Evidence-based practice in primary prevention of spinal cord injury.

A spinal cord injury (SCI) not only causes paralysis, but also has long-term impact on physical and mental health. There are between 236,000 to 327,000 individuals living with the consequences of SCI in the United States, and the economic burden on the individuals sustaining the injury, their support network, and society as a whole is significant. The consequences of SCI require that health care professionals begin thinking about primary prevention. Efforts are often focused on care and cure, but evidence-based prevention should have a greater role. Primary prevention efforts can offer significant cost benefits, and efforts to change behavior and improve safety can and should be emphasized. Primary prevention can be applied to various etiologies of injury, including motor vehicle crashes, sports injuries, and firearm misuse, with a clear goal of eliminating unnecessary injury and its life-changing impact.

Relationship of physical therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: the SCIRehab project.

BACKGROUND/OBJECTIVE: Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury. METHODS: Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia. RESULTS: PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries. CONCLUSION: Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

The SCIRehab project: treatment time spent in SCI rehabilitation. Physical therapy treatment time during inpatient spinal cord injury rehabilitation.

BACKGROUND/OBJECTIVE: To describe the nature and distribution of activities during physical therapy (PT) delivered in inpatient spinal cord injury (SCI) rehabilitation and discuss predictors (patient and injury characteristics) of the amount of time spent in PT for specific treatment activities. METHODS: Six hundred patients from six inpatient SCI centers were enrolled in the SCIRehab study. Physical therapists documented details, including time spent, of treatment provided during 37 306 PT sessions that occurred during inpatient SCI rehabilitation. Ordinary least squares regression models associated patient and injury characteristics with time spent in specific PT activities. RESULTS: SCIRehab patients received a mean total of 55.3 hours of PT over the course of their rehabilitation stay. Significant differences among four neurologic groups were seen in the amount of time spent on most activities, including the most common PT activities of strengthening exercises, stretching, transfer training, wheelchair mobility training, and gait training. Most PT work (77%) was provided in individual therapy sessions; the remaining 23% was done in group settings. Patient and injury characteristics explained only some of the variations seen in time spent on wheelchair mobility, transfer and bed mobility training, and range of motion/ stretching. CONCLUSION: Analysis yielded both expected and unexpected trends in SCI rehabilitation. Significant variation was seen in time spent on PT activities within and among injury groups. Providing therapeutic strengthening treatments consumed the greatest proportion of PT time. About one-quarter of all PT services were provided in group settings. Details about services provided, including time spent, will serve as a starting point in detailing the optimal treatment delivery for maximal outcomes.

SCIRehab Project series: the physical therapy taxonomy.

BACKGROUND/OBJECTIVE: Outcomes research is in need of a classification system of physical therapy (PT) interventions for acute traumatic spinal cord injury (SCI) rehabilitation in the United States. The objective of this study was to describe a taxonomy (system to categorize and classify interventions) to examine the effects of PT interventions on rehabilitation outcomes. METHODS: The SCIRehab study uses the rigorous observational practice-based evidence methodology to examine current treatment processes without changing existing practice. PT clinicians and researchers from 6 centers developed a taxonomy to describe details of each PT session. RESULTS: The PT taxonomy consists of 19 treatment activities (eg, bed mobility, transfers, wheelchair mobility, strengthening and stretching exercises) and supplementary information to describe the associated therapeutic interventions. Details that focus on patient assistance needs and family involvement are included as additional descriptors to help to describe and justify PT activity selection. Time spent on each activity is used as the measure of intensity. CONCLUSION: The detailed PT taxonomy documentation process, which offers efficiency in data collection, is being used for all PT sessions with 1,500 patients with acute traumatic SCI at the 6 participating centers. It might be the first attempt to document the many details of the PT rehabilitation process for patients with SCI in the United States.