group therapy utilization in inpatient spinal cord injury rehabilitation

9
ORIGINAL ARTICLE Group Therapy Utilization in Inpatient Spinal Cord Injury Rehabilitation Jeanne M. Zanca, PhD, MPT, a Marcel P. Dijkers, PhD, FACRM, a Ching-Hui Hsieh, PhD, OT, b Allen W. Heinemann, PhD, c,d Susan D. Horn, PhD, e Randall J. Smout, MS, e Deborah Backus, PT, PhD f From the a Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY; b MedStar National Rehabilitation Hospital, Washington, DC; c Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL; d Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL; e Institute for Clinical Outcomes Research, Salt Lake City, UT; and f Crawford Research Institute, Shepherd Center, Atlanta, GA. Abstract Objective: To describe group therapy utilization in spinal cord injury (SCI) inpatient rehabilitation. Design: Prospective observational study. Setting: Six inpatient rehabilitation facilities. Participants: Patients (NZ1376) receiving initial rehabilitation after traumatic SCI. Interventions: Not applicable. Main Outcome Measure: Time spent in group versus individual therapy for physical therapy (PT), occupational therapy (OT), therapeutic recreation (TR), and psychology (PSY) therapies. Results: The majority (98%) of patients participated in at least 1 group therapy session, with 83%, 81%, 80%, and 54% of patients receiving group PT, OT, TR, and PSY, respectively. On average, 24% of treatment sessions and 27% of treatment timewas provided in group sessions, with TR providing the greatest percent of its time in groups. Group therapy time and time spent in specific activities varied among patient subgroups with different injury characteristics. Group therapy time also varied widely among centers (range, 1.2e6.6h/wk). Across all injury subgroups, individual and group therapy hours per week were negatively correlated for OT and positively correlated for TR. Patient characteristics, clinician experience, and treatment center predicted 32% of variance in group hours per week. PT and OT strengthening/endurance interventions and TR outings were the most common group activities overall. Conclusions: While the majority of inpatient SCI rehabilitation consists of individual sessions, most patients participate in group therapy, which contributes significantly to total therapy time. Patterns of group utilization fit with functional expectations and clinical goals. A trade-off between group and individual therapy may occur in some disciplines. Utilization of group therapy varies widely among centers, and further study is needed to identify optimal patterns of group therapy utilization. Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S145-53 ª 2013 by the American Congress of Rehabilitation Medicine Group therapy, in which 2 patients participate in therapy activities together, is a common component of rehabilitation programs and is thought to offer unique benefits beyond those obtained from individual (1-on-1) therapy. 1-8 Group therapy sessions provide an opportunity to interact with others with similar conditions, thus providing opportunities for peer support and reducing social isolation. In group sessions, feedback and encouragement may be provided by both the therapist(s) leading the group and by group members, increasing motivation to participate in therapy. Group sessions offer opportunities to interact and communicate with others to a greater extent than Presented to the American Congress of Rehabilitation Medicine, October 11e15, 2011, Atlanta, GA. Supported in part by the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Education (grant nos. H133A060103, H133N060028, H133N060009, H133N060027, and H133N060014). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. 0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Rehabilitation Medicine http://dx.doi.org/10.1016/j.apmr.2012.11.049 Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S145-53

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Page 1: Group Therapy Utilization in Inpatient Spinal Cord Injury Rehabilitation

edicine and Rehabilitation

Archives of Physical M journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S145-53

ORIGINAL ARTICLE

Group Therapy Utilization in Inpatient Spinal Cord InjuryRehabilitation

Jeanne M. Zanca, PhD, MPT,a Marcel P. Dijkers, PhD, FACRM,a Ching-Hui Hsieh, PhD, OT,b

Allen W. Heinemann, PhD,c,d Susan D. Horn, PhD,e Randall J. Smout, MS,e

Deborah Backus, PT, PhDf

From the aDepartment of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY; bMedStar National Rehabilitation Hospital,Washington, DC; cDepartment of Physical Medicine and Rehabilitation, Northwestern University, Chicago, IL; dCenter for RehabilitationOutcomes Research, Rehabilitation Institute of Chicago, Chicago, IL; eInstitute for Clinical Outcomes Research, Salt Lake City, UT; andfCrawford Research Institute, Shepherd Center, Atlanta, GA.

Abstract

Objective: To describe group therapy utilization in spinal cord injury (SCI) inpatient rehabilitation.

Design: Prospective observational study.

Setting: Six inpatient rehabilitation facilities.

Participants: Patients (NZ1376) receiving initial rehabilitation after traumatic SCI.

Interventions: Not applicable.

Main Outcome Measure: Time spent in group versus individual therapy for physical therapy (PT), occupational therapy (OT), therapeutic

recreation (TR), and psychology (PSY) therapies.

Results: The majority (98%) of patients participated in at least 1 group therapy session, with 83%, 81%, 80%, and 54% of patients receiving

group PT, OT, TR, and PSY, respectively. On average, 24% of treatment sessions and 27% of treatment time was provided in group sessions, with

TR providing the greatest percent of its time in groups. Group therapy time and time spent in specific activities varied among patient subgroups

with different injury characteristics. Group therapy time also varied widely among centers (range, 1.2e6.6h/wk). Across all injury subgroups,

individual and group therapy hours per week were negatively correlated for OT and positively correlated for TR. Patient characteristics, clinician

experience, and treatment center predicted 32% of variance in group hours per week. PT and OT strengthening/endurance interventions and TR

outings were the most common group activities overall.

Conclusions: While the majority of inpatient SCI rehabilitation consists of individual sessions, most patients participate in group therapy, which

contributes significantly to total therapy time. Patterns of group utilization fit with functional expectations and clinical goals. A trade-off between

group and individual therapy may occur in some disciplines. Utilization of group therapy varies widely among centers, and further study is needed

to identify optimal patterns of group therapy utilization.

Archives of Physical Medicine and Rehabilitation 2013;94(4 Suppl 2):S145-53

ª 2013 by the American Congress of Rehabilitation Medicine

Group therapy, in which �2 patients participate in therapyactivities together, is a common component of rehabilitation

Presented to the American Congress of Rehabilitation Medicine, October 11e15, 2011,

Atlanta, GA.

Supported in part by the National Institute on Disability and Rehabilitation Research, Office of

Special Education and Rehabilitative Services, U.S. Department of Education (grant nos.

H133A060103, H133N060028, H133N060009, H133N060027, and H133N060014).

No commercial party having a direct financial interest in the results of the research supporting

this article has or will confer a benefit on the authors or on any organization with which the authors

are associated.

0003-9993/13/$36 - see front matter ª 2013 by the American Congress of Re

http://dx.doi.org/10.1016/j.apmr.2012.11.049

programs and is thought to offer unique benefits beyond thoseobtained from individual (1-on-1) therapy.1-8 Group therapysessions provide an opportunity to interact with others with similarconditions, thus providing opportunities for peer support andreducing social isolation. In group sessions, feedback andencouragement may be provided by both the therapist(s) leadingthe group and by group members, increasing motivation toparticipate in therapy. Group sessions offer opportunities tointeract and communicate with others to a greater extent than

habilitation Medicine

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S146 J.M. Zanca et al

could occur in individual sessions, and group participants maylearn new information from questions raised and commentsprovided by other members of the group. Group therapy alsoallows more patients to be seen by fewer staff members, which canreduce waiting times for services and reduce cost of care byreducing the direct staff time required for therapy delivery.4,5

Thus, group therapy is thought to offer advantages for both theeffectiveness and efficiency of care, and is considered an impor-tant component of therapy programs.

Group therapy is addressed in recent federal health carereimbursement policy. In its 2010 Prospective Payment System(PPS) final rule for inpatient rehabilitation facilities (IRFs), theCenters for Medicare and Medicaid Services (CMS) stated thatgroup therapy should be used as an “adjunct to one-on-one therapyservices which should be the standard of care in therapy serviceprovided to IRF patients.”9(p39796) CMS further stated that it “plan[s] to consider the adoption of specific standards on the use ofgroup therapies at a future date.”9(p39797) As of May 2012, nostandards have been proposed in IRF federal regulations issued byCMS. However, a new definition and payment policy for grouptherapy was published in the 2012 PPS final rule for skillednursing facilities.10 This regulation defined group therapy as“therapy provided simultaneously to four patients who are per-forming the same or similar therapy activities.”10(p48514) The rulealso required that group therapy minutes in a given session be splitamong the participants for purposes of reimbursement, and thatgroup therapy minutes that will be counted for reimbursement ina given discipline will be limited to 25% of the total weeklyminutes provided by that discipline, as previously described in theJuly 30, 1999 final rule.11 The extent to which CMS will extendsimilar policies to IRFs is not known, but CMS’ recent commentshave led many IRFs to examine their use of group therapy andconsider the implications of possible policy changes.

There are few data available to guide CMS and others in theformulation of policies for group therapy use in adult inpatientrehabilitation, particularly for individuals with spinal cord injury(SCI). van Langeveld et al12 described inpatient physical therapy(PT), occupational therapy (OT), and sports therapy interventionsprovided to patients with SCI at 6 European rehabilitation centers.The percent of treatment time patients spent in group therapyvaried widely among the facilities, from 6% to 39%. The amountof group therapy provided by each discipline was not reported, andoutcomes associated with the use of group therapy were notexplored. In the Daniel and Manigandan13 study of outcomesassociated with participation in leisure education groups forinpatients with paraplegia, group participants had larger increasesin leisure satisfaction and quality of life than a control group thatdid not participate in leisure intervention groups as part of their

List of abbreviations:

AIS ASIA Impairment Scale

CMS Centers for Medicare and Medicaid Services

CSI Comprehensive Severity Index

IRF inpatient rehabilitation facility

LOS length of stay

LTCH long-term care hospital

OT occupational therapy

PPS Prospective Payment System

PSY psychology

PT physical therapy

SCI spinal cord injury

TR therapeutic recreation

inpatient rehabilitation program. The only other published dataabout the use of group therapy in inpatient rehabilitation for SCIare from an analysis of data collected in the first year of thecurrent investigation.14 This analysis found that the majority ofpatients participated in group PT sessions and that approximately23% of PT treatment time was provided in groups. Strengthening,manual wheelchair mobility, gait training, endurance activities,and range of motion/stretching were the most common group PTactivities; outcomes of participation in these activities were notexplored.14

Reports of group therapy use in other inpatient rehabilitationpopulations are also limited, but those that exist show benefitsassociated with group therapy use. Trahey4 reported that patientswith total hip replacement who participated in group OT supple-mented by individual OT achieved their therapy goals equally wellas those who received primarily individual therapy, with one thirdless direct labor cost. The introduction of group sessions in aninpatient rehabilitation program for stroke was reported by DeWeerdt et al15 to increase time spent in therapy by 8% and topromote social interaction with both peers and therapists. Kur-asik16 found that patients with hemiplegia who participated ingroup therapy as part of their inpatient rehabilitation achieved theirgoals earlier than patients receiving individual treatment only.Several additional studies reported positive outcomes associatedwith outpatient group therapy in non-SCI populations.3,5,17-19

A better understanding of the nature and extent of grouptherapy use in inpatient SCI rehabilitation is needed to inform thedevelopment of guidelines and policies related to group therapy.The previous report from the current investigation providedinformation only about group therapy use in PT14 and examinedfewer cases than are now available. The objectives of the currentanalysis are (1) to describe the extent and nature of group therapyprovided in inpatient rehabilitation for individuals with SCI, (2) toassess differences in group therapy utilization among injurysubgroups, (3) to examine the relation between individual andgroup therapy time, and (4) to identify factors associated withgroup therapy use.

Methods

Study design and participating centers

Data are derived from the SCIRehab study,20,21 a 5-year multicenterinvestigation using practice-based evidence methodologydaprospective observational approach in which detailed data on patientcharacteristics, interventions, and outcomes are collected to allowrelations between these factors to be examined.20-23 The method-ology of the SCIRehab study is described in detail elsewhere20,21,24

and summarized here. Six clinical centers participated in the study(Craig Hospital, Englewood, COdlead centerdRehabilitationInstitute of Chicago, Chicago, IL; Shepherd Center, Atlanta, GA;MedStar National Rehabilitation Hospital, Washington, DC; Caro-linas Rehabilitation, Charlotte, NC; and The Mount Sinai MedicalCenter, New York, NY), with project implementation and dataanalysis support provided by the Institute for Clinical OutcomesResearch, Salt Lake City, UT, a research center.

Participants

Participants were 1376 individuals aged �12 years who receivedinitial rehabilitation for acute traumatic SCI and were admitted

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Group therapy in SCI rehabilitation S147

between August 2007 and December 2009. Informed consent wasobtained from all participants or their parents or guardians, whereappropriate. Institutional review board approval for the study wasobtained at all centers.

Data collection

Patient characteristicsDemographic characteristics, diagnoses, and other data needed todescribe the medical and functional status of participants wereobtained through a detailed chart review completed by trained dataabstractors. Data included classification of SCI, as defined in theInternational Standards for Neurological Classification of SCI,25

and functional status, as described by the FIM.26 Data aboutmedical diagnoses and the most severe signs and symptoms ofthese diagnoses observed over the entire rehabilitation stay wereentered into specialized software to calculate a ComprehensiveSeverity Index (CSI) score, which provided a measure of greatestillness severity during the rehabilitation stay.27 Higher CSI scoresindicate a greater burden of illness.

Rehabilitation interventionsTime spent in group therapy was documented by 4 disciplines: PT,OT, therapeutic recreation (TR), and psychology (PSY). Speechtherapy, nursing, and social work staff also completed documen-tation on time spent with patients, but did not use group therapyand therefore are excluded from the current analysis. Cliniciansdocumented details about each therapy session using handheldelectronic devices with a customized software application.20,28-31

The application included electronic data entry forms designedfor each discipline that allowed clinicians to document the natureof the treatment session (individual vs group), the type(s) oftreatment activities taking place, and the number of minutes spenton these activities. A group session was defined as �2 patientsbeing treated simultaneously by �1 clinicians. Clinicians under-went training in the use of these devices; periodic reliabilitychecks were performed to assess consistency of documentationand identify ongoing training needs.

Rehabilitation length of stayLength of stay (LOS) in rehabilitation was defined as the numberof days between initial admission and final discharge, excludingdays spent off the unit because of transfers to acute care or otherinterruptions.

Clinician experienceClinicians reported years of experience in SCI rehabilitation viaa questionnaire.

Data processing and analysis

Calculation of therapy timeSessions that lacked a valid date or number of treatment minutesprovided, or that appeared to be duplicates of other sessions (samepatient, clinician, date, and start time) were excluded from anal-ysis (2% of 195,281 sessions reported). Total hours of grouptherapy received over the rehabilitation stay were calculated bysumming the duration of all group sessions documented withineach discipline and then summing the disciplines’ time.a A similarapproach was used to calculate individual therapy hours over thestay. Percent of time spent in group therapy for PT, OT, TR, andPSY also was calculated, for each patient, for each discipline, and

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for all 4 disciplines combined. Total hours are highly correlatedwith LOS; therefore, hours per week were also calculated toprovide an LOS-adjusted measure of therapy time. Time spent ingroup interventions (strengthening/endurance, manual wheelchairmobility, range of motion/stretching, education, power wheelchairmobility, and balance) that were provided by PT as well as OTwere summed across these 2 disciplines to aid examination ofgroup therapy activities.

Formation of injury subgroupsPatients were divided into 4 subgroups defined by the level andcompleteness of injury: C1-4 ASIA Impairment Scale (AIS)grades A, B, and C; C5-8 AIS grades A, B, and C; paraplegia AISgrades A, B, and C; and AIS grade D (all levels). These groupswere formed in an effort to divide the larger sample intosubgroups containing patients with similar functional status, whilekeeping subgroup size sufficiently large for intergroup compari-sons. Differences between injury subgroups in therapy timereceived were assessed using analysis of variance with a 2-sidedalpha level of .05.

Clinician experience index calculationA clinician experience index was created for use in regressionanalyses by weighting the experience of each clinician treatinga particular patient by the number of hours of treatment eachclinician provided. The index describes average years of SCIrehabilitation experience among the clinicians treating a particularpatient. The index used in the current analysis is based on allclinicians seeing a particular patient, regardless of discipline.

FIM score transformationFIM scores were transformed to a 0 to 100 range using the Raschmeasurement model24 to mitigate problems resulting from the useof ordinal scores.

Regression analysisStatistically significant predictors of hours per week spent ingroup therapy were identified using ordinary least-squares step-wise linear regression models.b For purposes of regression anal-ysis only, the sample of 1376 patients was divided randomly intoa primary analysis subset containing 75% of patients and a vali-dation subset containing the remaining 25% of patients (seeWhiteneck and Gassaway24). All other analyses in this report arebased on the full dataset of 1376 participants. The primary anal-ysis and validation datasets did not differ significantly on anydependent or independent variable included in the analyses.24

A regression analysis was performed on the primary analysisdataset with the following independent variables allowed to enterthe model: age, sex, marital status, racial/ethnic group, preinjuryprimary occupational status, education level, traumatic SCIetiology, work-relatedness of injury, injury subgroup, body massindex, English speaking status, payer, number of days from traumato rehabilitation admission, ventilator use on admission, maximumCSI score, clinician experience index, and Rasch-transformedadmission FIM motor and cognitive scores. R2 values andadjusted R2 values (which take into account the number ofpredictors in the model) describe the amount of variationexplained by the model. Semipartial R2 values indicate theproportion of the variance in the dependent variable that isuniquely associated with the predictor variable after controllingfor all other variables in the model. Parameter estimates are pre-sented to indicate the direction and strength of the association

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S148 J.M. Zanca et al

between each independent variable and group therapy hours perweek. The model produced from the primary analysis subset wasvalidated by performing a regression analysis on the validationdataset using only the statistically significant predictors from theoriginal model and determining the reduction in adjusted R2

values (relative shrinkage) that occurred. A relative shrinkage of<0.1 was interpreted as strong validation of the original model,0.1 to 0.2 was moderate validation, and >0.2 was poor validation.

Results

Patient characteristics and LOS

The majority of patients were men, white, spoke English as theirprimary language, were working at the time of injury, and hadprivate insurance coverage (table 1). Average age at injury was 41years. The largest injury subgroup in the sample was paraplegiaAIS grades A, B, and C (36%) followed by C1-4 AIS grades A, B,and C (29%), C5-8 AIS grades A, B, and C (20%), and AIS gradeD (15%). LOS was 55 days on average; patients with C1-4 AISgrades A, B, and C injuries had the longest LOS (74d on average),while patients with AIS grade D injuries had the shortestLOS (33d).

Extent of group therapy use

All disciplines combinedGroup therapy recipients, sessions, and time are presented intable 2. The majority (98%) of patients received at least 1 sessionof group therapy, and nearly one quarter of all therapy sessions(24%) was provided in groups. On average, patients spent 36.8hours in group therapy over the rehabilitation stay and 4.7 hours ingroup therapy each week. They spent 26.7% of their total therapyhours in group therapy on average, with considerable variationobserved among patients. The average time patients spent in grouptherapy varied considerably among centers, ranging from 1.2 to6.6 hours per week.

Group therapy use within disciplines and centersMost patients (80%e83%) received group PT, OT, and TR, whileonly 54% received group PSY. Within disciplines, TR used groupsmost often, with 41% of its treatment sessions taking place ingroups and more than half (54.6%) of its total hours provided ingroups. While PSY provided the least total hours (2) and leasthours per week (0.3) of group therapy of any discipline, thepercent of PSY time provided in groups (29.5%) was second onlyto TR. OT provided the most total hours of group therapy (12.9),but hours per week of group therapy were very similar for OT, PT,and TR (1.5h/wk for all 3 disciplines). Mean hours per weekvaried widely among centers, ranging from 0.7 to 2.7 for PT, 0.4to 3.8 for OT, 0.0 to 2.5 for TR, and 0.0 to 0.5 for PSY.

Group therapy use within injury subgroupsThe 4 injury subgroups differed significantly in total hours ofgroup therapy received, hours per week of group therapy received,and proportion of time spent in group therapy (see table 2).Patients with C5-8 AIS grades A, B, and C injuries received themost group therapy time, whether measured by total hours (54.3)(fig 1), hours per week (5.5), or percent of time spent in groups(29.4). The distribution of group therapy by discipline alsodiffered among the injury subgroups.

Group therapy activitiesThe most common group therapy activity was strengthening/endur-ance, with patients receiving 12.7 hours of this activity on averageover the course of the rehabilitation stay (table 3). Outings with TRwere the next most common activity performed in group sessions(7.2h), followed by manual wheelchair mobility (2.4h) and leisureskills in the center (2.0h). Less than 2 hours, on average, was spent inany of the other group therapy activities. Time spent in specific grouptherapy activities varied considerably among injury subgroups.

Relation between group and individual therapy time

A weak negative correlation (rZ�.14) was observed betweenindividual and group therapy hours per week (TR, PT, OT, and PSYcombined) for the entire sample (table 4). Group and individualhours per week were negatively correlated for the entire sample andall injury subgroups for OT (r range, �.21 to �.56), but werepositively correlated for TR (r range, .31e.54). The strength anddirection of the correlation between group and individual hours perweek varied among injury groups for PT and PSY (see table 4).

Predictors of hours per week spent in group therapy

Approximately 13% of the variance in group therapy hours perweek for all 4 disciplines combined was explained by patient,injury, and clinician characteristic variables, with no single vari-able predicting >2% of variance (table 5). Adding the center tothe model increased the variance explained to 32%. The regressionmodel validated moderately well with a relative shrinkage of .16.

Discussion

Group therapy time and activities

This report is the first, to our knowledge, to provide detailedinformation on group therapy use in inpatient rehabilitation forSCI in United States-based centers. The findings of the currentstudy indicate that the majority of therapy in inpatient SCI reha-bilitation are delivered in individual treatment sessions. This is thecase for all 4 disciplines combined (PT, OT, PSY, TR), and forsessions provided by PT, OT, and PSY. Only for TR is the averagetime spent in groups greater than the time spent in individualsessions, likely because TR activities are often designed toencourage social interaction, therefore appropriately taking placein group rather than individual sessions, and tend to involvecommunity-related activities that require a substantial length oftime to complete. In its 2010 final rule, CMS expressed concernthat “some IRFs are providing essentially all group therapy totheir patients.”9(p39796) This does not appear to be the case for thefacilities participating in this investigation, which include 4 IRFsand 2 long-term care hospitals (LTCHs).

While the majority of therapy is provided 1-on-1, group therapycontributes significantly to the overall therapy package, with nearlyall patients receiving at least 1 group therapy session, andapproximately one quarter of therapy time provided in groups. Theproportion of therapy time reported here falls within the rangereported by van Langeveld et al,12 though the 2 studies includea different mixture of disciplines. The findings of the currentanalysis regarding group PT are similar to those of the previouslypublished analysis of the first year data subset from the SCIRehab

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Table 1 Patient characteristics by neurologic group

Characteristics

C1-4 AIS

Grades AeC

(nZ393)

C5-8 AIS

Grades AeC

(nZ270)

Paraplegia AIS

Grades AeC

(nZ499)

AIS Grade D

(nZ214)

All Patients

(NZ1376)

Age at injury (y), mean � SD* 40�17 34�16 33�14 48�18 41�17

Sex, % male 82 80 80 82 81

Race/ethnicity, %*

White 73 79 70 62 71

Black 19 16 23 28 21

Hispanic 2 2 4 4 3

Other/not reported 5 3 4 7 5

English as primary language, % 94 95 95 94 94

Marital status at injury, % married* 43 33 35 43 38

Highest level of education completed, %*

�College 26 27 22 29 25

High school diploma or general

equivalency diploma

54 47 51 47 51

<12y 17 23 23 15 20

Other or unknown 2 3 3 9 4

Employment status at injury, %*

Working 65 63 68 60 65

Student 13 22 16 10 15

Retired 10 4 3 17 8

Unemployed/other 11 11 13 13 12

Injury etiology, %*

Violence 7 9 17 5 11

Sports 16 24 3 8 11

Fall 26 20 20 36 25

Vehicular 50 46 54 44 50

Medical/surgical/other 1 1 6 7 4

Work-related injury, % no 87 88 84 90 86

Payer, %*

Medicare 9 5 4 18 8

Medicaid 17 20 21 12 18

Worker’s compensation 10 10 11 9 10

Private insurance/private pay 65 66 64 62 64

Days from injury to rehabilitation

admission, mean � SD*39�31 32�27 29�26 17�14 31�27

Rehabilitation LOS, mean � SD* 74�44 67�37 44�25 33�21 55�37

BMI at admission �30, % 20 14 20 21 19

Admission motor FIM, mean � SD* 14�3 18�5 31�9 29�14 23�11

Admission cognitive FIM, mean � SD* 26�7 29�5 30�5 30�5 29�6

CSI, mean � SD* 55�38 42�28 34�25 22�19 40�31

Abbreviation: BMI, body mass index.

* Statistically significant differences among groups at P<.05.

Group therapy in SCI rehabilitation S149

study,14 though approximately 10% more patients in the previousanalysis were defined as receiving group PT, because didacticeducation classes were considered a form of group PT. Anychanges in policy that impact the ability of centers to provide grouptherapy would likely necessitate changes in current clinical prac-tice to avoid reductions in the amount of therapy provided duringinpatient rehabilitation. Analyses of the relation between grouptherapy utilization and outcomes are needed to identify optimalpatterns of group therapy use, to inform policy formulation and thedevelopment of clinical guidelines.

The most common form of group therapy intervention,strengthening/endurance activities, is well suited to group therapy.These activities require therapist instruction in exercise techniqueand periodic adjustment of task demands, but the therapeutic

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effect of these activities comes mostly from repetitions orincreased time spent in the activity, neither of which requirescontinuous and exclusive guidance from a therapist once thepatient demonstrates the ability to perform the activity safely andappropriately. Indeed, one could argue that for these interventionsa group format makes far better use of clinicians’ time, and thatextended 1-on-1 sessions for these activities would be inefficient.A group setting also may make repetitive activity more palatableto patients, and may encourage healthy competition between themthat could increase motivation to participate in therapy. It remainsto be determined how much time during the rehabilitation stayshould be spent in strengthening/endurance activities, and whetherdifferences in the distribution of that time between individual andgroup therapy produces differences in outcome.

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Table 2 Group therapy recipients, sessions, and time by neurologic group and discipline

Discipline

C1-4 AIS

Grades AeC

(nZ393)

C5-8 AIS

Grades AeC

(nZ270)

Paraplegia AIS

Grades AeC

(nZ499)

AIS Grade D

(nZ214)

All Patients

(NZ1376)

All disciplines combined

% of patients receiving group therapy 98.0 98.0 98.0 96.0 98.0

% sessions delivered in group therapy* 18.0 27.0 25.0 29.0 24.0

Mean � SD total hours group therapy received*y 37.3�33.4 54.3�42.4 31.9�24.7 25.5�26.4 36.8�33.0

Mean � SD h/wk group therapy received*y 3.7�2.6 5.5�3.1 4.9�2.9 5.0�3.1 4.7�3.0

Mean � SD % total hours spent in groupsy 22.0�13.0 29.4�14.2 28.5�14.3 28.2�16.5 26.7�14.5

PT

% of patients receiving group therapy 70.0 89.0 89.0 88.0 83.0

% sessions delivered in group therapy* 12.0 20.0 29.0 28.0 21.0

Mean � SD total hours group therapy received*y 7.8�13.5 13.6�15.3 14.0�18.5 10.3�11.4 11.6�15.8

Mean � SD hours/week group therapy received*y 0.8�1.1 1.3�1.2 1.9�2.0 2.1�1.6 1.5�1.7

Mean � SD % total hours spent in groupsyz 10.2�13.0 17.2�13.7 22.6�18.4 24.4�18.0 18.0�16.9

OT

% of patients receiving group therapy 86.0 92.0 74.0 77.0 81.0

% sessions delivered in group therapy* 23.0 32.0 19.0 30.0 25.0

Mean � SD total hours group therapy received*y 15.8�20.1 22.7�25.2 6.7�10.2 9.8�13.3 12.9�18.5

Mean � SD h/wk group therapy received*y 1.3�1.4 2.0�1.8 1.1�1.3 1.8�1.8 1.5�1.6

Mean � SD % total hours spent in groupsyz 18.4�17.8 25.4�21.3 15.6�18.7 21.8�21.7 19.2�19.7

TR

% of patients receiving group therapy 87.0 86.0 80.0 56.0 80.0

% sessions delivered in group therapy* 44.0 43.0 38.0 36.0 41.0

Mean � SD total hours group therapy received*y 11.6�11.8 15.2�15.9 9.3�10.8 4.3�6.6 10.3�12.2

Mean � SD h/wk group therapy received*y 1.3�1.4 1.9�2.0 1.6�2.0 0.9�1.2 1.5�1.8

Mean � SD % total hours spent in groupsyz 59.7�28.0 57.7�28.1 51.2�28.6 46.9�34.8 54.6�29.5

PSY

% of patients receiving group therapy 51.0 64.0 58.0 40.0 54.0

% sessions delivered in group therapy* 15.0 10.0 18.0 18.0 17.0

Mean � SD total hours group therapy received*y 2.1�3.0 2.8�3.5 1.9�2.2 1.1�1.8 2.0�2.8

Mean � SD h/wk group therapy received*y 0.3�0.3 0.3�0.4 0.4�0.4 0.2�0.4 0.3�0.4

Mean � SD total hours time spent in groupszx 23.6�27.5 29.0�28.0 29.0�28.7 25.3�31.2 26.9�28.6

* Calculated among all patients, including those who did not receive group therapy.y Difference among subgroups statistically significant at P<.001.z Percent therapy time in groups was calculated within patients.x Difference among subgroups statistically significant at P<.05.

S150 J.M. Zanca et al

Patterns of group therapy delivery varied among injury groupsin a manner consistent with functional expectations and clinicalgoals. First, patients with C1-4 AIS grades A, B, and C injuries,who would be expected to have the most difficulty participating intherapy activities without physical assistance, received the leastgroup therapy according to LOS-adjusted measures of time (hoursper week and percent of total hours spent in group therapy).Second, the time distribution among disciplines within injurysubgroups fits well with the typical areas of focus of these disci-plines. Patients with AIS grade D injuries, for whom walking isa key clinical focus, spent more group therapy time in PT than anyother injury subgroup. Persons with paraplegia, who are leastlikely to have upper-extremity impairments, spent the least time ingroup OT. Third, time spent in mobility-related group activitiesvaried among injury subgroups in a pattern consistent with theanticipated mode of mobility at discharge. Patients with AIS gradeD injuries spent the most time in group gait activities, personswith paraplegia spent the most time in group manual wheelchairmobility, and patients with C1-4 AIS grades A, B, and C tetra-plegia spent the most time in group power-wheelchair mobility.Thus, group therapy time and activities vary among injury

subgroups in patterns consistent with clinical goals, suggestingthat patient needs specific to the type of SCI are considered whenmaking decisions about group therapy use.

Predictors of time spent in group therapy

Patient characteristics and clinician experience explained relativelylittle of the variance (13%) in number of hours per week spent ingroup therapy, though the amount of variance explained more thandoubled when the rehabilitation center was added to the model(adjusted R2Z.32). While the centers vary in case mix and clinicianexperience, these factors are accounted for by the inclusion ofspecific patient and clinician experience variables. The increase inR2 after the addition of the center suggests that other, as yetunspecified, factors that differ among the 6 participating centers arecreating thewide variation observed in group hours per week. Thesefactors may include type of facility licensure (IRF vs LTCH), statepolicies, local health system factors, staff-to-patient ratios, center-specific customs and programs, among others. The wide variationin practice patterns among centers highlights the need for more

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Page 7: Group Therapy Utilization in Inpatient Spinal Cord Injury Rehabilitation

Fig 1 Total hours received in group and individual therapy among injury subgroups. *Total treatment hours provided in group therapy differed

among injury subgroups at P<.001. Abbreviation: Para, paraplegia.

Group therapy in SCI rehabilitation S151

information about the impact of group therapy on outcomes, toallow guidelines for optimal group therapy use to be created.

Relation between group and individual therapy

An open question about group therapy utilization is whethera trade-off exists between individual and group therapy, such that

Table 3 Mean total hours spent in commonly used group therapy act

Discipline and Activity

C1-4 AIS

Grades AeC

C5-8 A

Grades

Activities provided by PT and OT

Strengthening/endurance 11.2 20.3

Manual wheelchair mobility 0.6 2.3

Range of motion/stretching 2.0 1.6

Education 1.4 1.0

Power wheelchair mobility 1.1 0.9

Balance 0.3 0.5

Activities provided by PT only

Gait 0.5 0.5

Activities provided by OT only

Therapeutic activity* 2.3 3.5

Home management skills 0.8 1.7

Communicationy 0.7 1.1

TR activities

Outingsz 8.0 10.9

Leisure skills (in the center) 2.2 2.9

Leisure education and counseling 1.4 1.4

PSY activities

Psychoeducational interventions 1.5 2.1

Psychotherapeutic interventions 0.6 0.7

* Includes fine motor activities, tenodesis training, manual therapy, ve

retraining, visual/perceptual training, desensitization, and donning/doffingy Includes writing, page turning, and phone use.z Includes leisure skill, camping/hunting, and other community outings.

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patients who spend more time in groups receive less 1-on-1 time.This appears to be the case for OT for all injury subgroups, for PTin the AIS grade D subgroup, and for PSY in the C1-4 AIS gradesA, B, and C subgroup. For TR, patients who received more grouptreatment time generally also received more individual treatmenttime. Notably, OT and PT time are included in documentingcompliance with CMS’s 3 hour rule, which considers at least

ivities

IS

AeC

Paraplegia AIS

Grades AeC AIS Grade D All Cases

10.8 10.4 12.7

4.7 0.6 2.4

1.5 0.9 1.6

0.4 0.5 0.8

0.1 0.2 0.6

0.7 0.5 0.5

0.4 2.4 0.8

0.3 2.7 1.9

0.3 0.5 0.7

0.1 0.3 0.5

6.4 2.8 7.2

1.7 0.9 2.0

1.2 0.7 1.2

1.5 0.8 1.5

0.5 0.3 0.5

stibular training, edema management, breathing exercises, cognitive

adaptive equipment.

Page 8: Group Therapy Utilization in Inpatient Spinal Cord Injury Rehabilitation

Table 4 Correlation between individual and group therapy time (h/wk) by discipline and within injury subgroups

Discipline

C1-4 AIS

Grades AeC

(nZ393)

C5-8 AIS

Grades AeC

(nZ270)

Paraplegia AIS

Grades AeC

(nZ499)

AIS Grade D

(nZ214)

All Patients

(NZ1376)

All disciplines combined �.02 �.13* �.12y �.36z �.14z

PT .03 �.10 �.08 �.28z �.10z

OT �.37z �.56z �.21z �.43z �.34z

TR .46z .46z .31z .54z .39z

PSY �.12* �.09 .13y �.01 .03

* P<.05.y P<.01.z P<.001.

S152 J.M. Zanca et al

3 hours of therapy per day at least 5 days per week to be theminimum standard for the intensive therapy services provided byan IRF.32,33 Anecdotally, participating clinicians indicated thatgroup therapy was helpful in meeting the 3 hour target for therapy(clinicians at LTCHs reported that they aim to adhere to a similarstandard), and that group sessions were sometimes used to bringtotal therapy time up to 3 hours if an individual therapy session

Table 5 Factors associated with hours per week of group

therapy (PT, OT, TR, and PSY combined): results of multiple

regression analysis*

Independent VariableyParameter

Estimate Semipartial R2

Injury classification .02

C1-4 AIS Grades AeC 0.69

Admission cognitive FIM

(Rasch-transformed)

0.02 .01

No. of days from trauma to

rehabilitation admission

�0.01 .01

Age at injury �0.02 <.01

Employment status at injury .01

Unemployed/other �0.64

Student 0.67

Highest education level

completed at time of injury

.01

Other/unknown �1.27

Body mass index �30 0.44 <.01

Clinician experience index 0.11 .01

R2 .15

R2 after addition of center .34

Adjusted R2 .13

Adjusted R2 after addition

of center

.32

* Data presented are based on the analytic data set of 1032 patients.y Only variables found to be significant (P<.05) are shown above.

Variables allowed into the model that were not significant included:

injury classification (C5-8 AIS grades AeC, paraplegia AIS grades AeC,

AIS grade D); ventilator use at rehabilitation admission; FIM motor

score at admission to rehabilitation (Rasch-transformed); CSI score;

etiology of injury (medical/surgical/other, violence, sports, fall,

vehicular); male sex; married; employment status at injury (retired,

working); highest education level completed at time of injury (high

school, college, <12y); work-related injury; primary language is

English; and primary payer (Medicare, Medicaid, worker’s compensa-

tion, private insurance/private pay).

was missed and could not be made up. The use of group therapy inresponse to missed individual therapy time could explain the weakinverse relation between individual and group therapy time. TRexperiences no pressure to meet the 3 hour rule, because TRservices are covered by insurers as part of the bed rate, are notbilled separately, and do not count toward the expected 3 hours oftherapy in IRFs. Patients who are appropriate for and choose toparticipate in TR may receive as much TR in groups or in indi-vidual form as is feasible to provide. Given the unique dynamicsof groups and the potential benefits those dynamics offer inachieving certain clinical goals, a trade-off between individual andgroup therapy does not necessarily imply a pattern of practice thatis less likely to produce positive outcomes. The extent to whichgroup therapy should be used in place of, or addition to, individualtherapy requires further study.

Study limitations

Data on group size were not collected; group size may have variedwidely. The analyses presented here tend to overestimate thepercent of therapy provided in groups as part of the overall therapypackage for all disciplines combined, because individual treatmenttime provided by disciplines other than PT, OT, TR, and PSY(eg, speech therapy and nursing) was not included in the calcu-lation of total treatment time. While considerable efforts weremade to monitor incoming data and retrieve missing data, sometreatment sessions were undocumented. Finally, these data werecollected from 2007 to 2010, and do not reflect changes in practicethat may have occurred subsequently.

Future work

Future analyses are needed to assess how the amount and timing ofgroup versus individual therapy in the rehabilitation package, overallor for specific disciplines or treatment types, relate to outcomes.Cost-effectiveness analyses would also be beneficial in assessing thevalue of group therapy in inpatient rehabilitation for SCI.

Conclusions

While the majority of inpatient rehabilitation services areprovided in individual sessions, most patients participate in grouptherapy, and group sessions contribute significantly to totaltherapy time. Time spent in group therapy varied considerablyamong centers, and it appears that factors other than patient

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Page 9: Group Therapy Utilization in Inpatient Spinal Cord Injury Rehabilitation

Group therapy in SCI rehabilitation S153

characteristics and clinician experience may contribute tobetween-center differences in group therapy use. Variation ingroup activities among injury subgroups is consistent with func-tional expectations and clinical goals. A trade-off between groupand individual therapies may occur for some disciplines in someinjury subgroups, but may be clinically appropriate depending onthe therapeutic goals of the group activity. Further study is neededto determine the impact of group therapy utilization on outcomesto identify optimal patterns of group therapy utilization.

Suppliers

a. SPSS version 20.0; IBM Corp, 1 New Orchard Rd, Armonk,NY 10504-1722.

b. SAS Version 9.3; SAS Institute Inc, 100 SAS Campus Dr, Cary,NC 27513-2414.

Keywords

Health services; Health services research; Occupational therapy;Physical therapy specialty; Psychology; Recreation therapy;Rehabilitation; Spinal cord injuries

Corresponding author

Jeanne M. Zanca, PhD, MPT, Kessler Foundation, 1199 PleasantValley Way, West Orange, NJ 07052. E-mail address: [email protected].

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