Intensity

Although it is commonly assumed that the therapies delivered during inpatient rehabilitation are effective, there is little direct evidence that demonstrates a clear relationship between rehabilitation practices and enhanced functional recovery (Heinemann et al. 1995). Due to the nature of SCI, outcomes are influenced by a complicated mix of demographic, clinical, and environmental factors, rather than the intensity or frequency of treatment (Al-Habib et al. 2011; Heinemann et al. 1994; Johnston & Miller 1986; Truchon et al. 2017). To complicate things further, there is no evidence that establishes a recommended intensity or amount of therapy that should be delivered to produce the desired result. Indeed, a paucity of studies has examined this issue.

Discussion

Heinemann et al. (1995) employed a case series design to examine the effect of increased therapeutic intensity on functional rehabilitation outcomes as indicated by motor, cognitive and total FIM scores as well as FIM efficiencies. These investigators performed a comprehensive chart review of patients with SCI (N=106) and traumatic brain injury (N=140) to determine the number of 15-minute therapy units delivered in the provision of PT, OT, SLP, and psychology services. They then performed multiple regression analyses to determine if the amount of therapy was associated with positive outcomes. For the most part, there was little evidence that increased therapeutic intensity had any effect on improving outcomes for the SCI sub-sample although the paucity of well-controlled studies in this area limits the strength of the conclusions that can be drawn.

Similarly, in a post-hoc analysis of data obtained from several phase I and II randomized controlled trials, Kapadia and colleagues (2014) compared the therapeutic benefits of single versus double dose conventional OT to functional electrical stimulation plus conventional OT. Although improvements were seen in all groups on the FIM and SCIM self-care sub-scores, no significant differences were observed between groups. This suggests that the intensity of rehabilitation alone may not improve hand function in individuals with incomplete sub-acute C3-C7 SCI.

Through a series of observational studies, Whiteneck et al. (2011; 2012) examined the nature, extent and intensity of treatments patients received during inpatient rehabilitation to determine if patient characteristics or treatment quantity affect rehabilitation outcomes at rehabilitation discharge and one-year post-injury. In the first study, they found that treatment times and intensities varied extensively across patient groups. However, these differences were not explained by patient, injury or clinician characteristics, instead, a weak association was found between length of stay and total hours of therapy received. In the second study, they determined which treatment interventions and intensities are associated with positive outcomes. Interestingly, more time in PT and therapeutic recreation was positively associated with improved motor outcomes, physical independence, social integration, reduced rehospitalization, and incidence of pressure ulcers. Although these results are promising, more research is necessary to examine this relationship and draw any definitive conclusions.

In this regard, physical and rehabilitation medicine guidelines established by Rapidi and colleagues (2018) suggest that physicians act as coordinators of their multidisciplinary team to “establish objectives of treatment decisions/plans/programs according to the specific needs of individuals with SCI in terms of duration and intensity of a specific treatment, in agreement with team and patient/family caregivers.”

Conclusion

There is level 4 (from one case series: Heinemann et al. 1995) that increased therapeutic intensity may not be associated with functional benefit as measured by the Functional Independence Measure.

There is level conflicting level 5 evidence (from one observational study and one post-hoc analysis: Kapadia et al. 2014; Whiteneck et al. 2012) that increased therapeutic intensity may be associated with increased functional benefit (as measured by the FIM and SCIM), independence, social integration, reduced hospitalizations, and pressure ulcer incidence.

There is level 5 evidence (from one observational study: Whiteneck et al. 2011) that treatment times and intensities vary extensively between patients and may be associated with length of stay, rather than patient, injury, or clinician characteristics.