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Rehabilitation Practices

Early vs Delayed Admission to Specialized SCI Units

As noted by others and in the previous section, earlier as opposed to delayed admission to interdisciplinary, specialized SCI units has been associated with a variety of beneficial outcomes (DeVivo et al. 1990). The question of whether earlier admission to an organized system leads to enhanced outcomes is inexorably linked to the question of specialist vs general care for individuals with SCI. In all studies in this and the preceding section the authors framed their studies as addressing either the question of delay or the question of interdisciplinary, specialist care yet similar designs were employed for each (i.e., retrospective case control). For those subjects experiencing a delay to admission to a specialized SCI unit, it was either presumed or established that preceding acute care was conducted at a general hospital unit. The author simply chose to characterize this as either a delay or more general care. For the present review we have maintained this distinction as originally intended by each author, especially, as in some cases, there is little or no verification of the general nature of the pre-admission care or the time of first admission, respectively. However, the reader is advised that the specific findings and conclusions reached in both sections are most likely associated with a delay to an interdisciplinary, specialized acute or rehabilitation SCI unit with prior care delivered at a general hospital facility. In addition, much variation exists in the literature that addresses the question of delayed admission. There is no uniform or accepted definition of what constitutes a delay and this varies depending on the context of the study, most notably whether it is conducted from an acute vs rehabilitation perspective. For the present review, all studies which examine this question by comparing 2 or more groups within the first week post-injury have been examined separately from those with an initial time period greater than 1 week post-injury. These have been termed 1) Acute and 2) Post-acute studies, respectively.

Author Year; Country
Research Design
PEDro Score
Total Sample Size

Methods Outcome

Dalyan et al. (1998); USA
Case Control
NInitial=482; NFinal=482

Population: 482 men and women with traumatic SCI admitted to a United States Model Systems SCI Centre with specialized SCI acute care and rehabilitation services. Subjects included those with tetraplegia (256) & paraplegia (226) and AIS A, B, C (362) & D (120).
Treatment: No intervention. Comparison of those admitted to a specialized spinal acute care and rehabilitation unit <24 hours post injury versus >24 hours-60 days post-injury
Outcome Measures: Incidence of contractures during initial post-traumatic hospitalization.

  1. Subjects who were admitted earlier (<24 hours) had significantly fewer contractures than those admitted later (>24 hours – 60 days) (p=0.05).
  2. Other factors associated with an increased incidence of contractures included tetraplegia versus paraplegia (p<0.01), presence of a pressure ulcer (p=0.05), co-existence of head injury (p<0.05).

De Vivo et al. 1990; USA
Case Control NInitial=661; NFinal=661

Population: 661 people with SCI admitted to a United States Model Care System Centre with specialized SCI rehabilitation services. Subjects included those with tetraplegia and paraplegia and also those with incomplete versus complete injuries but frequencies were not provided. Average ages for early versus delayed admission groups were 29.5 and 32.0 years old respectively.
Treatment: No tx per se, comparison of those admitted earlier (<24 hours post injury) versus later (>24 hours) to a specialized integrated spinal unit (i.e., combined acute care and rehabilitation). Subjects were sub- grouped into i) paraplegia, incomplete, ii) paraplegia, complete, iii) tetraplegia, incomplete, iv) tetraplegia, complete.
Outcome Measures: LOS, Hospital charges, Incidence of medical complications, Neurologic recovery, Mortality all collected at Discharge.

  1. Those with complete paraplegia (p=0.0169) & incomplete tetraplegia (p=0.0001) admitted earlier (<24 hours) had significantly shorter total hospitalization LOS. A similar trend for those with incomplete paraplegia (p=0.0568), no difference for those with complete tetraplegia (p=0.928).
  2. Mean hospital charges were less for subjects with complete (p=0.0099) and incomplete (p=0.0134) tetraplegia who were admitted earlier. Similar trend for those with incomplete paraplegia (p=0.0607), no difference for complete paraplegia (p=0.4777).
  3. In general, no overall differences were seen in the development of medical complications between the early versus late admission groups. A few differences for incidence specific complications.
  4. Trend for increased neurologic recovery with early admission in that 10/315 (3.2%) versus 4/401 (1.0%) in early versus late groups had complete recovery (p=0.08). Author warns of bias in this finding.
  5. Mortality comparisons not possible within sample for early versus late admission groups. Comparison with historical data suggests enhanced survival rates with early admission.

Author Year; Country
Research Design
PEDro Score
Total Sample Size

Methods Outcome

Scivoletto et al. (2006); Italy
Case Series
N=117

Population: Mean age=55.1yr; Gender: males=71, females=46; Level of injury: C=37, T=59, LS=21; Severity of injury: AIS A=36, C=53, D=28; Etiology of injury: non- traumatic=81, traumatic=36
Treatment: Charts of patients admitted to rehabilitation 90 days or more post injury (mean 136±55.6 days) were examined. All patients received individual PT 40 minutes twice a day, 5 days a week and one 60 min therapy on Saturday. Patients also received water therapy 45 mins twice weekly and OT 45 min 3day/week.
Outcome Measures: BI, Walking Index for Spinal Cord Injury (WISCI), Rivermead Mobility index (RMI), bladder management, discharge destination, AIS. All collected at admission and discharge.

  1. Delayed admission still resulted in significant improvement in:
  2. BI, WISCI, RMI, Motor scores, gait (p<0.001).
  3. Mean LOS was 99.7±62.5 days (median 100 days).
  4. At discharge 49 of 117 patients were able to achieve normal bladder control, 28 used clean intermittent catherization and 34 self intermittent catherization.
  5. 90% (104) patients returned home post rehabilitation, 8% were transferred to acute ward due to complications, and 2% were discharged to other rehabilitation facilities.
  6. No significant neurological recovery was seen in the AIS A group; however, 51% of those in the AIS C group improved to AIS D (p=0.007).

Amin et al. (2005); England
Case Control NInitial=432; NFinal=432

Population: SCI, tetraplegia, paraplegia, traumatic.
Treatment: No intervention. Comparison of those admitted to a specialized integrated spinal unit (i.e., combined acute and rehabilitation) with or without a delay between injury and referral (>3 days) and between referral and admission (>7 days).
Outcome Measures: LOS.

  1. Those admitted with a delay (>7 days) following referral had significantly longer LOS (p<0.001). This was for people with both complete (N=59) and incomplete (N=29) injuries but not for those without spinal cord damage (N=24).
  2. More severe injuries (as determined by Injury Severity Scores) were more likely to have longer LOS (Spearman’s =0.593, p<0.0001).
  3. Those who were admitted with a delay between injury and referral (>3 days) did not differ on LOS with those who did not experience a delay (p=0.44).
  4. The primary reasons for delays between referral and admission for those with complete injuries were I) achieving medical stability and ii) absence of beds. For those with incomplete injuries the same primary reasons were identified but in reverse order.

Scivoletto et al. (2005); Italy
Case Control NInitial=150; NFinal=150

Population: SCI, tetraplegia, paraplegia, complete, incomplete, traumatic.
Treatment: No intervention. Comparison of those admitted to a specialized Spinal Rehabilitation unit at one of 3 time periods following injury (<30 days, 31-60 days, >60 days).
Outcome Measures: LOS, AIS motor scores and impairment grade, BI, Rivermead Motor Index (RMI), Walking Index for SCI (WISCI), Efficiency measures for all were calculated by dividing by LOS.

  1. Those admitted earliest (<30 days) had significantly better BI at discharge than those with longer delays (>60 days) (p=0.006). They also demonstrated significantly greater changes (p=0.003) and greater efficiency (p<0.001) on the BI.
  2. Those admitted the earliest (<30 days) had significantly better mobility (i.e., RMI) at discharge than those with longer delays (>60 days) (p=0.03). They also demonstrated significantly greater changes (p=0.001) and greater efficiency (p=0.04) for the RMI.
  3. There were no significant differences between the early versus later admissions with respect to walking (WISCI) or ASIA motor scores (p=0.63 or p=0.81).
  4. Those admitted earliest had the shortest LOS; these differences were not significant (p=0.15).

Sumida et al. (2001); Japan
Case Control NInitial=139; NFinal =123

Population: 123 people with SCI admitted to a Japanese Hospital System with specialized SCI rehabilitation services following acute care. Subjects included those with tetraplegia and paraplegia (frequencies not provided) with AIS A (51), B (8), C (35) and D (29).
Treatment: No intervention. Comparison of those admitted earlier (<2 weeks post injury) versus later (>2 weeks) to a specialized spinal rehabilitation unit. Subjects were sub- grouped into i) tetraplegia, ii) paraplegia, iii) central cord.
Outcome Measures: LOS, FIM, FIM motor score, FIM gain, FIM efficiency all collected at Discharge.

  1. Subjects who were admitted earlier (<2 weeks) had significantly shorter LOS than those admitted later (p<0.0005).
  2. FIM gain (p<0.0001) and FIM efficiency (p<0.0001) were significantly greater for subjects admitted earlier versus later. Note: the early admission subjects had lower initial motor and total FIM scores than did the delayed admission group (p<0.05).
  3. Correlations between ASIA motor and FIM scores in various subgroups and at admission and discharge yielded a variety of associations ranging from very weak to strong correlations (r=0.03-0.92) with the majority of these correlations significant (p<0.05).

Aung & El Masry (1997); UK (Wales)
Case Control NInitial=219; NFinal=219

Population: 173 men (mean age 35.5) and 46 women (mean age 44.2) with traumatic SCI admitted to a Spinal Injuries Centre with specialized SCI acute care and rehabilitation services. Subjects included those with tetraplegia (116) and paraplegia (103).
Treatment: No intervention. Comparison of those admitted 1. (<1 week post injury) versus 2. (<2 month) versus 3. (>2 months) to a specialized spinal acute care and rehabilitation unit.
Outcome Measures: LOS, incidence of secondary complications all collected at discharge (i.e., during initial post-traumatic hospitalization).

  1. Subjects with paraplegia who were admitted earlier (<1 week and <2 months) had significantly shorter LOS than those admitted later (p<0.05).
  2. Subjects with tetraplegia who were admitted earlier (<1 week) had significantly shorter LOS than those admitted later (>2 months) (p<0.05).
  3. The incidence of most secondary conditions did not differ between early versus later admissions for those with paraplegia or tetraplegia. However, those with paraplegia or tetraplegia did have lower incidence of pressure sores with earlier admission (<1 week) (p<0.001).

Oakes et al. (1990); USA
Case Control NInitial=197; NFinal=197

Population: 197 people with traumatic SCI admitted within 1 year of injury to a Level 1 trauma Centre with specialized SCI rehabilitation services. Male / female (158 / 39); Tetraplegia / paraplegia (102 / 95); Average ages for groups were 27.2 –32 years old.
Treatment: No intervention. Comparison of those admitted earlier (<median) versus later (>median) to a specialized integrated spinal unit (i.e., combined acute care and rehabilitation). Subjects were grouped by tetra versus para and by early versus late admission by median admission values of 11 (tetraplegia) versus 21 (paraplegia) days.
Outcome Measures: LOS, incidence of medical complications, incidence of surgical intervention.

  1. Those admitted earlier had significantly shorter total hospitalization LOS (p<0.01).
  2. Those admitted earlier with tetraplegia had fewer medical complications and less frequent spinal surgery versus those admitted later (no group analysis performed). Those admitted earlier with paraplegia had no difference in medical complications and more frequent spinal surgery.
  3. Similar reductions in total hospitalization LOS with earlier admissions for both those with tetraplegia (p<0.01) and paraplegia (p<0.05) in a re-analysis of the sample with groupings based on admissions <24 hours versus >24 hours post-injury.

Discussion

The present section describes a series of studies in which investigators examined the effect of delayed admission to a specialist SCI unit. However, there is not a common definition of what constitutes a “delayed” admission. Therefore, to assist the reader in summarizing these delays, the details of the various time frames under examination are outlined along with their respective results in Table 13.

Study

Experimental Groups (time post- injury)

Outcome Measure Result

Amin et al. (2005)

  • <=3 days
  • >3 days
    or
  • <=7 days from referral*
  • >7 days from referral

LOS

LOS

+

Scivoletto et al. (2005)

  • <=30 days*
  • 30-59 days
  • >60 days

LOS
Functional Status
Neurological Status

~
+

Sumida et al. (2001)

  • <=2 weeks*
  • >2 weeks
LOS
Functional Status
Neurological Status

+
+
+

Dalyan et al. (1998)

  • <=24 hours*
  • >24 hours

Secondary complications (contractures)

+

Aung & El Masry (1997)

  • <=1 week*
  • <2 months

LOS
Secondary complications

+

DeVivo et al. (1990)

  • <=24 hours*
  • >24 hours

LOS
Secondary complications
Neurological Status

+

~

Oakes et al. (1990)

  • <=11 days (for tetraplegia)*
  • >11 days
    or
  • <=21 days (for paraplegia)*
  • >21 days

LOS
Secondary complications

+
+ (tetraplegia only)

Two acute studies were reviewed which each employed retrospective, 2 group (case control) designs with a definition of 24 hours as to what constituted an “early” vs a “delayed” admission (DeVivo et al. 1990; Dalyan et al. 1998). Each study examined a fairly large cohort admitted to a multidisciplinary, specialized SCI unit (i.e., US model system center) within 24 hours post-injury vs those admitted after 24 hours. Neither study reported the actual injury to admission times for the “delayed” admission group and both failed to provide information about the referral sources (e.g., specialist vs. general nature). DeVivo et al. (1990) noted that total hospital LOS (i.e., acute and rehabilitation) was reduced for all patient groups except for those with complete tetraplegia when admission was not delayed. Mean hospital charges were also reduced for early admission subjects except those with complete paraplegia and there were some reductions in the incidence of specific medical complications with early admission for some patient groups, most notably a trend for a reduction in pressure sores for all but those with incomplete paraplegia. In addition these authors also reported a trend for increased neurologic recovery and reduced mortality with earlier admission, although they also noted methodological concerns associated with the actual measures employed. Dalyan et al. (1998), in a study focusing on the development of contractures, noted a reduced incidence of contractures for those admitted within 24 hours to a specialized unit. Of the studies examining time periods longer than one week (i.e., post-acute), five studies have been reviewed (Oakes et al. 1990; Aung & el Masry 1997; Sumida et al. 2001; Amin et al. 2005; Scivoletto et al. 2005). The initial admission delays examined ranged from 1 week (Aung & el Masry 1997) to 1 month (Scivoletto et al. 2005). All studies employed retrospective case control designs and all examined LOS for the entire period of initial hospitalization as a primary outcome measure. In all cases, those admitted earlier had reduced LOS, regardless of the considerable variation between studies in the definition of what constituted a delay in admission. It should be noted that this difference to LOS was statistically significant for all studies but one; for which it was reported as a trend (p=0.15). This study examined the longest delay of 1 month (Scivoletto et al. 2005). Functional benefits were also demonstrated for individuals admitted earlier. Scivoletto et al. (2005) reported that those admitted earlier than 1 month had significantly greater gains and greater efficiency associated with the Barthel Index (BI) as well as greater mobility gains and efficiency as measured by the Rivermead Mobility Index (RMI) but there was no difference with respect to walking as measured by the Walking Index for SCI (WISCI). Similarly, Sumida et al. (2001) reported increased Functional Independence Measure (FIM) gains and efficiencies for those admitted earlier than 2 weeks post-injury as compared to those admitted later. Interestingly, these investigators also showed that for a majority of the various patient groups tested (i.e., paraplegia and tetraplegia, early and late), significant associations were seen between a measure of function (i.e., FIM) and a measure of impairment (i.e., ASIA motor scores). However, Scivoletto et al. (2005) found no effect of early vs. late admission on AIS motor scores. A follow-up study conducted by Scivoletto et al. (2006) reported significant improvements in all measures employed in their prior study (i.e., BI, RMI, WISCI, ASIA motor scores) as assessed between admission to discharge even in those subjects that were admitted at ≥90 days post-injury – although there was no control condition reported to confirm that these improvements were different than might have been seen with earlier admission. Taken together, these studies suggest better outcomes are seen with earlier admission, although improvements are still possible even if rehabilitation onset is delayed for several months. Other investigators examined the role of early vs late admission on the incidence of secondary medical complications. Oakes et al. (1990) reported that earlier admissions were associated with a reduced incidence of secondary medical complications in those with tetraplegia and Aung and el Masry (1997) noted a reduction in the number of pressure sores for all subjects with earlier admission. Despite the apparent benefits of earlier admission to a multidisciplinary, specialized integrated SCI unit, there are significant issues which serve to constrain the strength of evidence in this area. First and foremost is the retrospective nature of all studies conducted to date. It is difficult to ascertain how comparable the “early” vs “later” groups truly are with respect to potential confounding variables. In particular, there is a paucity of information on the pre-admission level of care and medical status, especially for the delayed admission groups. In addition, it is difficult to discern the potential role that medical status or the presence of secondary medical complications may have played in admission delays. The retrospective nature of the studies outlined in this and the previous section makes it difficult to determine if individuals prone to complications and with poorer medical status would have naturally comprised a greater proportion of the delayed admission groups. Therefore, as noted earlier, more carefully controlled prospective studies would be required to strengthen the evidence in this area.

Conclusions – Benefits of Early vs Later Admission

Based on several retrospective, case-control studies there is level 3 evidence that individuals admitted earlier to interdisciplinary, integrated specialist SCI units have a shorter total hospitalization length of stay than those admitted later.

There is level 3 evidence that individuals admitted earlier to interdisciplinary, integrated specialist SCI units make greater functional gains in a shorter period of time (i.e., greater efficiency) than those admitted later.

There is level 3 evidence that individuals admitted earlier to interdisciplinary, integrated specialist SCI units have fewer secondary medical complications (especially pressure sores) than those admitted later.

There is level 4 evidence for positive utility of admission to rehabilitation even at delays ≥90 days post injury. Because of the variability between studies as to what constitutes “early” admission to interdisciplinary, specialist integrated SCI units, it is not possible to determine a specific period for optimal admission. At least one study has demonstrated benefits with an early admission described as ≤30 days post-injury. The majority of studies defined early admissions as 1-2 weeks post-injury, while studies focused on acute care describe early admission as within 24 hours post-injury.

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