Rev. 2018; 25: 143-154
        • Gelman A
        • Carlin J
        • Stern H
        • Dunson D
        • Vehtari A
        • Rubin D.
        Bayesian Data Analysis.
        Third Edition. Third ed:. Chapman & Hall/CRC Texts in Statistical Science, 2014
        • Gelman A
        • Goodrich B
        • Gabry J
        • Vehtari A.
        R-squared for Bayesian Regression Models.
        The American Statistician. 2019; 73: 307-309
        • Evans N
        • Hartigan C
        • Kandilakis C
        • Pharo E
        • Clesson I.
        Acute cardiorespiratory and metabolic responses during exoskeleton-assisted walking overground among persons with chronic spinal cord injury.
        Top Spinal Cord Inj Rehabil. 2015; 21: 122-132
        • Kressler J
        • Thomas CK
        • Field-Fote EC
        • et al.
        Understanding therapeutic benefits of overground bionic ambulation: exploratory case series in persons with chronic, complete spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 1878-1887
        • van der Meer P
        • Post MW
        • van Leeuwen CM
        • van Kuppevelt HJ
        • Smit CA
        • van Asbeck FW.
        Impact of health problems secondary to SCI one and five years after first inpatient rehabilitation.
        Spinal Cord. 2017; 55: 98-104
        • Green LW
        • Glasgow RE
        • Atkins D
        • Stange K.
        Making evidence from research more relevant, useful, and actionable in policy, program planning, and practice slips “twixt cup and lip.
        Am J Prev Med. 2009; 37: S187-S191
        • Castro FG
        • Barrera Jr, M
        • Martinez Jr., CR
        The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit.
        Prev Sci. 2004; 5: 41-45
        • Chay W
        • Kirshblum S.
        Predicting outcomes after spinal cord injury.
        Phys Med Rehabil Clin N Am. 2020; 31: 331-343
      2. Centers for Medicare and Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) Application Summaries and Coding Decisions: First Biannual, 2020 Coding Cycle for Durable Medical Equipment (DME) and Accessories; Orthotics, Prosthetics (O & P), and Supplies. Available at: https://www.cms.gov/files/document/2020-hcpcs-application-summary-bi-annual-1-2020-durable-medical-equipment-dme-and-accessories.pdf. Accessed January 10, 2021.

        • McColl MA
        • Charlifue S
        • Glass C
        • Lawson N
        • Savic G.
        Aging, gender, and spinal cord injury.
        Arch Phys Med Rehabil. 2004; 85: 363-367
        • Stapleton JN
        • Martin Ginis KA
        • Group S-SR
        Sex differences in theory-based predictors of leisure time physical activity in a population-based sample of adults with spinal cord injury.
        Arch Phys Med Rehabil. 2014; 95: 1787-1790
        • Hausmann LR
        • Myaskovsky L
        • Niyonkuru C
        • et al.
        Examining implicit bias of physicians who care for individuals with spinal cord injury: a pilot study and future directions.
        J Spinal Cord Med. 2015; 38: 102-110