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Rehabilitation Practices

Age

In the coming decades, demographic changes will result in a significant increase in the proportion of older individuals all over the globe. For example, in Canada, it is estimated that seniors will account for 30% of the population by 2068, an increase of 17% from 2018 (Statistics Canada 2019). When considering epidemiological evidence that found the highest rates of SCI-related hospital admission following trauma in Ontario, Canada was for those over 70 years of age, this has significant implications for the delivery of rehabilitation and support services to this group of patients (Pickett et al. 2006). In addition, many centers in various places around the world provide rehabilitation services to individuals with spinal cord damage as the result of a variety of non-traumatic etiologies and often these people are much older than those injured due to trauma (McKinley et al. 2001; McKinley et al. 2002; New 2005; Scivoletto et al. 2003).  Given these trends, it is important to understand the effects of age on rehabilitation outcomes. Several studies have investigated age as an interventional trait to identify which individuals may have better rehabilitation outcomes.

Author Year; Country
Research Design
PEDro Score
Total Sample Size

Methods

Outcome

Franceschini et al. 2020; Switzerland
Observational
Ninitial=510, Nfinal=497

Population: Mean age=50±20yr; Gender: male=402, female=95, Level of injury: not reported; Severity of injury: AIS A=173, B=78, C=122, D=104, E=2.
Intervention: No intervention. Prospective analysis of patient characteristics on functional gains and discharge destination in patients with SCI admitted to rehabilitation.
Outcome measures: SCIM
  1. Older individuals were less likely to improve on the SCIM(p<.05).

Furlan & Fehlings 2009; Canada
Observational
NInitial=499, NFinal=396

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.
Older Individuals (>65yr; n=44): Mean age=75yr; Gender: male=92.7%, female=7.3%; Level of injury: cervical=89.5%, thoracolumbar=10.5%; Severity of Injury: complete=29.5%, incomplete=70.5%; Time since injury=not reported.
Intervention: No intervention. Prospective observational analysis of the impact of age on mortality, impairment and disability among adults with acute traumatic SCI. Outcome measures were assessed at 6wk, 6mo and 12mo.
Outcome Measures: Mortality, FIM.
  1. Mortality rates among older individuals were significantly greater than younger individuals (38.6% versus 3.1%; p<0.0001).
  2. Among survivors, age was not significantly correlated with motor recovery or change in pain scores in the acute and chronic stages of SCI (p>0.05).
  3. Older individuals experienced greater functional deficit (as measured by FIM) than younger individuals (p<0.05) despite experiencing similar rates of sensorimotor recovery.

Osterthun et al. 2009; Netherlands
Case control
NInitial=919, NFinal=919

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%
Intervention: No intervention. Those with traumatic SCI were compared to those with non-traumatic SCI.
Outcome Measures: Functional status, LOS.
  1. Age and better functional status on admission was associated with shorter length of stay (p=0.001).
  2. Functional outcome was not correlated with age; however it was significantly correlated with functional status at admission and LOS.

Gupta et al. 2008; India
Case Control
NInitial=76, NFinal=76

Population: Traumatic (n=38): Mean age=32.86yr; Gender: males=34, females=4.
Non-traumatic (n=38): Mean age=31.10; Gender: males=16, females=22
Intervention: Admission/discharge data from all surviving non-traumatic and traumatic spinal cord lesion (SCL) patients in a neurological rehabilitation facility was assessed over a 2yr period.
Outcome Measures: Length of stay; AIS collected at admission and discharge.
  1. The traumatic SCL group was not significantly different in age, marriage, education or socioeconomic factors (p>0.05).

McKinley et al. 2008; USA
Case control
NInitial=594, NFinal=594

Population: Infection related spinal cord disease (IR-SCD): Mean age=53.3yr; Gender: males=64.7%; Level of injury: paraplegia=74%.
Traumatic SCI: Mean age=40.4yr; Gender: males=83.8%; Level of injury: paraplegia=49%
Intervention: No intervention. Data was reviewed of individuals diagnosed with infection related SCD against those with traumatic SCI.
Outcome Measures: Acute and rehabilitation hospital LOS, FIM motor scores, FIM motor change, FIM motor efficiency, AIS change.
  1. When compared with traumatic SCI (n=560), patients with IR-SCD comprised significantly less of the SCI/D rehabilitation admissions (3% versus 61%), were older (53 versus 40yr), and more often female (35% versus 16%). Injuries were more commonly located in the thoracic region (48% versus 38%).

Tchvaloon et al. 2008; Israel
Case series
NInitial=143, NFinal=143

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%.
Intervention: No intervention. Data from patients with a SCI due to a road accident was analyzed.
Outcome Measures: Neurological recovery, Functional recovery, complications.
  1. Negative association was seen between survival and age at injury (p<0.001) and pressure sores (p=0.006).
  2. No significant effect on recovery was seen due to age at injury, gender, presence of pressure sores and complications.

Anzai et al. 2006; Canada
Case series
NInitial=52, NFinal=52

Population: Mean age=45.3yr; Gender: males=77%, females=23%; Level of injury: C4=63%; Severity of Injury: AIS A=60%
Intervention: No intervention. Retrospective chart review was conducted on patients admitted to GF Strong Spinal Cord Program between 1994 and 2003.
Outcome Measures: Discharge destination, factors associated with discharge to ECU.
  1. Older individuals had a 4% increased risk of being discharged to an extended care unit.
  2. Good levels of social support were found to be protective factors
  3. Pre-existing medical conditions were associated with 10 times greater risk
  4. Unemployment and not having funding from insurance were associated with 5 times greater risk.

New et al. 2005; Australia
Case Series
NInitial=70, NFinal=62

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.
Intervention: No intervention. Outcomes associated with non-traumatic SCI rehabilitation were assessed.
Outcome Measures: Demographics, clinical characteristics, LOS, Discharge setting, level of lesion and AIS, FIM, mobility, bowel and bladder function. Collected at admission to and discharge from rehabilitation.
  1. Those subjects’ male, younger, more mobile, more independent bowel and bladder function and less severe AIS grades were more likely to be discharged home.

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.
Intervention: No intervention. Retrospective analysis of the factors that influence hospital LOS.
Outcome Measures: LOS, SCI etiology, SCI severity, decade of admission to rehabilitation, and Spinal Cord Independence Measure II (SCIM II).

  1. The mean LOS was 239±168 for individuals with TSCI and 106±137 for individuals with NTSCI.
  2. SCI severity, etiology and decade of admission to rehabilitation were significantly associated with LOS (p<0.001).
  3. SCIM II gains were positively associated with LOS, when LOS was short (<70 days; r=0.81-0.82, p<0.001).
  4. Age had no significant effect on LOS (p=0.08).

Pollard & Apple 2003; USA
Case Series
NInitial=412, NFinal=95

Population: Mean age=not reported; Gender: not reported; Level and severity of injury: incomplete tetraplegia; Time since injury=not reported.
Intervention: No intervention. Retrospective review of patients with incomplete tetraplegia to determine what patient characteristics, injury variables and management strategies are associated with improved neurological outcomes.
Outcome Measures: Motor score, motor level sensory score, sensory level and ASIA grade.
  1. Neurological recovery was not significantly related to gender, race, type of fracture, or mechanism of injury (p>0.05).
  2. Improved motor outcomes were observed in patients <18yr (34±18) when compared to those >18yr (24±19) (p=0.002). However, no significant difference was observed in sensory scores between groups (p>0.05).

Kennedy et al. 2003; UK
Case Control (Inadequate control)
NInitial=200, NFinal=192

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.
Intervention: No intervention. Various outcomes associated with inpatient rehabilitation focusing on goal attainment in younger versus older patients.
Outcome Measures: Needs Assessment Checklist (NAC) collected within 2wk of mobilization and within 6wk of discharge.
  1. Improvements were noted in ↓ “percentage to be achieved” scores for all nine areas of need (p<0.0001). No significant differences were seen between age groups.
  2. Those with complete lesions showed greater improvement in bowel management than those with incomplete lesions (p<0.005) and those with tetraplegia showed greater improvement in the area of skin care than those with paraplegia group (p<0.005) Otherwise no other differences.
  3. Mobility needs of older subjects were significantly higher compared to the younger subjects (p<0.005) initially, but lower for the community score (p=0.01). Higher scores (i.e., more unmet need) assessed close to discharge were noted for older versus younger for the areas of skin management (p<0.01), bladder management (p<0.01), bowel management (p<0.05) and mobility (p<0.01).

Scivoletto et al. 2003; Italy
Case Control
NInitial=284, NFinal=284

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.
Intervention: No intervention. Various outcomes associated with inpatient rehabilitation focusing on younger (<50) versus older (>50) patients. Mean LOS was 98.7±68.1 days.
Outcome Measures: LOS, AIS, ASIA Motor Index, BI, Rivermead Mobility Index (RMI), Walking Index for SCI (WISCI), Discharge Destination. All collected at admission and discharge.
  1. Although LOS was longer for younger patients (111.3±63.88 versus 89±69.9, p<0.008) which was related to a higher incidence of incomplete lesions and etiology, a matched-block sub-analysis (n=130) showed differences were not significant.
  2. Neurological recovery was more frequent with younger group (p=0.006) and for those at AIS C. Matched group sub-analysis showed more ASIA grade (p=0.027) and motor score improvements in younger group.
  3. Gains for independence of daily living measures (BI and RMI) were significantly greater for younger group (p<0.001).
  4. Younger age group had more people reach independent walking levels on WISCI than in older group (p<0.004). Similar findings for related subscales in BI and RMI.
  5. Younger age group had more people reach autonomous bladder (p=0.005) and bowel control (p=0.014) than in older group. Similar findings for bladder subscales in BI.

McKinley et al. 2002; USA
Case Control
NInitial=381, NFinal=183

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.
Intervention: No intervention. Various outcomes associated with non-traumatic (stenosis) versus traumatic SCI rehabilitation were compared. Outcome measures were collected at admission to and discharge from rehabilitation.
Outcome Measures: LOS, charges, Discharge rates to home, FIM (score, change and efficiency).
  1. As compared to those with trauma (before matching), those with stenosis were significantly (p<0.01):
    1. Older (64.1 versus 44.4).
    2. More likely female (38.8 versus 21.2%)
    3. More likely to have paraplegia (69.4% versus 45.5%)
    4. More likely to be incomplete injury (AIS C or D) (100% versus 49.3%)

Seel et al. 2001; USA
Case Control
NInitial=180, NFinal=180

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.
Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between three age categories.
Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM. All collected at admission to acute care and admission to rehabilitation care and discharge.
  1. FIM improvement was greater for the younger and middle group that for the older group (p<0.001). FIM efficiency was greater for the young group as compared to the 2 older groups (p<0.001).
  2. There were no significant differences in ASIA motor index scores at any of the time points across the different ages.
  3. No systematic significant differences were noted between the 3 age groups for acute care LOS or hospital charges.
  4. Rehabilitation LOS was significantly shorter for younger than middle or older groups. There was no difference in associated hospital charges for the 3 groups.
  5. All age groups were equally likely to be discharged to a private residence (≥92%).

Van der Putten et al. 2001; Netherlands
Case Series
NInitial=100, NFinal=100

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.
Intervention: No intervention. Optimal outcomes were regressed against various factors associated with non-traumatic rehabilitation.
Outcome Measures: Demographics, clinical characteristics, level of lesion and AIS, FIM motor score and change score. Collected at admission to and discharge from rehabilitation.
  1. Age (i.e., younger), etiology (i.e., hereditary pathology) and lesion level (i.e., cervical) were individually associated with improved functional outcomes but did not improve prediction of overall model.

Eastwood et al. 1999; USA
Case Series
NInitial=5180, NFinal=3904

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.
Intervention: No intervention. Retrospective chart review of patients discharged between 1990 and 1997 with traumatic SCI to determine predictors of acute rehabilitation length of stay and their association with medical and social outcomes. Outcomes were assessed at rehabilitation discharge and one yr following injury.
Outcome Measures: Rehabilitation LOS, age, race, method of bladder management, tetraplegia, education, marital status, discharge disposition, one-year presence of pressure ulcers, rehospitalization, place of residence, days per week out of residence.
  1. From 1990 to 1997 rehabilitation LOS declined from 74 days to 60 days, while discharge to nursing homes and rehospitalizations increased.
  2. Lower FIM score at admission, year of discharge, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS (p<0.05)
  3. At one yr following injury lower FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence (p<0.05).
  4. Of those discharged to nursing homes, 44% returned home by year one and these individuals had higher functional status and were younger.

Cifu et al. 1999; USA
Case Control
NInitial=375, NFinal=375

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.
Intervention: No intervention. Various outcomes associated with inpatient acute and rehabilitation care focusing on age effects by comparing results between three age categories.
Outcome Measures: LOS, Charges, ASIA motor index score, FIM, change scores and efficiencies for FIM and ASIA motor index, Discharge destination. All collected at admission to acute care and admission to rehabilitation care and discharge.
  1. The younger the age group, the greater the FIM motor score improvement and greater FIM motor efficiency.
  2. The younger and middle age groups had significantly greater ASIA motor index score increases and efficiency than the older age group.
  3. No systematic significant differences related to age were noted for acute care or rehabilitation Length of Stay or hospital charges.
  4. The older the age group, the more likely individuals would be discharged to an institutional setting.

Cifu et al. 1999; USA
Case Control (Inadequate control)
NInitial=2,169, NFinal=2,169

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.
  1. FIM improvement was less for people ≥60 than those younger.
  2. There were no significant differences in ASIA motor index scores, change scores or efficiency scores across different ages.
  3. No systematic significant differences were noted for acute care LOS or hospital charges.
  4. Rehabilitation LOS was longer and associated hospital charges greater for older individuals (trend beginning for those >54 and peaking in the 60-64 age group).
  5. Younger age groups were more likely injured as a result of vehicular crashes or violence while older groups were more likely injured as a result of falls or other events including being struck by falling objects, pedestrian accidents and medical/surgical complications.

McKinley et al. 1999; USA
Case Control
NInitial=4035, NFinal=58

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.
Intervention: No intervention. Various outcomes associated with rehabilitation care of non-traumatic (neoplastic cord compression) versus traumatic SCI. Outcome measures were collected at admission to and discharge from rehabilitation.
Outcome Measures: LOS, Discharge destination, FIM (total score, change and efficiency).
  1. As compared to those with trauma (before matching), those with neoplastic cord compression were:
    1. Older (57.8 versus 30.45).
    2. More likely to have paraplegia (88.2% versus 52.5%)
    3. More likely to be incomplete (88.2% versus 56.7%)
    4. No different FIM efficiency

Devivo et al. 1990; USA
Case control
NInitial=866, NFinal=866

Population: Group 1 (Age=1-15yr): Gender: males=80%, females=20%; Level of injury: paraplegia=47.5%, tetraplegia 52.5%; Severity of injury: complete=52.5%, incomplete=47.5%; Time since injury=not reported.
Group 2 (Age=16-30yr): Gender: males=84.6%, females=15.4%; Level of injury: paraplegia=52.1%, tetraplegia=47.9%; Severity of injury: complete=55%, incomplete=45%; Time since injury=not reported.
Group 3 (Age=31-45yr): Gender: males=81.1%, females=18.9%; Level of injury: paraplegia=52%, tetraplegia =48%; Severity of injury: complete=45.9%, incomplete=54.1%; Time since injury=not reported.
Group 4 (Age=46-60yr): Gender: males=79%, females=21%; Level of injury: paraplegia=46%, tetraplegia=54%; Severity of injury: complete=43%%, incomplete=57%; Time since injury=not reported.
Group 5 (Age=61-86yr): Gender: males=70%, females=30%; Level of injury: paraplegia=28.6%, tetraplegia 71.4%; Severity of injury: complete=36.2%, incomplete=63.8%; Time since injury=not reported.
Intervention: No intervention. Patients were retrospectively divided into five age groups: Group 1 (1-15yr), Group 2 (16-30yr), Group 3 (31-45yr), Group 4 (46-60yr), Group 5 (61-86yr). Data was then used to assess the effects of age on rehabilitation outcome.
Outcome Measures: Relationship of age with clinical outcomes.
  1. Increase in age at admission was significantly related to increase in:
    1. Cervical injuries with patients over 60 yr old (p=0.006).
    2. Diabetes (p<0.001).
    3. Obesity (p=0.007).
    4. Alcohol abuse (p<0.001).
    5. Heart disease (p<0.001).
    6. Arthritis (p<0.001).
    7. Pulmonary embolus (p<0.001).
    8. Gastrointestinal hemorrhage (p=0.008).
    9. Pneumonia (p=0.003).
    10. Mechanical ventilatory support use (p=0.004).
  2. Increase in age was significantly related to a decrease in:
    1. Percentage of complete lesions (p=0.039).
  3. No significant relationship was found between age at admission and:
    1. Number of days from injury to admission.
    2. Initial length of hospitalization of acute care.
    3. Hospital charges.
    4. Days of rehospitalization in the second year post injury.
  4. Increasing age at admission was inversely related to percentage of patients independent in self-care activities at discharge (p=0.016).

Yarkony et al. 1988; USA
Case control
NInitial=708, NFinal=708

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%.
Intervention: No intervention. Patients were retrospectively divided into four groups: Group 1 (6-19yr), Group 2 (20-39yr), Group 3 (40-59yr), Group 4 (60-88yr) and data was analyzed.
Outcome Measures: Relationship of age to clinical outcomes.
  1. Age was not significantly related to admission or discharge MBI.
  2. Admission and discharge MBI was related to level of injury (p<0.001) and severity (p<0.001).
  3. Increase in age in patients with complete paraplegia was related to increased dependence in seven functional skills including: bathing, upper and lower body dressing, stair climbing, and transfers to chair, toilet and bath.

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 (Cifu et al. 1999; DeVivo et al. 1990; Scivoletto et al. 2003; Seel et al. 2001; Yarkony et al. 1988) as compared to those deemed as having an inadequate method of controlling for potential confounds (Cifu et al. 1999; 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. (1999) reported reduced rehabilitation LOS for those with paraplegia due to trauma or mixed etiology Osterthun et al. (2009) whereas no differences were seen in investigations of those with tetraplegia due to trauma (Cifu et al. 1999) and also with the mixed sample of people with both traumatic and non-traumatic SCI (Ronen et al. 2004; Scivoletto et al. 2003).

Yarkony et al. (1988) were the first to look at the independent effect of age on rehabilitation outcomes in SCI. This study found that functional outcome was only related to age in patients with complete paraplegia. Among these individuals, Yarkony et al. (1988) demonstrated a trend between the increase in age and increased dependence on seven functional skills including bathing, upper and lower body dressing, stair climbing, and transfers to a 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 patients’ age and their level of independence in self-care activities. Anzai et al. (2006) and Eastwood et al. (1999) 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 support. Similarly, New et al. (2005) reported that younger individuals were more likely to be discharged home.

Conversely, all studies examining functional change showed that younger individuals demonstrated greater functional improvements as indicated by increases in the FIM (i.e., motor FIM scores, change scores, efficiencies) (Cifu et al. 1999; Cifu et al. 1999; Furlan & Fehlings 2009; Pollard & Apple 2003; Seel et al. 2001; van der Putten et al. 2001), BI (Scivoletto et al. 2003) or SCIM (Franceschini et al. 2020). These similar results were obtained from studies involving those with paraplegia (Cifu et al.  1999; Seel et al. 2001), tetraplegia (Cifu et al. 1999), and a mixed sample comprised of those with both traumatic and non-traumatic SCI (Scivoletto et al. 2003). On the other hand, Kennedy et al. (2003) employed the Needs Assessment Checklist developed internally at Stoke-Mandeville, United Kingdom, and demonstrated that there were few systematic age-related differences associated with goal attainment in a mixed traumatic, non-traumatic sample. The Needs Assessment Checklist 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 in 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 utilizing measures of neurological status, both studies limited to those with paraplegia and showed no age effects (Cifu et al. 1999; Seel et al. 2001). Conversely, similar studies of those with tetraplegia or a mixed traumatic and non-traumatic SCI sample demonstrated that younger individuals were more likely to make significant neurological gains during inpatient rehabilitation (Cifu et al. 1999; Scivoletto et al. 2003). Additionally, conflicting findings exist in relation to the mechanism of injury with Gupta and colleagues (2008) reporting that traumatic versus non-traumatic injuries are not associated with age. Conversely, McKinley et al. (2008; 1999; 2002) found that non-traumatic injuries are significantly associated with older age.

Despite mixed research regarding the impact of age on SCI rehabilitation, it is reasonable to assume that older individuals require individualized care. In light of this, guidelines established by Rapidi and colleagues (2018) suggest that therapeutic exercise programs in SCI should be prescribed and adapted to each individual’s needs, according to the neurological level of injury, age, and comorbidities.

Conclusions

There is level 3 evidence (from four case control studies: Cifu et al. 1999; Cifu et al. 1999; Osterthun et al. 2009; Seel et al. 2001) that shorter rehabilitation LOS is associated with younger versus older individuals with paraplegia. The same may not be true for those with tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI.

There is level 3 evidence (from four case control studies: DeVivo et al. 1990; Kennedy et al. 2003; Scivoletto et al. 2003; Yarkony et al. 1988; and one observational study: Franceschini et al. 2020) that age is inversely related to patient’s independence level.

There is level 3 evidence (from five case control studies: Cifu et al. 1999; Cifu et al. 1999; Kennedy et al. 2003; Scivoletto et al. 2003; Seel et al. 2001) that younger as compared to older individuals are more likely to obtain greater functional benefits during rehabilitation.

There is level 3 evidence (from two case control studies: Kennedy et al. 2003; Scivoletto et al. 2003) 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 non-traumatic SCI. The same may not be true for those with paraplegia.

There is conflicting level 3 evidence (from three case control studies: Gupta et al. 2008; McKinley et al. 1999; McKinley et al. 2002) that older individuals are more likely to experience a non-traumatic than traumatic SCI.

There is level 4 evidence (from one case series: Tchvaloon et al. 2008) that older individuals are more at risk of developing pressure sores.

There is level 4 evidence (from two case series: Anzai et al. 2006; New 2005) that older individuals are more likely to be discharged to an extended care unit.

There is level 4 evidence (from one case series: Eastwood et al. 1999) that age may be associated with a longer length of rehabilitation stay.

There is level 4 and 5 evidence (from two case series and one observational study: Furlan & Fehlings 2009; Pollard & Apple 2003; van der Putten et al. 2001) that younger patients are more likely to experience improved motor outcomes when compared to older individuals. However, both groups experience similar sensory deficits.

There is level 5 evidence (from one observational study: Ronen et al. 2004) that age has no effect on the length of acute hospital stay.

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