Rehabilitation Practices

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.

Author, Year Country
Research Design
PEDro Score
Total Sample Size

 Methods Outcome

Kapadia et al. 2014; Canada Post-Hoc Analysis
NInitial=27, NFinal=27

Population: Conventional Occupational Therapy 1 (COT1; n=5): Mean age=60.8yr; Gender: males=5, females=0; Level of injury: C3=3, C4=2; Severity of injury: not reported; Time since injury=43.6 days. COT2 (n=12): Mean age=44.75yr; Gender: male=9, female=3; Level of injury: C4=7, C5=5, C6=1; Severity of Injury: AIS level B=4, C=8. Time since injury=58.33 days. Functional Electrical Stimulation (FES) + COT (FES+COT; n=10): Mean age=43.2yr; Gender: male=8, female=2; Level of injury: C3=1, C4=3, C5=1, C6=5; Severity of Injury: AIS level B=4, C=5, D=1; Time since injury=69.9 days.
Intervention: Retrospective post hoc analysis of data from phase I and II RCTs. COT1 received 45hr of therapy, COT2 received 80hr, and FES + COT received 40hr of each therapy for a total of 80hr. Outcome measures were assessed at baseline and at discharge.
Outcome Measures: FIM, self-care sub- scores of the Spinal Cord Independence Measure (SCIM).
  1. Mean scores on the FIM self-care sub-score were 12.8, 10, and 20.1 for the COT1, COT2, and FES+COT groups, respectively.
  2. The mean scores on the SCIM self-care sub-scores for the COT1, COT2, and FES-COT groups were 2.6, 3.16, and 10.2 for the COT1, COT2, and FES-COT groups, respectively.
  3. All groups showed improvement in FIM and SCIM scales from baseline to discharge; however, no significant differences were observed between groups (p>0.05).

Whiteneck et al. 2011; USA Observational
NInitial=600, NFinal=600

Population: Total Group (TG; n=600): Mean age=37.2±16.6yr; Gender: males=80.5%, females=19.5%; Level of injury: C1-C4=132, C5-C8=151, T1 and below=317; Severity of injury: AIS level A, B, C=506, D=94; Time since injury=31.7±28.1 days.
Group 1 (C1-C4, AIS A, B, C; n=132): Mean age=41.9±17.0yr; Gender: males=80.3%, females=19.7%; Time since injury=42.1±30.5 days.
Group 2 (C5-C8, AIS A, B, C; n=151): Mean age=33.7±15.6yr; Gender: males=80.8%, females=19.2%; Time since injury=33±28.7 days.
Group 3 (T1 and below, AIS A, B, C; n=223): Mean age=33.4±14.2yr; Gender: males=81.6%, females=18.4%; Time since injury=31.5±28.1.
Group 4 (T1 and below, AIS D; n=94): Mean age=45.3±18.5yr; Gender: males=77.7%, females=27.3%; Time since injury=15.5±12.4 days.
Intervention: No intervention. Prospective observation of time patients spent in various therapeutic activities. Patients were group by neurological level and completeness of injury. Outcome measures were assessed for the duration of the patient’s stay and correlated with patient, injury and clinician characteristics.
Outcome Measures: Total time spent in rehabilitation, total minutes of treatment per week, LOS
  1. The average length of stay for the TG was 55±37 days, during which 180±106hr of total treatment was received, or 24±5hr per wk.
  2. Across individual groups, treatment times and intensities varied extensively and were not correlated with patient, injury or clinician characteristics (R2=0- 0.19).
  3. LOS was weakly correlated with total hours of therapy (R2=0.47).

Whiteneck et al. 2012; USA Observational
NInitial=1376, NFinal=1032

Population: Total Group (TG; n=1032): Mean age=37.7±16.7yr; Gender: males=81%, females=19%; Level of injury: C1-C4=294, C5-C8=204, T1 and below=534; Severity of injury: AIS level A, B, C=874, D=161; Time since injury=31.0±27.8 days.
Group 1 (C1-C4, AIS A, B, C; n=294): Mean age=40.9±17.1yr; Gender: males=82%, females=18%; Time since injury=38.9±32.2 days.
Group 2 (C5-C8, AIS A, B, C; n=204): Mean age=33.8±15.8yr; Gender: males=81%, females=19%; Time since injury=33±28.2 days.
Group 3 (T1 and below, AIS A, B, C; n=373): Mean age=32.7±13.3yr; Gender: males=80%, females=20%; Time since injury=30.0±26.0.
Group 4 (T1 and below, AIS D; n=161): Mean age=48.1±18.1yr; Gender: males=84%, females=16%; Time since injury=16.5±13.0 days
Intervention: No intervention. Prospective observation of time patients spent in various therapeutic activities, correlated with patient characteristics and outcome. Patients were group by neurological level and completeness of injury. Outcome measures were assessed at rehabilitation discharge and 1yr post injury.
Outcome Measures: Total time spent in rehabilitation, LOS, FIM, CHART physical independence, social integration, mobility dimensions, rehospitalization, pressure ulcer incidence.
  1. Patient characteristics (level of injury, admission FIM, time from trauma to rehabilitation, age at injury, BMI≥30) are strong predictors of motor FIM outcome at discharge (p<0.05).
  2. More time in PT was associated positively with motor FIM score at discharge and 1yr follow-up (p<0.001), as well as CHART physical independence (p<0.001), social integration (p=0.015), mobility dimensions (p<0.001), smaller likelihood of rehospitalization after discharge (p<0.001) and reporting of pressure ulcers (p=0.001) at 1yr follow-up.
  3. More time in therapeutic recreation had similar positive associations with social integration (p=0.006), mobility (p=0.009), smaller likelihood of rehospitalization (p=0.010) and reporting of pressure ulcers (p=0.023) at discharge and follow- up.
  4. Time spent in other disciplines had fewer and mixed relationships. OT was negatively associated with discharge FIM score (p=0.003) and positively associated with pressure sore at follow-up (p=0.026). No significant associations between social work and discharge/follow-up FIM. Psychology was negatively associated with CHART physical independence (p=0.002). Nursing positively associated with rehospitalization (p=0.037). SLP negatively associated with pressure sore incidence at follow- up (p=0.017).

Heinemann et al. 1995; USA
Case Series NInitial=264, NFinal=246

Population: SCI: Mean age=38.9yr; Gender: males=79%, females=21%.
Intervention: No intervention. Retrospective review of variation in therapy intensity (OT, BT, SLP, psychology). Also examined effect of various other factors including length of stay, interruptions, onset days, admission scores and age.
Outcome Measures: FIM (motor, cognitive, total), FIM Efficiency (motor or cognitive) all collected at Discharge.
  1. When analyzed together, none of the individual therapy intensities were predictive of improved outcomes. When analyzed individually, very little was significant in the prediction with only greater LOS associated with greater achievement of potential motor gains (p<0.05) and interrupted rehab associated with less achievement of potential motor gains (p<0.05).
  2. Patients with >intervals between onset and admission had less motor function at discharge, achieved less of their potential motor gains and made less efficient motor gains (all p<0.05).
  3. Therapy intensity was predicted to a small degree by the various functional, demographic and medical variables (psychology intensity had highest explained variance with 26.3%; SLT 17.2%, All therapies combined 16.6%, OT 7.3%, PT 6.5%).
  4. People with lower cognitive and motor function at admission receive more intense therapy (all therapy types p<0.05).

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.

Treatment times and intensities vary extensively between patients.

Increased therapeutic intensity has not been shown to have functional benefits.

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