Age
Historically, traumatic SCI has been viewed as a young, male concern although there have been recent shifts in the demographics of SCI such that an increasing proportion of recently injured individuals are older (both male and female). In fact, recent epidemiological evidence from Ontario, Canada found that the highest rates of SCI-related hospital admission following trauma in this jurisdiction was for those over 70 years of age although the frequency of specific etiologies (e.g., falls vs motor vehicle crashes) varied with age (Pickett et al. 2006). In the US the average age at injury has increased steadily over the last 30 years with the US Model Systems National SCI Statistical Center (2006) reporting an average age of injury of 38.0 years for the period from 2000-2006 as compared to 28.7 years for the period from 1973-1979. In addition, many centers in various jurisdictions around the world also provide rehabilitation services to individuals with spinal cord damage as the result of a variety of nontraumatic etiologies and often these people are much older than those injured due to trauma (McKinley et al. 2001; McKinley et al. 2002; Scivoletto et al. 2003; New 2005). Given these trends for increasing age in those undergoing rehabilitation it is important to understand the effects of age on rehabilitation outcomes. Several investigators have employed retrospective assessments of single or multi-centre patient databases to examine this issue (Cifu et al. 1999a; Cifu et al. 1999b; Seel et al. 2001; Scivoletto et al. 2003; Kennedy et al. 2003).
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Author Year; Country Research Design PEDro Score Total Sample Size |
Methods | Outcome |
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Furlan & Fehlings, (2009); Canada Observational |
Population: Younger Individuals (<65yr; n=455): Mean age=31.9yr; Gender: males=82.9%, females=17.1%; Level of injury: cervical=65.6%, thoracolumbar=24.4%; Severity of injury: complete=51.9%, incomplete=48.1%; Time since injury=not reported. |
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Osterthun et al. (2009); Netherlands |
Population: Traumatic SCI: Mean age=43.4yr; Gender: male:female=2.8:1; Level of injury: tetraplegia=49.6%; Severity of injury: complete=52.3%; Non-traumatic SCI: Mean age=57.2yr; Gender: male:female=1.2:1; Level of injury: tetraplegia=24.2%; Severity of injury: complete=25.9% |
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Gupta et al. (2008); India |
Population: Traumatic (n=38): Mean age=32.86yr; Gender: males=34, females=4. |
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McKinley et al. (2008); USA |
Population: Infection related spinal cord disease (IR-SCD): Mean age=53.3yr; Gender: males=64.7%; Level of injury: paraplegia=74%. |
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Tchvaloon et al. (2008); Israel |
Population: Mean age=37.8yr; Gender: M:F=4.95:1; Level of injury: C=43%, T=49.3%, L=7.7%; Severity of injury: complete=41%, incomplete=59%. |
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Anzai et al. (2006); Canada |
Population: Mean age=45.3yr; Gender: males=77%, females=23%; Level of injury: C4=63%; Severity of Injury: AIS A=60% |
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New et al. (2005); Australia |
Population: Non-traumatic SCI: Mean age=69yr; Level and severity of injury: AIS B-D, tetraplegia=32.9%, AIS A, paraplegia=8.6%, AIS B-D=58.6%; Time since injury: <7 days=78.6%; Time to rehabilitation=30.9 days. |
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Ronen et al. (2004); Israel Observational NInitial=1367, NFinal=1367 |
Population: Traumatic Spinal Cord Injury (TSCI; n=250): Mean age=34.5±15.3yr; Gender: males=5, females=0; Level of injury: cervical=37%. Thoracic=32%, lumbosacral=31%; Severity of injury: Frankel grade A=74, B=42, C=100, D=34; Time since injury=59 days. Non-Traumatic Spinal Cord Injury (NTSCI; n=1117): Mean age=47.1±16.8yr; Gender: male=9, female=3; Level of injury: cervical=32%, thoracic=44%, lumbosacral=24%; Severity of Injury: Frankel grade A=32, B=146, C=506, D=433. Time since injury=51mo. |
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Pollard & Apple (2003); USA |
Population: Mean age=not reported; Gender: not reported; Level and severity of injury: incomplete tetraplegia; Time since injury=not reported. |
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Kennedy et al. (2003); UK |
Population: Traumatic and non-traumatic SCI: Mean age=40.7yr; Gender: males=147, females=45; Level and severity of injury: incomplete tetraplegia=23%, complete tetraplegia=21%, complete paraplegia=34%, incomplete paraplegia=22; Mean time post-injury to admission=28.8 days. |
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Scivoletto et al. (2003); Italy |
Population: Mean age=50.4yr; Gender: males=184, females=100; Level of injury: cervical=81, thoracic=148, lumbosacral=55; Severity of injury: AIS: A- D; Mean time post-lesion to admission=56.9 days. |
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McKinley et al. (2002); USA |
Population: Non-traumatic SCI secondary to stenosis (n=81) versus traumatic SCI (n=102) within a single centre; Matching from N=381 sample on paraplegia versus tetraplegia and completeness. |
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Seel et al. (2001); USA |
Population: Traumatic SCI from United States Model Systems database: Gender: male, female, three equal (N=60) age groups (18-39, 40-59, >59) matched for neurological level and ASIA classification, paraplegia, AIS A-D, 84% admitted within 21 days post-injury. |
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Van der Putten et al. (2001); Netherlands Case Series |
Population: Non-traumatic SCI: mean age=55yr; Gender: male=54%; Level of injury: cervical=49%, upper thoracic=21%, lower thoracic and lumbar=22%; Time from onset to rehabilitation=4.8yr. |
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Eastwood et al. (1999); USA |
Population: Age: <21=882, 21-30=1182, 31-40=803, 41-50=484, >50=552, unknown=1; Gender: males=3157, females=747; Level and severity of injury: paraplegia-incomplete=777, paraplegia- complete=1202, tetraplegia- incomplete=1065, tetraplegia- complete=782, unknown=78; Time since injury=not reported. |
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Cifu et al. (1999); USA |
Population: Traumatic SCI from United States Model Systems database: Gender: male and female, three equal (N=125) age groups (18-34, 35-64, >64) matched for neurological level and completeness, tetraplegia, AIS A-D, 85% admitted within 21 days post-injury. |
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Cifu et al. (1999); USA |
Population: Traumatic SCI from United States Model Systems database: Mean age =31.72yr; Gender: males =83%, females =17%; Level of injury: paraplegia; Severity of injury: AIS: A-D. Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between 11 age categories. Mean acute LOS was 13.2±16.92 days. Mean rehabilitation LOS was 56.76±34.28 days. Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM and ASIA motor index. All collected at admission to acute care and admission to rehabilitation care and discharge. |
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McKinley et al. (1999); USA |
Population: Non-traumatic SCI secondary to neoplastic cord compression admitted over 5 years (within a single centre (n=29) versus traumatic SCI (n=29) from the United States Model Systems database matched by age, level of injury and AIS; Age =57.8 years; AIS A-D; C4- L2. |
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Devivo et al. (1990); USA |
Population: |
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Yarkony et al. (1988); USA |
Population: Traumatic SCI: Mean age=28.3yr; Gender: males=82%, females=18%; Level and severity of injury: complete paraplegia=30%, incomplete paraplegia=15%, complete tetraplegia=27%, incomplete tetraplegia=28%. |
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Discussion
Similar approaches involving case control study designs have been employed by various investigators to examine the effect of age on rehabilitation outcomes. However, in the present review, studies employing some form of matching across different age groups were assessed as representing a higher level of evidence (i.e., Level 3) (Cifu et al. 1999b; Devivo et al. 1990; Seel et al. 2001; Scivoletto et al. 2003; Yarkony et al. 1988) as compared to those deemed as having an inadequate method of controlling for potential confounds (i.e., Level 4) (Cifu et al. 1999a; Kennedy et al. 2003). Several of these studies have demonstrated differences between age groups for a variety of rehabilitation outcomes although there were also some contradictory findings within these studies, albeit some of this may have been due to variation between the sampling frames and methods employed in each study.
For example, Seel et al. (2001) and Cifu et al. (1999a) reported reduced rehabilitation LOS for those with paraplegia due to trauma whereas no differences were seen in investigations of those with tetraplegia due to trauma (Cifu et al. 1999b) and also with the mixed sample of people with both traumatic and nontraumatic SCI (Scivoletto et al. 2003).
Yarkony et al. (1988) was the first study to look at the independent effect of age on rehabilitation outcomes in SCI. This study found functional outcome was only related to age in patients with complete paraplegia. Within these individuals, Yarkony et al. (1988) demonstrated a trend between increase in age and increase dependence in seven functional skills including: bathing, upper and lower body dressing, stair climbing, and transfers to chair, toilet and bath. Yarkony attributed this trend to the fact that there is a “greater residual muscle function” in these individuals. Devivo et al. (1990) later supported this trend by demonstrating an inverse relationship between patient’s age and their level of independence in self-care activities. Anzai et al (2006) reported that older individuals were at increased risk of being discharged to an extended care facility due to pre-existing co-morbidities and lack of social and financial supports.
Conversely, all studies examining functional change showed that younger individuals demonstrated greater functional improvements as indicated by increases with the FIM (i.e., motor FIM scores, change scores, efficiencies) (Cifu et al. 1999a; Cifu et al. 1999b; Seel et al. 2001) or BI (Scivoletto et al. 2003). These similar results were obtained from studies involving those with paraplegia (Cifu et al. 1999a; Seel et al. 2001), tetraplegia (Cifu et al. 1999b) and a mixed sample comprised of those with both traumatic and nontraumatic SCI (Scivoletto et al. 2003). On the other hand, Kennedy et al. (2003) employed the Needs Assessment Checklist (NAC) developed internally at Stoke-Mandeville, UK and demonstrated that there were few systematic age-related differences associated with goal attainment in a mixed traumatic, nontraumatic sample. The NAC is a client-focused outcome measure that assesses the degree to which specific behavioural outcomes particularly relevant to the client are achieved. Tchvaloon et al (2008; N=143) also reported no significant effect on recovery due to age at injury on an Israeli population of people with traumatic SCI.
In addition to functional outcomes, effective rehabilitation has also been associated with increases in neurological status as indicated by AIS or ASIA motor scores. Of the studies reviewed and possessing measures of neurological status, both studies limited to those with paraplegia showed no age effects (Cifu et al. 1999a; Seel et al. 2001). Conversely, similar studies of those with tetraplegia or a mixed traumatic and nontraumatic SCI sample demonstrated that younger individuals were more likely to make significant neurological gains during inpatient rehabilitation (Cifu et al. 1999b; Scivoletto et al. 2003).
Conclusions
There is level 3 evidence that significantly shorter rehabilitation LOS is associated with younger vs older individuals with paraplegia. The same may not be true for those with tetraplegia or for mixed cohorts involving traumatic and nontraumatic SCI.
There is level 3 evidence that age is inversely related to patient’s independence level.
There is level 3 evidence that younger as compared to older individuals are more likely to obtain greater functional benefits during rehabilitation.
There is level 3 evidence that significant increases in neurological status during rehabilitation are more likely with younger than older individuals with tetraplegia or for mixed cohorts involving traumatic and nontraumatic SCI. The same may not be true for those with paraplegia.
