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Functional Independence

Motor and sensory impairments after spinal cord injury cause a variety of functional impairments. Functional impairments are defined as restrictions that hinder an individual’s ability to perform tasks or activities (Jette 2006). Functional tasks are often described in terms of basic activities of daily living such as walking, climbing stairs, bathing and grooming. With complete lesions, higher levels of injury cause greater motor and sensory impairment, which are associated with greater functional impairments (Aidinoff et al. 2011). Incomplete lesions produce a more complicated pattern of motor and sensory impairments (Yilmaz et al. 2005). Individuals who have problems performing functional tasks frequently rely on a combination of assistive devices and assistance from others. Haisma et al. (2008) found that functional motor independence improved during in-patient rehabilitation and remained relatively stable one year post-discharge. Given that functional independence is a strong, significant predictor of care needs over time (Cohen et al. 2012), it is extremely important to understand the long-term functional independence of individuals with spinal cord injury.

In this section, 1 systematic review and 5 longitudinal studies on functional independence after SCI are reviewed.

Table 12: Systematic Review on Functional Independence

Author Year; Country

Date included in the review

Total Sample Size
Level of Evidence

Type of study



Al-Habib et al. 2011;

Saudi Arabia


Reviewed published articles from 1966 to April 2008




Level of Evidence:

Class 1 and 2:


Type of study:

3 retrospective cohort

1 retrospective analysis of an RCT

3 observational




Method: Literature search for published English articles that explored clinical factors associated with neurological and functional outcomes following traumatic SCI in adults.

No intervention.

Outcome measures include ASIA classification, FIM, SCIM and SF36.


Databases: MEDLINE and EMBASE.

1.     Patient related Predictors:

Level 2 Evidence:

– Motor recovery (as measured by ASIA) and functional recovery (as measured by SCIM) decreases with advancing age for complete SCI patients.

– Age is not a significant predictor when incomplete SCI were included in the analysis.

In this systematic review, the authors report thatmotor and functional recovery decreases with advancing age for complete SCI. They also report no association between recovery and age for individuals with incomplete SCIs. Only three studies were included in this review that examined the association with age. This may indicate a dearth of evidence on the impact of aging on functional independence, and that the results should be interpreted with caution.

Table 13: Aging and Functional Independence

Author Year; Country
Research Design
Total Sample Size
Eriks-Hoogland et al. 2016;

The Netherlands


Level 2




Population: At discharge: 138 people with SCI (71.7% M);

Mean TSI (d)=311 (range 98-809); mean age (y)= 39.4 (range 18.6-66.3);

Type of injury: tetraplegia (34.1%), motor complete (65.2%);

90 had the ability to independently transfer.


Methodology: Participants were recruited from 8 Dutch rehabilitation centers. Participants completed measures of shoulder ROM and pain assessment at discharge, and completed the questionnaire data 5 years after discharge.


Outcome Measures: Peak power output (POpeak), Wheelchair Skills Test (WST), FIM motor score, ability to transfer, Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), mobility range and social behavior subscales of the Sickness Impact Profile 68 (SIPSOC), and employment status.

1.     Shoulder ROM, but not shoulder pain at discharge, was associated with a lower ability to make an independent transfer, a lower FIM motor score, and a lower likelihood to return to work five years later.

2.     Neither shoulder ROM nor shoulder pain at discharge were found to be associated with POpeak, SIPSOC, and the PASIPD scores 5 years after discharge.


Hinrichs et al. 2016;



Level 5





Population: 949 participants with SCI (73.8% M, 27.2% F); median age (y) = 51 (range 17-90); median TSI (y)= 18 (8-29)


84 people were aged 16-30 (8.9%); 256 people were aged 31-45 (27%); 367 people were aged 46-60 (38.7%); 195 people were aged 61-75 (20.6%); 47 people were aged 76+ (5%);


Injury characteristics: Tetraplegia (n=294, 31.1%), paraplegia (n=650, 68.9%)


Methodology: Participants using a wheelchair who were able to move moderate distances of 10-100 m were included to answer paper and web-based questionnaires

and telephone interviews.


Outcome Measures: Mobility-related items of the Spinal Cord Independence Measure-Self Report (SCIM-SR) were matched to the three principal domains “changing basic body position,” “transferring oneself” and “moving around.” Binary outcomes (“independence” vs. “no independence”) were created for every domain and analyzed using multivariable logistic regression (adjusted for sex, socioeconomic factors, SCI characteristics, and health conditions)

1.     A systematic decrease in independence for performing mobility tasks when progressing from 16- to 30-year-old up to 76+ year-old wheelchair users with SCI was observed.

2.     The odds of being independent decreased with age in all mobility domains.

3.     Men had higher odds of being independent in “transferring oneself” and in “moving around” than women.


Hernandez et al. 2014;


Level 2






Population: 144 participants in the SCI group: mean age (y) = 37.33±15.02;


260 participants in the burns group: mean age (y) = 39.97±16.97;


260 participants in the IAF (interarticular fractures) group: mean age (y) = 44.33±17.83


Participants were a subset of a larger longitudinal study conducted by the Injury Control Research Center at the University of Alabama.


Methodology: Outcome measures were administered 12, 24, 48, and 60 months post discharge to study life satisfaction trajectories over the first 5 years following medical discharge for an SCI, burn injury, or IAF. Data was collected through interviews.


Outcome Measures: Functional Independence Measure (FIM), Family Satisfaction Scale (FSS), Life Satisfaction Index (LSI), marital status

1.     There were significant FIM score differences between injury groups. At initial measurement, individuals with an SCI had significantly greater functional impairment than individuals with an IAF or burns.


LaVela et al. 2016;



Level 5



Population: 496 people with SCI (93.71% M): mean age (y)=62.1 (range 25-91); mean TSI (y)=23.06 (range 2-62); paraplegia (60.28%), tetraplegia (39.72%)


233 were “below norm” with regards to self-care, and 263 were “above norm”.


Methodology: To examine factors influencing self-care behaviors in people with spinal cord injuries and disorders (SCI/D), veterans with living with SCI/D reported perceptions of independence in performing self-care behaviors, and resilience.


Outcome Measures: Spinal Cord Injury- Quality of Life (SCI-QOL), Spinal Cord Injury-Functional Index (SCI-FI)


1.     Level of injury, resilience, marital status, and living arrangement were positively related to higher self-care behaviors

2.     Completeness of injury, age, age at injury, and number of comorbid health conditions showed negative relationships with self-care. So a positive relationship with health care is related to younger age, living alone, paraplegic level injury, and fewer health conditions.

Ma et al. 2016;



Level 5







Population: 87 sustained a pediatric SCI (61 M, 26 F): mean age (y)=38.6±12.3, mean YPI=24.1±14.0


87 sustained a SCI in adulthood; 62M, 25 F): mean age (y)=39.5±10.9, mean YPI=12.8±10.0


Total of 174 people with SCI: complete injury (47.1%), incomplete injury (52.9%)


Methodology: Participants who sustained an SCI <19 years old (pediatric injury) were matched for lesion level, severity, gender, age, education and ethnicity with participants who sustained an SCI ≥19 years old (adult injury) to compare differences in status, participation and life satisfaction.


Outcome Measures: Functional Independence Measure (FIM), Short Form (36) Health Survey (SF-36), physician visits, Patient Health Questionnaire (PHQ-9), Physical Activity Recall Assessment for People with SCI (PARA-SCI), Craig Handicap Assessment and Reporting Technique (CHART), Satisfaction with Life Scale (SWLS)

1.     Those with a pediatric SCI reported significantly less pain, fewer visits to the physician in the past year, greater functional independence, social participation, occupational participation and minutes per day of moderate-to-vigorous physical activity than those who sustained an SCI in adulthood.

2.     No significant differences were found for the measures of depression, perceived health status or life satisfaction.

3.     With the exception of moderate-to-vigorous physical activity and visits to the physician in the past year, between-group differences were independent of YPI.

Wirz et al. 2015;



Level 2



Population: 214 younger adults with SCI (age 20-39); 139 motor complete, 75 motor incomplete;


199 elderly participants with SCI (age 60-79); 65 motor complete, 134 motor incomplete


Methodology: Data on participants was acquired by SCI rehab centers within the study group of EMSCI. Examinations were performed at 2 weeks, 1, 3, 6, and 12 months after SCI to examine the recovery of sensorimotor function and ADLs after cervical SCI and the influence of age.


Outcome Measures: Upper Extremity Motor Score (UEMS), Spinal Cord Independence Measure (SCIM), activities of daily living (ADL), and compound motor action potentials (CMAP) to ulnar nerve stimulation.

1.     Initial UEMS and its change over 5 months, as well as the initial SCIM score, did not differ between younger adults (20–39 years) and elderly (60–79 years) participants. However, the change in SCIM score over 5 months was significantly greater in the younger patient group.

2.     Initial UEMS, SCIM, and ulnar CMAP, reflecting peripheral nerve damage (motoneurons and roots), were significantly greater in incomplete, compared to complete, SCI, regardless of age group.

3.     The initial assessment of UEMS in combination with CMAP recordings allows an early prediction of ADLs outcomes in both younger and older adults.

Dunn et al. 2014;

New Zealand


Level 2




Population: 18 males and 1 female with SCI;

Mean age (y)= 53±4 (range 47-62), mean TSI (y)= 31±4 (range 26-39), mean time since first upper limb surgery (y)=26±2 (range 23-30)

Level of SCI: C5=3, C6=9, C7=7


Methodology: Hand function outcomes in 2012 were compared with those obtained 11 years earlier. Participants in this study have all had previous forearm tendon transfer surgeries in between 1982 and 1991.


Outcome Measures: International Classification of Hand Surgery for Tetraplegia (ICSHT), digital analyzer (DA) for key pinch and grip strength, Lamb and Chan questionnaire

1.     Performing pressure relief and propelling a manual wheelchair on level ground or up a ramp were characterized as being worse or much worse over the past 11 years. These findings correspond with the increased number of participants who used a power wheelchair in 2012 (64%) compared with 2001(26%).


Rodakowski et al. 2014;



Level 2





Population: 1660 participants with SCI (78.6% M): mean age at injury (y)=34.4±14.6 (range 6-88); incomplete paraplegia (15.7%), complete paraplegia (33%), incomplete tetraplegia (29.9%), complete tetraplegia (21.3%);


Methodology: Participants attending the SCI Model Systems between 1988-2011. Data was mostly collected at the initial hospitalization and every 5 years post-SCI to examine the additive effect of age on disability for adults with SCI.


Outcome Measures: Motor items from the Functional Independence Measure (FIMmotor)

1.     Age at injury, but not necessarily aging, was significantly associated with the motor FIM score. Those who were younger at time of injury had higher motor FIM scores when discharged from rehabilitation.

2.     The older an individual is when they sustain an SCI, the more rapidly their disability progressed over time.

3.     When plotted against time since injury over 15-20 years, motor FIM scores, indicated that an individual’s level of independence in daily activities increased before it decreased.

Wilson et al. 2014;



Level 2




Population: 335 “Younger” (<65 y/o) people with SCI (79.7% M): mean age (y)=39.7±14.2; AIS A (37.6%), AIS B (15.8%), AIS C (14.6%), AIS D (31.9%)


41 “Older” (≥65 y/o) people with SCI (65.6% M): mean age (y)=72.5±5.6; AIS A (24.4%), AIS B (24.4%), AIS C (22%), AIS D (29.3%)


Methodology: SCI patients from a multicenter dataset included in the analysis were split to study the age-related differences in long-term functional outcome after traumatic SCI after a 1-year follow up.


Outcome Measures: Functional Independence Measure (FIM) motor score at 1-year.

1.     In participants aged 65 or older there was a significantly lower mean FIM motor score observed among them as compared with the younger group.

2.     There were no significant differences in motor recovery or AIS grade conversion between the younger and older groups, regardless of the cutoff considered

3.     Although older patients had decreased follow-up FIM motor scores overall, this effect was greatest for AIS B and AIS C patients and lesser for AIS A and AIS D patients.

Cohen et al. 2012;


Level 3 Case-control

Level 4


Population: 11,685 people with SCI (9071M, 2614F); Available number of participants at follow up: Year 1=9644, Year 5=5323, Year 10=2763, Year 15=1144, Year 20=191.

Methodology: Data from the National Spinal Cord Injury Statistical Center database (1988–2010) were analyzed. The authors investigated the association between motor FIM at rehabilitation discharge and residential status, survival and outcomes at 1, 5, 10, 15 and 20 years follow-up. Regression controlled for injury completeness, neurological level, demographic characteristics and temporal effects.

Outcome Measures:  FIM, residential status, hospitalizations, days hospitalized in previous year, daily paid and total care and paid hours worked.




Pershouse et al. 2012; Australia

Level 3 Case-control

Level 4


Population: 270 persons with traumatic SCI (81% male); mean (SD) age in yrs: 43.3(11.4), range 20-76; mean (SD) age at injury in yrs: 27.3(9.7).

Methodology: Data were collected via telephone interviews and written questionnaires annually over 5 years, between 2004 and 2008, across 6 strata comprising participants grouped according to time since injury (<5y, 5–9y, 10–14y, 15–19y, 20–24y, ³25y).

Outcome Measures:  motor subscale of FIM (mFIM)

1.     There was a significant decrease in activity as measured by the mFIM for higher functioning individuals

2.     Activity limitations significantly increased with duration of injury.


Mitchell & Adkins 2010;


Longitudinal with AB controls

Level 2

N SCI=26

N controls=38

Population: 26 individuals with SCI, mean(SD) age at baseline 50.3(11.2) yrs, mean(SD) YPI at baseline 25.2(14.2); YPI >5 yrs, no cognitive impairment. 38 age matched AB controls, mean(SD) age at baseline 50.4(11.5) yrs.

Methodology: Data collection at two time periods 5 years apart from 1999 – 2002, and 2004 -2007.

Outcome Measures:  

1.     Over time, the SCI group differed significantly from comparison group on the following measures: lower score on ADLs and lower score on IADLs.

follow-up mean=4.42 vs.2.42) control group (6.95 vs. 6.45).

Amsters et al. 2005;



Level 2


Population: 84 persons with SCI (70M, 14F) who sustained injury >20 yrs previously and were >15 yrs old at time of injury; mean (SD) age in yrs: 52(9.3), range 40-78; mean (SD) DOI in yrs: 28(6.2), range 20-51; mean (SD) age at onset in yrs: 24(7.2), range 15-49.

Methodology: Motor subset scores of the Functional Independence Measure (FIM) and a single scale measuring mobility aids status (MAIDS) were collected via telephone interview with participants for three points in time – post discharge from initial rehabilitation (discharge point), approx. 10 YPI (mid point), and currently (current point).

Outcome Measures:  Motor subset scores of FIM (included items on self care, sphincter control, mobility, and locomotion), single scale measuring mobility aids status

1.     A significant number of participants (n=45) perceived that their function had increased between the discharge and mid points and had subsequently decreased between the mid and current points (n=39). Age, age at onset and duration of injury did not significantly differ between those who experienced functional improvement, remained unchanged or declined.

2.     More individuals experienced functional improvement between the discharge and mid points for Mobility, Locomotion, and Self Care while significantly more individuals experienced functional decline between the mid and current points for Mobility, Locomotion, and Self Care.

3.     Participants also reported an increasing dependence on mobility aids between the mid point and the current point.

3.     Those who reported functional decline between the mid and current points were significantly older than those who did not report functional decline but did not differ in duration of injury or age at onset.

Hall et al. 1999;



Level 2

N: at rehab admission (3971);

Discharge (4033); 1 year post-injury (903); 2 years post-injury (712); 5 years post-injury (570)


Population: Data drawn from SCI Model Systems National Database. The total number of cases at each time point are listed. Inclusion criteria include, >16 years old, AIS A/B/C, admitted to inpatient rehabilitation within 60 days after injury.


Methodology: FIM scored by observation at inpatient rehabilitation admission and discharge. Follow-up ratings obtained mostly by interview of the client, either by phone or in person.


Outcome Measures:  FIM motor and cognition subscales

1.     FIM motor items were consistent with level of injury and neurological status, providing information on functional independence across a continuum.

2.     Trends over years 1, 2, and 5 were stable for both motor and cognition subscales. FIM motor gains were greatest between admission and discharge, and gains continued through 1 year after injury, but at a much-decreased rate.

3.     No difference in FIM mean motor gain scores between those whose neurological level did or did not improve between inpatient rehab admission and discharge. Gains remained the same for those who improved from grade A to B or C. However, statistically significant greater gains were seen for those who improved from B to C, B to D or C to D.

Piazza et al. 2015;


Level 5

Cross-section w/ AB




Population: 239 persons with SCI; mean age (y)= 50.3±11.5, mean TSI (y)=20.3±11.66 (range 5-65); tetraplegia (52%), paraplegia (47%)


Methodology: An SCI sample and non-SCI sample (NSDE II) were age and gender matched. Both groups were interviewed to examine whether there are age differences in daily affect and affective reactivity to daily stressors.


Outcome Measures: Activities of Daily Living (ADL), chronic health conditions, daily negative affect (NA), daily positive affect (PA), Daily Inventory of Stressful Experiences (DISE).

1.     Of the 1,079 NSDE II participants, 375 reported having some difficulty bathing/dressing oneself; climbing one flight of stairs; and walking one block so they were subsequently excluded as possible comparison participants.



All the studies report some decline in functional independence over time, although interestingly, Amsters et al. (2005) found that individuals with SCI perceived functional improvements in the first 10 years post-injury and then a subsequent decline. This study suffers from recall bias as individuals were asked to recount their function from up to 10 years post-injury.


There is level 4 evidence from one retrospective longitudinal study (Pershouse et al. 2012) that functional independence decreases with more years post injury for individuals who were higher functioning at one year.

There is Level 4 evidence from one longitudinal study (Amsters et al. 2005) that individuals with SCI (³20 YPI) perceive functional improvements up to 10 YPI and subsequent functional decline and greater dependence on mobility aids after 10 or more YPI.

  • Functional independence decreases with more years post injury.