SCIM III (Spinal Cord Independence Measure version III): reliability of assessment by interview and comparison with assessment by observation.

STUDY DESIGN: Psychometric study. OBJECTIVES: The objective of this study was to examine the reliability of the Spinal Cord Independence Measure III (SCIM III) by interview and compare the findings with those of assessment by observation. SETTING: This study was conducted at Loewenstein Rehabilitation Hospital, Israel. METHODS: Thirty-five spinal cord lesion (SCL) patients who underwent rehabilitation at Loewenstein Rehabilitation Hospital in Israel were assessed during the last week before discharge with SCIM III by observation and by interview. Nineteen of the patients were also assessed by interview by a third rater to examine inter-rater reliability. Total agreement, kappa, Bland-Altman plots and intraclass correlation (ICC) were used for comparison between interviewers and between interviews and observations. RESULTS: Total agreement between the interviewers' scores and between interviews and observations was low to moderate (kappa coefficient 0.11-0.80). Bland-Altman analysis revealed good agreement, with low mean difference for almost all SCIM III subscales and total scores, between pairs of interviewers (bias -4.15, limits of agreement -22.51 to 14.19, for total score) and between interviews and observations (bias 1.62, limits of agreement -20.55 to 23.81, for total score). ICC coefficients for the SCIM III subscales and total scores were high (0.637-0.916). CONCLUSION: The findings of this study support the reliability and validity of SCIM III by interview, which appears to be useful for research of SCL patient groups. Individual scoring of SCIM III by interview, however, varied prominently between raters. Therefore, SCIM III by interview should be used with caution for clinical purposes, probably by raters whose scoring deviation, in relation to observation scores, is known.

Coronary artery disease and hypertension in a non-selected spinal cord injury patient population.

STUDY DESIGN: Retrospective observational comparative study. OBJECTIVES: The objectives of this study were to assess the atherosclerosis diseases and risk factors prevalence after spinal cored injury (SCI). SETTING: Loewenstein Rehabilitation Hospital, Israel. METHODS: Data of 154 traumatic and non-traumatic SCI patients were retrospectively collected. Coronary artery disease (CAD), myocardial infarction (MI), hypertension (HT) and risk factors for atherosclerotic diseases were examined after SCI for prevalence and effects, and compared with published corresponding data of the general population. RESULTS: CAD, MI and HT were found in 11.7, 6.7 and 29.2% of 120 patients, aged 53.4±11.1 years, 83.3% males, who survived until the end of the follow-up. Corresponding values for the general population, adjusted for age, gender and years of education, are 8.5, 6.6 and 24.9% in Israel, and 10.2% for CAD and 40.3% for HT, in US. Body mass index>30 increased the odds of acquiring CAD (P=0.016). Hypercholesterolemia and older age at injury increased the hazard for HT (P=0.044; P=0.019, respectively). A steady partner decreased the risk of CAD (P=0.029). HT was more prevalent at T4-T6 than above T4 (52 vs 23.3%, P=0.02). Patients with SCI below T6 had a higher rate of diabetes mellitus, hypercholesterolemia, and past smoking, and fewer years of education than those with SCI above T7 (P=0.016; P=0.032; P=0.034; P=0.014, respectively). CONCLUSION: The prevalence of CAD, HT and some of their risk factors after SCI is generally, but not consistently and not statistically significant, slightly higher than in the corresponding general population. The challenge is to reduce the prevalence of atherosclerotic morbidity after SCI below that in the general population.

Non-linear formulas for the spinal cord injury ability realization measurement index.

STUDY DESIGN: The spinal cord injury ability realization measurement index (SCI-ARMI) assesses rehabilitation potential and efficacy based on the linear relationship between the Spinal Cord Independence Measure (SCIM) and the American Spinal Injury Association impairment scale (AIS) motor scores (AMS). OBJECTIVES: The objective of this study is to develop new SCI-ARMI formulas using a more flexible approach that is less sensitive to the distribution of the AMS score among spinal cord lesion (SCL) patients. SETTING: Loewenstein Rehabilitation Hospital, Raanana, and the Statistical Laboratory, School of Mathematics, Faculty of Exact Sciences, Tel-Aviv University, Israel. METHODS: SCIM III and AMS of 226 Israeli SCL patients were monitored. Linear formulas, quadratic formulas and non-parametric formulas were estimated to express the relationship between the 95th percentile of the SCIM III values for patients with given AMS at discharge from rehabilitation (SCIM95) and the corresponding AMS value. This relationship was used to calculate SCI-ARMI values, defined as the ratio of the observed SCIM score and the respective SCIM95 for a given patient's AMS score. RESULTS: The estimated quadratic formula for the relationship between the 95th percentile of the SCIM III and the AMS score was found to be most appropriate, and formulas are provided for SCIM95 calculation in the various areas of function. The use of these formulas to calculate SCI-ARMI values is presented. CONCLUSION: The new formulas improve the accuracy of calculated ability realization for any AMS. The new statistical procedure will be used for the upcoming data analysis of a larger-scale international SCI-ARMI study.

A new grading for easy and concise description of functional status after spinal cord lesions.

BACKGROUND: Disability scales do not enable the transmission of concise, meaningful and daily function description for clinical purposes. STUDY DESIGN: Cross-sectional statistical analysis of 328 patients' Spinal Cord Independence Measure (SCIM) III item scores (SIS). OBJECTIVE: To develop a concise and clinically interpretable data-based characterization of daily task accomplishment for patients with spinal cord lesions (SCLs). SETTING: Multi-center study at 13 spinal units in 6 countries. METHODS: Patients were grouped into clusters characterized by smaller differences between the patients' SIS within the clusters than between their centers, using the k-medoides algorithm. The number of clusters (k) was chosen according to the percent of SIS variation they explained and the clinical distinction between them. RESULTS: Analysis showed that k=8 SIS clusters offer a good description of the patient population. The eight functional clusters were designated as A-H, each cluster (grade) representing a combination of task accomplishments. Higher grades were usually (but not always) associated with patients implementing more difficult tasks. Throughout rehabilitation, the patients' functional grade improved and the distribution of patients with similar functional grades within the total SCIM III score deciles remained stable. CONCLUSIONS: A new classification based on SIS clusters enables a concise description of overall functioning and task accomplishment distribution in patients with SCL. A software tool is used to identify the patients' functional grade. Findings support the stability and utility of the grades for characterizing the patients' functional status.

Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions.

STUDY DESIGN: Multicenter international cohort study. OBJECTIVE: The objective of this study was to establish target values for Spinal Cord Independence Measure (SCIM) III scoring in rehabilitation for clinically complete spinal cord lesion (SCL) neurological levels. SETTING: In total, 13 spinal cord units in six countries from North America, Europe and the Middle East were taken. METHODS: Total SCIM III scores and gain at discharge from rehabilitation were calculated for SCL levels in 128 patients with American Spinal Injury Association Impairment Scale (AIS) grade A on admission to rehabilitation. RESULTS: Median, quartiles, mean and s.d., values of discharge SCIM III scores and SCIM III gain for the various SCL levels are presented. Total SCIM III scores and gain were significantly correlated with the SCL level (r=0.730, r=0.579, P<0.001). CONCLUSIONS: Calculated discharge SCIM III scores can be used as target values for functional achievements at various neurological levels in patients after AIS A SCL. They are generally, but not always, inversely correlated with SCL level.

SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions.

STUDY DESIGN: A multi-center international cohort study. OBJECTIVE: To evaluate the reliability and validity of the third version of the Spinal Cord Independence Measure (SCIM III), separately for patients with traumatic spinal cord lesions (SCLs). SETTING: A total of 13 spinal cord units in six countries from North America, Europe and the Middle-East. METHODS: SCIM III and Functional Independence Measure (FIM) were assessed for 261 patients with traumatic SCLs, on admission to rehabilitation and before discharge, by two raters. Conventional statistical measures were used to evaluate the SCIM III reliability and validity. RESULTS: In almost all SCIM III tasks, the total agreement between the paired raters was >80%. The κ coefficients were all >0.6 and statistically significant. Pearson's coefficients of the correlations between the paired raters were >0.9, the mean differences between raters were nonsignificant and the intraclass correlation coefficients (ICCs) were ≥ 0.95. Cronbach's α values for the entire SCIM III scale were 0.833-0.835. FIM and SCIM III total scores were correlated (r=0.84, P<0.001). SCIM III was more responsive to changes than FIM. In all subscales, SCIM III identified more changes in function than FIM, and in 3 of the 4 subscales, differences in responsiveness were statistically significant (P<0.02). CONCLUSION: The results confirm the reliability and validity of SCIM III for patients with traumatic SCLs in a number of countries.

Hemodynamic responses to head-up tilt after spinal cord injury support a role for the mid-thoracic spinal cord in cardiovascular regulation.

BACKGROUND: Data showing a role for the mid-thoracic spinal cord (SC) in the control of hemodynamic changes is scarce despite existing evidence for its involvement in autonomic regulation. STUDY DESIGN: On the basis of the open label prospective series comparing three groups. OBJECTIVE: To determine whether the mid-thoracic SC has a role in hemodynamic regulation during head-up tilt (HUT). SETTING: Spinal Research Laboratory, Loewenstein Rehabilitation Hospital. METHODS: A total of 13 healthy control subjects, 10 patients with T(4)-T(6) paraplegia and 11 with C(4)-C(7) tetraplegia were examined during supine rest and during HUT. Heart rate (HR), blood pressure (BP), HR spectral components (lower frequency fluctuation (LF), higher frequency fluctuations (HF) and LF/HF) and cerebral blood flow velocity (CBFV) were continuously measured or calculated. RESULTS: BP response to HUT differed among these groups (P<0.02). During HUT, BP decreased markedly in the tetraplegia group (from a mean value of 81.65 to 67.69 mm Hg), and increased in the control groups (from 92.89 to 95.44 mm Hg) and in the T(4)-T(6) paraplegia group (from 96.24 to 97.86 mm Hg). Significant correlation was found in the control and tetraplegia groups between increases in HR LF/HF and HR at HUT (r>0.7; P<0.01). No such correlation was found in the paraplegia group. HUT effect on HR and CBFV was significant in all groups (P<0.001), but group differences were statistically non-significant. CONCLUSION: Findings were generally compatible with those of comparable previously published studies, but they also support a role for the mid-thoracic SC in hemodynamic regulation, which should be considered in clinical setting and in research.

Insulin resistance in tetraplegia but not in mid-thoracic paraplegia: is the mid-thoracic spinal cord involved in glucose regulation?

STUDY DESIGN: Controlled experimental human study. OBJECTIVES: To assess insulin resistance (IR) in tetraplegia and paraplegia, and the role of the spinal cord (SC) in glucose regulation. SETTING: Laboratory of Spinal Research, Loewenstein Rehabilitation Hospital. METHODS: Glucose and insulin levels and the heart rate variation spectral components LF (low frequency), HF (high frequency) and LF/HF were studied at supine rest, head-up tilt and after a standard meal in three groups: 13 healthy subjects, 7 patients with T(4)-T(6) paraplegia and 11 patients with C(4)-C(7) tetraplegia. RESULTS: Glucose and insulin increased significantly after the meal in all groups (P<0.001). Glucose increased significantly more in the tetraplegia than in the other groups (P<0.01). Increases in insulin level tended to accompany increases in LF/HF after the meal in the tetraplegia and control groups but not in the paraplegia group. CONCLUSION: Post-prandial IR appears in C(4)-C(7) but not in T(4)-T(6) SC injury. The results of the study, combined with previously published findings, are consistent with the hypotheses that IR is related to activation of the sympathetic nervous system, and that below T(4) the mid-thoracic SC is involved in the regulation of glucose and insulin levels.

Survival, neurological recovery and morbidity after spinal cord injuries following road accidents in Israel.

DESIGN: A retrospective cohort study. OBJECTIVE: Assess outcomes in patients with spinal cord injuries (SCI) following road accidents, and factors that affect them. SETTING: Loewenstein Rehabilitation Hospital, Raanana, Israel. SUBJECTS: A total of 143 patients admitted for rehabilitation between 1962 and 2004. METHODS: Survival rates were estimated using the product limit (Kaplan-Meyer) method and their association with risk factors was analyzed with the Cox model. Neurological recovery was determined by comparing the Frankel grade at admission to rehabilitation and at discharge. The relation between recovery and various factors was tested with logistic regression. RESULTS: The risk of SCI in road accidents is higher among car drivers and motorcycle or bicycle riders. Median survival was 43 years. Survival was negatively associated with age at injury (P<0.0002) and with diagnosis of pressure sores (P=0.0065). Recovery of at least one Frankel grade occurred in 29.1% of patients. Useful recovery (upgrade to Frankel grade D or E) occurred in 23.1% of all patients. Neurological recovery was negatively associated with the severity of neurological deficit (P<0.001) and with thoracic injuries (P=0.046). The most common complications were pressure sores and those of the urinary and respiratory systems. CONCLUSIONS: In SCI following road accidents, survival rates were higher and recovery rates lower than in mixed types of trauma. This may be related to better compensation followed by better nursing for road accident victims in Israel, which may prevent life-shortening complications, and to more severe injuries caused by road accidents.

Cold pressor test in tetraplegia and paraplegia suggests an independent role of the thoracic spinal cord in the hemodynamic responses to cold.

BACKGROUND: Cold application to the hand (CAH) is associated in healthy people with increase in heart rate (HR) and blood pressure (BP). OBJECTIVE: To study hemodynamic responses to CAH in humans following spinal cord injuries of various levels, and examine the effect of spinal cord integrity on the cold pressor response. DESIGN: An experimental controlled study. SETTING: The spinal research laboratory, Loewenstein Hospital, Raanana, Israel. SUBJECTS: Thirteen healthy subjects, 10 patients with traumatic T(4-6) paraplegia and 11 patients with traumatic C(4-7) tetraplegia. MAIN OUTCOME MEASURES: HR, BP, HR and BP spectral components (low frequency, LF; high frequency, HF; LF/HF), cerebral blood flow velocity (CBFV) and cerebrovascular resistance index (CVRi). METHODS: The outcome measures of the three subject groups monitored for HR, BP and CBFV were compared from 5 min before to 5 min after 40-150 s of CAH. The recorded signals were digitized online and analyzed offline in both the time and frequency domains. RESULTS: During CAH, HR and CVRi increased significantly in all subject groups (P<0.001), and BP in control subjects and in the tetraplegia group (P<0.01). BP increase was not statistically significant in paraplegia, and CBFV, HR LF, HR HF and BP LF did not change significantly during CAH in any group. CONCLUSIONS: The CAH effect in tetraplegia and the suppressed BP increase in paraplegia, supported by the other findings, suggest a contribution of an independent thoracic spinal mechanism to the cold pressor response.

Modified cold pressor test by cold application to the foot after spinal cord injury: suggestion of hemodynamic control by the spinal cord.

OBJECTIVE: Study hemodynamic responses to cold application to the foot (CAF) to explore the autonomic cardiovascular control by the spinal cord. DESIGN: Controlled experimental study. Hemodynamic variables were measured or calculated for 13 healthy subjects, 10 patients with traumatic T4-T6 paraplegia, and 11 patients with traumatic C4-C7 tetraplegia. Subjects were continuously monitored for heart rate (HR), blood pressure (BP), and cerebral blood-flow velocity (CBFV) from 5 mins before to 5 mins after 40-120 secs of CAF by ice water foot immersion. The recorded signals were digitized online and analyzed offline in the time and frequency domains. RESULTS: During CAF, HR increased in the control group but decreased in patients (P < 0.001). BP increased significantly in the control and tetraplegia groups (P < 0.001) and nonsignificantly in the paraplegia group. HR and BP spectral components (LF, HF, LF/HF) did not change significantly. CBFV increased significantly in the patient groups (P < 0.05) but not in the control subjects. The cerebrovascular resistance increased significantly in the control and tetraplegia groups (P < 0.001), but not in the paraplegia group. CONCLUSIONS: The findings support the presence of hemodynamic autonomic control by the spinal cord and show that responses to CAF can be used to assess its integrity.

The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-center international study.

PURPOSE: To examine the third version of the Spinal Cord Independence Measure (SCIM III) for reliability and validity in a multi-center cohort study. METHOD: Four hundred and twenty-five patients with spinal cord lesions from 13 spinal cord units in six countries from three continents were assessed with SCIM III and the Functional Independence measure (FIM) on admission to rehabilitation and before discharge. RESULTS: Total agreement between raters was above 80% in most SCIM III tasks, and all kappa coefficients were statistically significant (P<0.001). The coefficients of Pearson correlation between the paired raters were above 0.9, and intraclass correlation coefficients were above 0.94. Cronbach's alpha was above 0.7. The coefficient of Pearson correlation between FIM and SCIM III was 0.790 (P<0.01). SCIM III was more responsive to changes than FIM in the subscales of Respiration and sphincter management and Mobility indoors and outdoors. CONCLUSIONS: The results support the reliability and validity of SCIM III in a multi-cultural setup. Despite several limitations of the study, the results indicate that SCIM III is an efficient measure for functional assessment of SCL patients and can be safely used for clinical and research trials, including international multi-center studies.

Repeated botulinum toxin injections can improve mobility in patients with spinal cord lesions.

AIM: The aim of this study was to increase the knowledge about the response to botulinum toxin (BTX) injections to spastic leg muscle motor points (MP) in spinal cord lesion (SCL) patients, and describe improvement of mobility with repeated BTX injections. METHODS: Six patients with ASIA grade C or D SCL were studied at the Loewenstein Rehabilitation Center, Israel. The main outcome measures were: modified Ashworth scale scores, range of motion (ROM), and mobility spinal cord independence measure (SCIM) scores. BTX was injected twice within a few weeks' interval to the MP of spastic leg muscles. The outcome measures were monitored before each injection and 2 weeks or more after the second injection. RESULTS: Following the first BTX injection the tonus decreased, ROM increased in all 6 patients, and mo- bility functioning improved in 4 of them. Following the repeated injection the tonus further decrea- sed, ROM further improved in 5 of 6 patients, and mobility functions further improved in 4 of 6 patients. CONCLUSION: BTX can improve mobility in patients with SCL. Repeated injections may enhance the effect despite the concern for resistance formation. Further research is needed to support the findings and determine the optimal BTX doses and intervals between injections.

Hemodynamic effects of liquid food ingestion in mid-thoracic paraplegia: is supine postprandial hypotension related to thoracic spinal cord damage?

BACKGROUND: Postprandial hypotension (PPH) appears in various conditions with autonomic failure and was symptomatic in a patient with thoracic paraplegia, but was not remarkable in patients with tetraplegia. OBJECTIVE: To determine whether the pathology causing PPH may include a thoracic but not a cervical spinal cord lesion (SCL). DESIGN: An experimental controlled study. SETTING: The spinal research laboratory, Loewenstein Hospital, Raanana, Israel. SUBJECTS: Thirteen healthy subjects, 10 patients with traumatic T(4)-T(6) paraplegia, and 11 patients with traumatic C(4)-C(7) tetraplegia. MAIN OUTCOME MEASURES: Heart rate (HR), blood pressure (BP), HR and BP spectral components (LF, HF, LF/HF), cerebral blood flow velocity (CBFV), and cerebrovascular resistance index (CVRi). METHODS: The effects of a standard liquid meal on the outcome measures were compared between the three subject groups monitored for HR, BP, and CBFV, from 55 min before to 45 min after the start of the meal. The recorded signals were digitized online and analyzed off-line in the time and frequency domains. RESULTS: After meal, BP decreased only in the paraplegia group (P<0.01), HR increased more prominently in this group (P<0.01), CVRi tended to decrease only in the paraplegia group, CBFV did not change significantly in any group, and HR LF/HF increased (P<0.001) in all groups but tended to increase more in paraplegia. CONCLUSIONS: Patients with mid-thoracic SCL may develop PPH. The pathology causing PPH can include a thoracic but not a cervical SCL. The normal hemodynamic reaction to liquid meal ingestion is mediated through the mid-thoracic spinal cord. The sympathovagal balance increases after food ingestion, more prominently in patients with PPH, and cerebrovascular resistance changes during PPH may help maintain the cerebral circulation.

A multicenter international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation.

BACKGROUND: A third version of the Spinal Cord Independence Measure (SCIM III), made up of three subscales, was formulated following comments by experts from several countries and Rasch analysis performed on the previous version. OBJECTIVE: To examine the validity, reliability, and usefulness of SCIM III using Rasch analysis. DESIGN: Multicenter cohort study. SETTING: Thirteen spinal cord units in six countries from North America, Europe, and the Middle-East. SUBJECTS: 425 patients with spinal cord lesions (SCL). INTERVENTIONS: SCIM III assessments by professional staff members. Rasch analysis of admission scores. MAIN OUTCOME MEASURES: SCIM III subscale match between the distribution of item difficulty grades and the patient ability measurements; reliability of patient ability measures; fit of data to Rasch model requirements; unidimensionality of each subscale; hierarchical ordering of categories within items; differential item functioning across classes of patients and across countries. RESULTS: Results supported the compatibility of the SCIM subscales with the stringent Rasch requirements. Average infit mean-square indices were 0.79-1.06; statistically distinct strata of abilities were 3 to 4; most thresholds between adjacent categories were properly ordered; item hierarchy was stable across most of the clinical subgroups and across countries. In a few items, however, misfit or category threshold disordering were found. CONCLUSIONS: The scores of each SCIM III subscale appear as a reliable and useful quantitative representation of a specific construct of independence after SCL. This justifies the use of SCIM in clinical research, including cross-cultural trials. The results also suggest that there is merit in further refining the scale.

Clinical and economic consequences of volume- or time-dependent intermittent catheterization in patients with spinal cord lesions and neuropathic bladder.

STUDY DESIGN: Open comparative study. OBJECTIVE: To compare the impact of volume-dependent intermittent catheterization (VDIC) and time-dependent intermittent catheterization (TDIC) on financial burden and clinical outcomes in patients with spinal cord lesions (SCL). SETTING: Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Israel. METHOD: Economic and clinical outcomes were examined in 13 SCL patients treated with VDIC following bladder volume measurement by a portable ultrasound device (the study group), and in 11 patients treated with TDIC (the control group). Patients were followed for 12-30 days. Costs were calculated according to December 2003 prices at Loewenstein Hospital. The t-test and the Fisher's Exact Test were employed for comparisons between the groups. RESULTS: The number of catheterizations per patient per day, the time required to perform volume measurements and catheterizations, and their total cost, were approximately 44, 49, and 46% lower in the study group than in the control group. SCIMU (representing bladder management functioning) increased during the study in both groups, and the increase was 31% higher in the study group than in the control group. Urinary infection was found in three patients in the control group and in none in the study group. CONCLUSION: VDIC has economic and probably also clinical advantages over TDIC.

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation.

BACKGROUND: Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH). STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To report on outcomes and factors affecting these. SETTING: The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel. SUBJECTS: A total of 158 patients with DH spinal neurological lesions (DHSNL). METHOD: Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA. RESULTS: The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time. CONCLUSIONS: Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.

Length of stay in hospital following spinal cord lesions in Israel.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To monitor length of stay (LOS) in a specialist spinal cord lesion (SCL) department in Israel, evaluate factors that affect it, and assess its association with other outcome measures. SETTING: Loewenstein Rehabilitation Hospital, Raanana, Israel. METHODS: In all, 1367 SCL patients treated between 1962 and 2000, and a group of 44 patients admitted between 1996 and 2002 were recruited. LOS, factors that affect it, and Spinal Cord Independence Measure second version (SCIM-II) gain and efficiency were measured. Data were collected from hospital charts and from the Population Registry of the Israel Ministry of Internal Affairs. LOS associations were analyzed with ANOVA, ANCOVA, Pearson's chi(2) test, Pearson's correlation, and Cox proportional hazard model. RESULTS: The mean LOS was 239 days for traumatic SCL (SD=168) and 106 days for non-traumatic SCL (SD=137). SCL etiology, SCL severity, and decade of admission to rehabilitation, were associated with the LOS (P<0.001). SCIM II gain correlated with LOS in the first 70 days after admission (r=0.81-0.82; P<0.001). In some patients, longer LOS was associated with a considerable increase in ability, through 5-8 months from admission. CONCLUSIONS: LOS of patients with SCL in Israel is within the customary LOS range in Europe. Longer LOS in a specialist SCL department may be positively associated with improved rehabilitation outcome. Further study is required to determine the LOS that allows optimal achievements.