rehabilitation outcome for patients with spinal cord injury

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Rehabilitation outcome for patients with spinal cord injury A. M. DREWES, A. T. OLSSON, 0. SLOT AND A. ANDREASEN Spinal Cord Injury Unit, Departmenr of Rheumatology, Viborg County Hospital, Denmark Acceprrd for publicurion: December 1989 Correrpondrnce to: Dr Asbjprrn Mohr Drewes, Department of Rheumatology. Viborg County Hospital, DK-8800 Viborg, Denmark Key words Life conditions - Disability evaluation - Social adjustment - Return to work Summary A follow-up study of 58 patients with spinal cord injury was conducted. As measure of function the Barthel index was used. There was correlation between functional capacity and ability of self-care as well as some social determinants. However, no association was found with cmployment rate or certain other determinants of independent living, such as going on a holiday. We conclude that the severity of the lesion is a fundamental factor in determining the outcome, but factors related to personal and psychosocial variables, not easily measured. also have great influence on the rehabilitation process. Introduction The primary objective in rehabilitation after spinal cord injury (SCI) is to achieve the highest level of independence in self-care, e.g. activities of daily living. On the other hand one must not forget the psychological and social aspects of the rehabilitation process. Formerly, SCI patients had to live in institutions, whereas nowadays they are mainly integrated into society and therefore socioeconomic and environmental conditions are becom- ing a major consideration. The purpose of this study was to describe the rehabili- tation outcome for patients with a persistent handicap after SCI, not only at the time of discharge but also after adaptation to society. Another objective was to identify certain numerical determinants correlated to the adap- tation process. Patients and methods A study of the medical records of patients treated for SCI in 1980-1984 was carried out in April 1988. A follow- up investigation of a representative group of SCI patients with persistent handicap was subsequently conducted. Only patients aged 18-65 and admitted to hospital in direct connection with the injury were included. Excluded were patients who recovered to the extent that their functional status was almost the same as that of the normal population; those with a progressive disease, such as cancer; and those with a concomitant brain lesion. A questionnaire was sent to the study group. When data were missing, or there were discrepancies between the patient’s records and questionnaire responses, patients were interviewed. Epidemiological, demographic, and social character- istics were abstracted from medical records and question- naires. The data included approximately 100 items con- cerning each patient. In order to estimate functional status the Barthel index was used.’-4 This measures a person’s ability to live independently on a scale from 0 to 100, a score of 60 or below reflecting serious limitations in personal care independence. Assessments of the index at the time of admission were collected retrospectively from data in the medical records and information given by the patients. Data at the follow-up were given by patients in the y uestionnairdinterview. Non-parametric methods were used for statistical anal- yses. Wilcoxon’s test was used to test the significance between Barthel scores at discharge and at follow-up. Results from two independent samples were compared with the Mann-Whitney test or the x* test with Yates’s correction. Correlations were calculated by use of the Spearman rank correlation coefficient. Statistical signifi- cance was regarded as p<0.05. Results During the period studied, 109 patients were admitted to hospital, of whom four died; 85 were aged 18-65 years in April 1988. According to the exclusion criteria 12 patients had recovered near-normal function, nine had a progressive disease, and five had brain lesions. Of the remaining 59 patients, 58 (the follow-up group) agreed to participate. The age and severity of SCI is illustrated in Figure 1 ; the median age of patients was 20 years and the ma1e:female ratio was 2.6: 1, with females distributed uniformly in the age groups. In the quadriplegic group Figure 1 Age distribution at SCI of patients followed up. 178 0370-0797189 $3W 0 1980 Taylor & Francis Ltd Disabil Rehabil Downloaded from informahealthcare.com by UB Giessen on 11/01/14 For personal use only.

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Page 1: Rehabilitation outcome for patients with spinal cord injury

Rehabilitation outcome for patients with spinal cord injury

A. M . DREWES, A. T. OLSSON, 0. SLOT A N D A. ANDREASEN

Spinal Cord Injury Unit, Departmenr of Rheumatology, Viborg County Hospital, Denmark

Acceprrd for publicurion: December 1989 Correrpondrnce to: Dr Asbjprrn Mohr Drewes, Department of Rheumatology. Viborg County Hospital, DK-8800 Viborg,

Denmark

Key words Life conditions - Disability evaluation - Social adjustment - Return to work

Summary A follow-up study of 58 patients with spinal cord injury was conducted. As measure of function the Barthel index was used. There was correlation between functional capacity and ability of self-care as well as some social determinants. However, no association was found with cmployment rate or certain other determinants of independent living, such as going on a holiday. We conclude that the severity of the lesion is a fundamental factor in determining the outcome, but factors related to personal and psychosocial variables, not easily measured. also have great influence on the rehabilitation process.

Introduction The primary objective in rehabilitation after spinal cord injury (SCI) is to achieve the highest level of independence in self-care, e.g. activities of daily living. On the other hand one must not forget the psychological and social aspects of the rehabilitation process. Formerly, SCI patients had to live in institutions, whereas nowadays they are mainly integrated into society and therefore socioeconomic and environmental conditions are becom- ing a major consideration.

The purpose of this study was to describe the rehabili- tation outcome for patients with a persistent handicap after SCI, not only at the time of discharge but also after adaptation to society. Another objective was to identify certain numerical determinants correlated to the adap- tation process.

Patients and methods A study of the medical records of patients treated for SCI in 1980-1984 was carried out in April 1988. A follow- up investigation of a representative group of SCI patients with persistent handicap was subsequently conducted. Only patients aged 18-65 and admitted to hospital in direct connection with the injury were included. Excluded were patients who recovered to the extent that their functional status was almost the same as that of the normal population; those with a progressive disease, such as cancer; and those with a concomitant brain lesion.

A questionnaire was sent to the study group. When data were missing, or there were discrepancies between the patient’s records and questionnaire responses, patients were interviewed.

Epidemiological, demographic, and social character- istics were abstracted from medical records and question- naires. The data included approximately 100 items con- cerning each patient.

In order to estimate functional status the Barthel index was used.’-4 This measures a person’s ability to live independently on a scale from 0 to 100, a score of 60 or below reflecting serious limitations in personal care independence. Assessments of the index at the time of admission were collected retrospectively from data in the medical records and information given by the patients. Data at the follow-up were given by patients in the y uestionnairdinterview.

Non-parametric methods were used for statistical anal- yses. Wilcoxon’s test was used to test the significance between Barthel scores at discharge and at follow-up. Results from two independent samples were compared with the Mann-Whitney test or the x* test with Yates’s correction. Correlations were calculated by use of the Spearman rank correlation coefficient. Statistical signifi- cance was regarded as p<0.05.

Results During the period studied, 109 patients were admitted to hospital, of whom four died; 85 were aged 18-65 years in April 1988. According to the exclusion criteria 12 patients had recovered near-normal function, nine had a progressive disease, and five had brain lesions. Of the remaining 59 patients, 58 (the follow-up group) agreed to participate.

The age and severity of SCI is illustrated in Figure 1 ; the median age of patients was 20 years and the ma1e:female ratio was 2.6: 1, with females distributed uniformly in the age groups. In the quadriplegic group

Figure 1 Age distribution at SCI of patients followed up.

178 0370-0797189 $ 3 W 0 1980 Taylor & Francis Ltd

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Page 2: Rehabilitation outcome for patients with spinal cord injury

-- DREWES a/ d.: R e h a b i l i t a t i o n outconie af tc r SCI

(n= 17) 5 (29%) were incomplete, and in the paraplegic group (n=41) 11 (27%) were incomplete.

Thc median time from injury to transfer to the rehahilitation hospital was 45 days (range 7-194). Median durations ot stay in hospital were 194 days for paraplegics (range 4(&-531) and 271 for quadriplegics (90-437). After initial hospitalization patients were readmitted for regular control visits. Median time from discharge to follow-up was 6.2 years (range 3-8).

Barthel scores at discharge from hospital were quite similar to the findings of Yarkony e l Our median Barthcl scores were 38 (range 0-100) for quadriplegia and 75 (34-100) for paraplegia. In their 711 patients Yarkony et al. recorded mean scores of 46.2 and 74.4, respcctively. At follow-up the median Barthel scores were 40 (Ok100) for quadriplegia and 75 (42-100) for paraplegia. When compared with Barthel scores at discharge there were no significant differences (pXI.85).

Figure 2 shows the marital status of the patients, 60% of whom were living alone on first admission to the hospital. Median age at SCI was 19 years in the single and 30 years in the married group. At the time of follow- up seven were married and four divorced, so that 55% still lived alone.

Prior to injury 79% were employed, whereas at follow- up 16 (28%) were employed. Nine were employed full- time, one part-time, and six received various kinds of support at work. There was no sighificant relationship between functional ability expressed by Barthel scores and occupational status (p>0.3), nor was there a significant correlation between the extent or the completeness of the lesion and the employment rate. The median age of those employed at follow-up was 26 years, the follow-up interval for these individuals being 6.2 years - the same as for the entire group. Eighty per cent of salaried employees and 71% of those who had finished upper secondary school were at work. In the group of unem- ployed people (n=42) 33 (79%) were either homemakers (31°/c,), studying (22%), or engaged in cultural activities.

Specialized self-help devices used are shown in Table 1. Forty-seven (81%) had their own car, and all except one ot the paraplegics were able to get into the car and lift their wheelchair in on their own; only six quadriplegics (36%) were able to do this task. There was a significant

‘ \ I 18-26 married/cohabiting 23

INJURY I FOLLOW- UP I I

I

Figure 2 Marital status at SCI a n d at follow-up

correlation @<0.001) between Barthel score and this means of independent mobility.

Patients were asked how much help they had for self- care, such as grooming, toilet use, and bathing, and how much was needed for cleaning. The help needed for self- care varied, and no quadriplegics were independent; the type of assistance needed is listed in Table 2. There were significantly more quadriplegics @<0.001) who required help for personal needs, but no differences between the groups concerning external aid for cleaning. When the Barthel scores were related to the total amount of external aid (expressed as hours per week), a significant linear correlation was found ( r ( S ) = -0.64, p<O.OOl). To esti- mate social and recreational activities patients were questioned about whether they engaged in sports, other spare-time activities, or were going on holiday - shown in Table 3. No statistical correlations between these activities and the level of the lesion were found. On the other hand, significant associations between Barthel scores and activities such as sport (p<04l) and other spare- time occupations (p<045) were found.

Discussion Compared with previous studieskx our study group was a typical population of SCI patients in regard to demographic profile, aetiology of the lesion, and func- tional status expressed as a Barthel score. Although the group was not large i t was fairly homogeneous. A mean follow-up duration of 6.2 years could be argued as being too short for evaluation of overall adjustment. Nevertheless, previous investigators”.’” have suggested that after 2-3 years one would expect patients to have adapted physically as well as psychologically.

Previous studies5.” have documented the value of the Barthel index as a numerical expression of functional status. It is easy to perform, and the main advantage is its simplicity. That there were no significant changes in Barthel scores from discharge to follow-up would suggest that the rehabilitation process was complete at discharge, and that no further progress in functional status was to be expected. However, the Barthel score reflects only major aspects of functional status. Undoubtedly a lot of minor adjustments to better function in lifc as a severely disabled person take place in the years after discharge from a rehabilitation centre, without these being reflected in the Barthel score.

Abilities achieved after specific training easily vanish if not maintained, the hazard being that many patients are considered helpless by members of their family and too much external aid does not motivate the patient to enhance independence. This could lower functional status, like limitations in the environment by architectural and

Table 2 Number of patients with SCI nccditig extcrniil aid

Help for personal nccda Clcaning ;issi\taiicc

N o . Percentage N o . Pc rce nt age

Table I Spccializcd self-hclp dcviccs used hy patients with SCI (not cxcIu5ivc) Quadriplegic I I 65 I 4 K1 Paraplegic 4 I0 2.3 ’ih

Paraplegic Quadriplegic

N o . I’crccntagc N o Pcrcciwgc

1-loapit;il bed 5 I 2 10 5Y 1 5 3 Electric whcclchair 5 0 ..

Manual whcclch;iir 35 K5 I 6 94 Disahlcmcnl ciir 34 8.3 13 16 Bracer oi crutches 35 KS I I 6.5 Other 3 7 X 47

Table 3 Sockal and recrcaticinal activities cngagcd iii hy peticnta with SCI

Sport Other ;ictivitic\ T’r;ivclling yearly

N o . Percentage No. Pcrccntiigc N o , 1’crccnl;igc

Quadriplcgic 5 29 13 17 13 I? Paraplegic 19 46 31 76 26 h3

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Page 3: Rehabilitation outcome for patients with spinal cord injury

Int. Disabil. Studies, 1989; vol. 1 1 , no. 4

transport barriers restricting activity. In this way the status quo in Barthel scores could represent an advance that is masked. The rehabilitation process includes many aspects of post-injury life, and the Barthel index describes only functional aspects of living. Another way of ex- pressing functional capacity is the amount of external aid needed, such as nurses, domestic help, etc. A linear correlation of external aid was found with functional status. Fifteen patients, nearly all quadriplegics, needed assistance for personal care, of whom 14 had a Barthel score of less than 60. These results are the same as reported in earlier

The marital status of our patients reflected the youn age at SCI, and was similar to the results of Ghatit. Most patients were functioning in their own homes, and only one was living in a nursing home. Outcome of independent living, mobile lifestyle, and employment was earlier found to correlate statistically to marital status,’>lS demonstrating the importance of a family participating in social and recreational activities. No such effect could be demonstrated in our study, possibly because of the small number of married patients.

The employment rate of nearly 80% prior to injury was very high considering the many young people in the group. After SCI only 24% were employed; results from other studies have shown varying employment rates?.

l 3 but generally seldom exceeded 50% and were often much lower.’ Relatively high unemployment rates in society in general might impair the chances for disabled individuals getting a job. In our study there was no association between employment rate, severity of the SCI, and the Barthel score. Such an association has been suggested in other w ~ r k , ’ . ~ ~ . ~ ~ but the finding is consistent with our opinion that factors such as motivation and educational and socioeconomic resources are much more important for post-injury employment. This impression is supported by the high employment rate of patients who were highly educated or were salaried employees prior to injury.

We found no interaction between a person’s disability in terms of quadri- or araplegia and recreational data,

score and sport and other spare-time activities. One could argue that this finding might be explained by the fact that the patients with the highest Barthel scores were independently mobile in their own cars, but there was no statistical association between independence in mobility by car and these two parameters. The most likely explanation is that possibilities for sports and hobbies are too few for severely disabled persons. There was no association between functional index and travelling, again

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but an association was cf emonstrated between the Barthel

indicating that much more complex and unpredictable factors are res onsible for the independent living outcome.

We conch B e that many of the problems of SCI in the community relate to complex variables that are not easily measured, We suggest that in predicting the outcome of SCI one must focus on the psychosocial resources of the individual patient, as well as on the functional severity of the injury.

References 1 Granger CV, Albrecht GL, Hamilton BB. Outcome of compre-

hensive medical rehab ation: measurement by PULSES profile and the Barthel index. Archives of Physical Medicine and Rehabilitation 1979; 60: 145-153.

2 Mathoney FI, Barthel DW. Functional evaluation: the Barthel index. Maryland State Medical Journal 1965; 14: 61-65.

3 Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: a reliability study. International Dbability Studies 1988; 10: 61-63.

4 Wade DT, Collin C. The Barthel ADL Index: a standard measure of physical disability? International Disability Studies 1988; 10: 64-67.

5 Yarkony GM, Roth EJ, Heinemann AW, Wu Y, Katz RT, Lovell L. Benefits of rehabilitation for traumatic spinal cord injury. Multivariate analyses in 71 1 patients. Archives of Neurol- ogy 1987; 44: 93-96.

6 Eskesen B. Spinal paraplegia. A follow-up investigation of medical and social rehabilitation. Ugeskrift for lreger 1970; 132: 849-854 (summary in English).

7 Kuhn W, Zach GA, Kochlin Ph, et al. Comparison of spinal cord injuries in females and in males, 1979-1981, Basle. Paraplegia 1983; 21: 154-160.

8 Kurtzke JF. Epidemiology of spinal cord injury. Experimental Neurology 1975; 48: 163-236.

9 DeVivo MJ, Fine PR. Employment status of spinal cord injured patients 3 years after injury. Archives of Physical Medicine and Rehabilitation 1982; 63: 200-203.

10 Richards JS. Psychologic adjustment to spinal cord injury during the first post-discharge year. Archives of Physical Medicine und Rehabilitation 1986; 67: 362-365.

11 Woolsey RM. Rehabilitation outcome following spinal cord injury. Archives of Neurology 1985; 42: 116-119.

12 Forner JV, Miro R, Manteiga A, el al. Social and working conditions of our paraplegics. Paraplegia 1976; 14: 74-80.

13 Ghatit AZE. Outcome of marriages existing at the time of males spinal cord injury. Journal of Chronic Diseases, 1975; 28: 383-388.

14 DeJong G , Branc LG, Corcoran PJ. Independent living outcomes in spinal cord injury: multivariate analyses. Archives of Physical Medicine and Rehabilitation 1984; 65: 66-73.

15 Urey JR. Marital adjustment following spinal cord injury. Archives of Physical Medicine and Rehabilitation 1987; 68: 69-74.

16 DeVivo MJ, Rutt RD, Stover SL, Fine PR. Employment after spinal cord injury. Archives of Physical Medicine und Rehabilitation 1987; 68: 494-498.

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