Gender

With respect to gender effects, studies investigating rehabilitation outcomes among women have focused on long-term psychosocial outcomes associated with issues such as marriage or motherhood or issues associated with community and vocational reintegration (DeVivo et al. 1995; Stuart et al. 1998; Shackelford et al. 1998; Westgren & Levi 1994). However, there has been little research concerning the influence of gender on rehabilitation.

Table 8. Effect of Gender on Rehabilitation Outcomes

Author Year; Country Research Design PEDro Score Total Sample Size	Methods	Outcome
Franceschini et al. 2020; Switzerland Observational N_initial=510, N_final=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.	Female individuals were less likely to improve on the SCIM.
Gupta et al. 2008; India Case Control N_Initial=76, N_Final=76	Population: Traumatic (n=38): Mean age=32.86yr; Gender: males=34, females=4. Non-traumatic (n=38): Mean age=31yr; 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: LOS, BI, AIS collected at admission and discharge.	The traumatic SCL group had significantly more males than females (p<0.05) and was not significantly different in age, marriage, education or socioeconomic factors.
McKinley et al. 2008; USA Case control N_Initial=594, N_Final=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.	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%).
Ronen et al. 2004; Israel Case Control N_Initial=1401, N_Final=1401	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 LOS. Outcome Measures: LOS, SCI etiology, SCI severity, decade of admission to rehabilitation, and Spinal Cord Independence Measure II (SCIM II).	The mean LOS was 239±168 for individuals with TSCI and 106±137 for individuals with NTSCI. SCI severity, etiology and decade of admission to rehabilitation were significantly associated with LOS (p<0.001). SCIM II gains were positively associated with LOS, when LOS was short (<70 days; r=0.81-0.82, p<0.001). Male patient LOS (147±183) was significantly higher than female patient LOS (105±82) (p<0.02).
Scivoletto et al. 2004; Italy Case Control N_Initial=281, N_Final=281	Population: SCI: Mean age=50.4yr; Gender (traumatic): males=82, females=23; Gender (non-traumatic): males=101, females=75; Level of injury: cervical=78, thoracic=152, lumbar=51; Severity of injury: AIS: A=84, B=18, C=127, D=52. Intervention: No intervention. Those with SCI were retrospectively evaluated to examine sex-related differences. Outcome Measures: Admission scores, discharge scores, length of stay, efficiency.	No significant difference was seen between males and females in all the outcome measures including: Admission age. Admission scores. Discharge scores. Length of stay. Efficiency scores. Female patients than male patients had a lower frequency of: Traumatic lesions. Complications at admission. Females had a higher frequency of incomplete lesions than males.
McKinley et al. 2002; USA Case Control N_Initial=381, N_Final=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).	As compared to those with trauma (before matching), those with stenosis were significantly (p<0.01): Older (64.1 versus 44.4). More likely female (38.8 versus 21.2%) More likely to have paraplegia (69.4% versus 45.5%) More likely to be incomplete injury (AIS C or D) (100% versus 49.3%)
Greenwald et al. 2001; USA Case Control N_Initial=1074, N_Final=1074	Population: Traumatic SCI from United States Model Systems database; matched male versus female by level of function, AIS and age: 50% were 18-34yr, 42% were 36-64yr and 8% were >64yr old; Level of injury: tetraplegia, paraplegia; Severity of injury: AIS A-D; Time to rehabilitation: 86% were admitted to Model systems within 21 days post-injury. Intervention: No intervention. Outcomes associated with inpatient acute and rehabilitation care focusing on gender effects were assessed. Outcome Measures: Length of Stay, Charges, ASIA motor index total score, FIM motor score, FIM motor change scores, FIM motor efficiency scores, and medical complications. Collected at admission to acute care and admission to and discharge from rehabilitation.	No significant differences were seen for acute care or rehabilitation Length of Stay or charges between males and females. No significant differences were seen in discharge destinations between males and females. No significant differences were seen in admission, discharge, or change scores for both functional (i.e., FIM) and neurological (i.e., AIS) assessments between males and females. Gender differences in the development of complications during rehabilitation, notably, pressure sores (p<0.001) and DVTs (p=0.003) were more likely in men. Younger patients had better functional outcomes than older patients with significantly higher FIM motor scores at discharge. Older patients had significantly greater ASIA motor scores on admission and discharge than middle-aged patients, who had significantly greater scores than younger patients.
Furlan et al. 2005; Canada Case Series N_Initial=55, N_Final=55	Population: Males (n=38): Mean age=51.5yr; Level of injury: C1 to C7; Severity of injury: AIS: A-D; Etiology of injury: falls=36.8%, motor vehicle accidents=31.6%, diving accident =7.9%, other=23.7% Females (n=17): Mean age=63.2 yr; Level of injury: C1 to C7; Severity of injury: AIS: A-D; Etiology of injury: falls=64.7%, motor vehicle accidents=23.5%, diving accident=11.8%. Intervention: No intervention. Those with acute cervical traumatic SCI were retrospectively analyzed to assess gender differences. Outcome Measures: Secondary complications, AIS.	No significant differences were seen between the two sexes was seen in: Secondary complications. Improvement in AIS scores. Women had significantly higher rate of psychiatric complications (p=0.054) and deep venous thrombosis (p=0.092) then men.
New et al. 2005; Australia Case Series N_Initial=70, N_Final=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.	Those subjects’ male, younger, more mobile, more independent bowel and bladder function and less severe AIS grades were more likely to be discharged home.
Sipski et al. 2004; USA Case Series N_Initial=14433, N_Final=14433	Population: SCI: Mean age=31.8 yr; Gender: males=11762, females=2671; Etiology of injury: vehicular collision=6092, violence=2888, diving/other sports=1550, falls=2807, other=1096. Intervention: No intervention. Patient data was retrospectively analyzed to assess gender differences in patients with SCI. Outcome Measures: AIS, FIM scores, motor score improvement.	Completeness of injury was significantly higher in: Males than females (p=0.007). Younger females (younger than 40yr) than older females (older than 50yr), p<0.001. AIS motor scores from admission to 1yr post injury, were significantly higher for women than men with complete (p=0.035) or incomplete (p=0.031). At 1yr post injury, improvement of motor scores on the left side was significantly greater for women than for men with complete injuries (p=0.018) and incomplete injuries (p=0.016). Women with motor incomplete tetraplegia at C1-4 levels had higher discharge FIM motor scores than men. However, motor complete men had higher discharge FIM scores than motor complete women.
Pollard & Apple 2003; USA Case Series N_Initial=412, N_Final=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.	Neurological recovery was not significantly related to gender (p>0.05).
Krause et al. 2006; USA Observational N_Initial =1342, N_Final=1278	Population: Mean age=41.6yr; Gender & Race: 75% white, 74% male, 56% white male, 21% white female, 18% African American men, 5% African American females; Injury Duration: Mean=9.7yr; Level of injury: cervical=55%: Injury severity: no sensation or movement=29.4%, sensation but no movement=28.5%, movement but not ambulation=20.8%, useful function including ambulation =21.5%. Intervention: No intervention. Cross-sectional survey to examine the effect of race and gender on health status and healthcare utilization and the mediating effects of education and income. Outcome Measures: Three general health indicators from the Behavioral Risk Factor Surveillance (self-rated health, days of poor physical health, days of poor mental health) and 3 healthcare utilization measures (number of hospitalizations, days of hospitalizations, number of doctor visits).	Differences in gender were seen in the significantly higher rates of non routine physician visits by females than males, but not for the other general health or healthcare utilization indicators. After accounting for mediators, the gender differences remained significantly different for higher rates of non routine physician visits by females than males, however this gender effect was substantially less than that evident with the mediating variables of income and education.

Discussion

Greenwald et al. (2001) employed a mixed, block design, matching male and female subjects to control for covariant effects of injury characteristics (level and AIS) and age at injury. They retrospectively analyzed 1,074 subjects over a 10-year period from 1988 to 1998 by using United States Model Systems data culled from 20 different SCI centers over a variety of geographic regions. In general, there were no significant differences between males and females for rehabilitation outcomes including discharge disposition, LOS, FIM motor scores (including change scores and efficiencies), or ASIA motor scores. There were also no reported gender-related differences in the incidence of most medical complications encountered during rehabilitation stay including pneumonia, autonomic dysreflexia, pulmonary embolism, cardiac arrest, kidney calculi, or gastrointestinal hemorrhage. However, men did have significantly higher rates for pressure sores although the authors reported that these differences were not robust and did not result in increased stays, charges, or lower functional outcomes.

One case control study conducted by Ronen et al. (2004) found that males experience greater rehabilitation LOS when compared to females. However, this may be related to injury type and severity rather than gender. Further analysis of this trend is necessary.

In one case series, New et al. (2005) found that males were more likely to be discharged home. Although these patients were also younger, more mobile, independent, and less severely impaired.

Studies have found mixed evidence for gender-related differences in the incidence of deep vein thrombosis in the SCI population. Greenwald et al. (2001) demonstrated a significantly higher rate of deep vein thrombosis in men while Furlan et al. (2005) found a higher rate in women.

The prevalence of psychiatric complications was found to be higher in women than men in the SCI population (Furlan et al. 2005). After SCI, women in the chronic stage had more symptoms of depression than men in the chronic stage (Furlan et al. 2005) but Krause et al. (2006) did not report a gender difference with regard to the number of days adversely impacted by poor mental health in women.

Pollard and Apple (2003) demonstrated that as a whole no gender-related differences were seen in neurological recovery. However, in contrast to Pollard and Apple (2003), Greenwald et al. (2001), and Furlan et al. (2005) studies, Sipski et al. (2004) found women’s ASIA motor scores were significantly higher than men’s 1 year after injury. Also, in contrast to Greenwald et al. (2001), Sipski et al. (2004) found men showed significantly greater FIM motor improvement than women by discharge. Additionally, there is some evidence to suggest that males experience more traumatic injuries than females as demonstrated by the findings of Gupta et al. (2008) and McKinley (McKinley et al. 2008; McKinley et al. 2002).

Overall, it appears there is only minimal evidence that suggests gender differences for most rehabilitation outcomes. Of note, the study with the strongest design (i.e., case control with matching to limit potential confounding) found few gender-related differences (Greenwald et al. 2001). Of note, Krause et al. (2006) found a significant difference between men and women in only one (i.e., non-routine physician visits) of six measures addressing healthcare utilization and general health status. Upon analysis of the effect of the potential mediating variables of education and income, it was found that these had substantially more impact on the likelihood of women having more nonroutine physician visits than did the role of gender differences.

Conclusion

There is conflicting level 3 (from three case control studies: Greenwald et al. 2001; Ronen et al. 2004; Scivoletto 2004) and level 4 evidence (from four case studies: Furlan et al. 2005; New 2005; Pollard & Apple 2003; Sipski et al. 2004) that there is no difference with respect to gender on discharge destination, rehabilitation LOS and neurological or functional outcomes associated with rehabilitation.

There is conflicting level 3 (from four case control studies: Gupta et al. 2008; McKinley et al. 2008; McKinley et al. 2002; Scivoletto et al. 2004) and level 4 evidence (from one case series: Sipski et al. 2004) that male patients experience more traumatic and incomplete injuries and of those that are female, younger females experience more complete injuries.

There is conflicting level 4 evidence (from one case series: Furlan et al. 2005) that women may experience more complications at admission, psychiatric complications, and deep vein thrombosis than men.

There is level 5 evidence (from one observational study: Krause et al. 2006) that female patients utilize more non-routine physician visits than males.

There are no significant effects of gender on rehabilitation outcomes.