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Rehabilitation Practices

Traumatic vs Non-traumatic SCI

Those individuals sustaining damage to the spinal cord due to nontraumatic causes are often treated in specialized inpatient SCI rehabilitation centres more commonly associated with those with SCI due to traumatic etiologies. Various reports have estimated that one-quarter to one half of all cases seen in specialized SCI rehabilitation centers are associated with nontraumatic etiologies (Muslumanoglu et al. 1997; McKinley et al. 1999b; van der Putten et al. 2001). Despite these significant numbers, relatively little systematic research is directed at nontraumatic SCI (van der Putten et al. 2001; McKinley et al. 2002). Common causes of nontraumatic SCI includes space occupying lesions such as tumours or prolapsed intervertebral discs, spondylosis such as that seen with degenerative spinal changes resulting in compression of the spinal cord, vascular ischemia as in arteriovenous malformations or spinal infarction, inflammation (e.g., idiopathic transverse myelitis, tropical spastic paraparesis, sarcoid) and those associated with congenital or familial etiologies (Adams & Salam-Adams 1991; McKinley et al. 1999b; McKinley et al. 2001). Although estimates of the incidence of nontraumatic SCI have been provided (e.g., 8 per 100,000) (Kurtzke 1975), it is difficult to ensure accuracy given the heterogeneous nature of nontraumatic SCI and the variety of facilities and programs where these patients may receive care.

Studies comparing those with damage to the spinal cord due to nontraumatic vs. traumatic etiologies have demonstrated a variety of systematic differences between these 2 patient groups. In general, those with nontraumatic SCI are more likely to be older, female, have paraplegia and have an incomplete injury than those with traumatic SCI (McKinley et al. 1996; McKinley et al. 2001; McKinley et al. 2002; New 2005). In the present section, we review the studies characterizing rehabilitation outcomes between those with SCI due to nontraumatic vs traumatic causes.

Author Year; Country
Research Design
PEDro Score
Total Sample Size

Methods Outcome

Non-traumatic versus Traumatic

Non-traumatic versus Traumatic

Non-traumatic versus Traumatic

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. Functional status at admission and gain during rehabilitation was significantly higher in patients with non-traumatic SCI (p<0.001)
  2. No significant difference between the two groups was seen in their admission to rehabilitation.
  3. Age and better functional status on admission was associated with shorter length of stay (p=0.001).
  4. Functional outcome was not correlated with age; however it was significantly correlated with functional status at admission and LOS.

Bradbury et al. (2008); Canada
Case control NInitial=20, NFinal=20

Population: SCI/TBI: Mean age=35.9yr; Gender: males=7, females=3; Level of injury: C=6, L=1, T=3; Severity of injury: complete=3, incomplete=7; SCI: Mean age=36.3yr; Gender: males=7, females=3; Level of injury: C=6, L=1, T=3; Severity of injury: complete=3, incomplete=7.
Intervention: No intervention. Rehabilitation data of patients with SCI and TBI was analyzed against those with SCI alone.
Outcome Measures: Behavioral incidents, Personality Assessment Inventory, Stroop, FIM, costs.

  1. No significant difference between the two was seen in motor FIM scores.
  2. Patients with both SCI and TBI tended to stay longer in rehabilitation however this trend did not reach significance.
  3. The difference in average cost of a dual diagnosis compared to the single SCI diagnosis had clinical significance ($169,638 versus $130,773, p=0.17).
  4. Clinical significance was also reached in the total cost per FIM change score between the two groups (p=0.13).

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: LOS, BI, AIS collected at admission and discharge.

  1. 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.
  2. LOS was 66.0±47.7 days (trauma) and 60.7±45.7 which was not significantly different between groups.
  3. Both trauma and non trauma patients showed significant gains in function with BI increasing significantly from admission to discharge (p<0.05) although there was no between group differences.
  4. AIS scores showed non traumatic patients had significantly more impairment than the traumatic at both admission and discharge (p=0.020, p=0.017) (Overall change in AIS not reported).

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%).
  2. Patients with IR-SCD more often had incomplete injuries (94% versus 57%).
  3. Thirty-two percent of IR-SCD patients had improvements in ASIA impairment scale classification. LOS was longer on acute care (25 versus 16 days), but similar on rehabilitation (36 versus 34 days), and with lower FIM motor changes (16.2 versus 22.8) during rehabilitation.
  4. Patients with IR-SCD were less often discharged to home (56% versus 75%).

Ones et al. (2007); Turkey
Case control NInitial=194, NFinal=194

Population: SCI Non-traumatic (n=63): Mean age=49.87yr; Gender: males=30, females=33; Level of injury: paraplegia=52, tetraplegia=11; Severity of injury: complete=18, incomplete=45; Work status: working=22, not working=41.
Traumatic (n=131): Mean age=35.82yr; Gender: males=91, females=40; Level of injury: paraplegia=98, tetraplegia=33; Severity of injury: complete=83, incomplete=48; Work status: working=98, not working=33.
Intervention: No intervention. Records of people with SCI were retrospectively reviewed.
Outcome Measure: FIM scores, complications.

  1. Traumatic SCI group was significantly different from non-traumatic SCI group in:
  2. Admission FIM scores were lower in traumatic (74.32) versus non- traumatic (89.68) SCI group (p=0.004).
  3. FIM efficiency scores were higher in traumatic (0.15) versus non traumatic (0.07) SCI group (p=0.04).
  4. No significant difference was seen between the two groups in:
    1. Discharge FIM scores between the two groups (p=0.303).
    2. LOS values (p=0.565).
  5. Most common complication in non- traumatic group was UTI.

Yokoyama et al. (2006); Japan
Case control NInitial=34, NFinal=34

Population: SCI due to aortic aneurysm: Mean age=58.6yr; Level of injury: T=17; Severity of injury: AIS A=8, B=2, C=3, D=4.
Traumatic SCI: Mean age=57.2yr; Level of injury: T=17; Severity of injury: AIS A=8, B=2, C=3, D=4.
Intervention: No intervention. Data of patients with spinal cord injury associated with aortic aneurysm repair (SCI-AA) was compared to those with traumatic spinal cord injury (SCI). All patients had previously underwent a rehabilitation program consisting of 40 min of PT, 40 min of OT and 40 min of rehabilitation sports therapy per day for 5 days a wk.
Outcome Measures: FIM, LOS, discharge, complications.

  1. No significant difference was seen between the two groups in their LOS in the acute or rehabilitation hospital.
  2. The two groups showed no difference in admission FIM scores; however, SCI group had significantly greater discharge FIM total scores (p=0.02), motor scores (p=0.03), total change (p=0.03), motor change (p=0.03) and efficiency (p<0.01). FIM cognitive score and cognitive change did not show significant differences.
  3. Of all the medical complications and comorbidities only hypertension and cardiac disease were seen to be significantly higher in the SCI-AA group compared to the SCI group (p=0.01).
  4. The amount of PT and OT was not significantly different between the two groups, while the SCI group was the only group receiving rehabilitation sports therapy.

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%)
  2. As compared to those with trauma (after matching), those with stenosis had significantly (p<0.05):
    1. ↓ LOS (22.1 versus 32.2 days)
    2. ↓ charges
    3. admission FIM and FIM motor scores
    4. ↓ total and motor FIM change and FIM efficiency
    5. No difference in discharge FIM totals
    6. No difference in discharge destination.

McKinley et al. (2001); USA
Case Control NInitial=174, NFinal=174

Population: Non-traumatic SCI (n=87) from a single centre versus traumatic SCI (n=87) from the United States Model Systems database; Matched on level and completeness of lesion and age; 2/3rds 30-59yr, 1/3rd 60+ yr; 93% were admitted within 21 days of injury; 68% were paraplegic; AIS C 36%, AIS D 41%. Outcomes were collected at admission to and discharge from rehabilitation.
Intervention: No intervention. Outcomes associated with non- traumatic versus traumatic rehabilitation.
Outcome Measures: LOS, charges, motor FIM (score, change and efficiency).

  1. As compared to those with trauma (after matching), those with non- traumatic SCI had:
    1. ↓ rehabilitation LOS (22.46 versus 41.49days) (p=0.000)
    2. ↓ overall charges (p=0.003) and ↓ daily charges (p=0.019)
    3. No difference on motor FIM at admission and motor FIM efficiency with rehabilitation
    4. ↓ motor FIM at discharge and ↓ motor FIM change
    5. No difference in discharge destination.

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

Population: Non-traumatic SCI secondary to neoplastic cord compression admitted over 5yr (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%)
  2. As compared to those with trauma (after matching), those with neoplastic cord compression:
    1. Had ↓ LOS (25.17 versus 57.46 days)
    2. Had ↓ motor FIM change
    3. Had ↓ motor FIM scores at discharge
    4. No different FIM efficiency
    5. No different for discharge destination.

Non-Traumatic

Non-Traumatic

Non-Traumatic

Gupta et al. (2009); India
Observational
NInitial=64, NFinal=64

Population: Mean age=30.64yr; Gender: males=28, females=36; Level of injury: paraplegia=67.2%, tetraplegia=32.8%; Duration of illness=7.1±9.2mo.
Intervention: No intervention. Admission/discharge data for non- traumatic patients admitted for neurological rehabilitation from June 2005 to January 2008 was analyzed. Outcome Measures: Functional (BI) and neurological (AIS) outcomes and complication prevalence collected at admission and discharge.

  1. LOS was 55.8±40.9 days (Range 14- 193 days).
  2. BI scores showed significant functional recovery (p=0.000).
  3. AIS score showed significant neurological recovery during rehabilitation (p=0.001).
  4. # of patients at AIS A went from 31.3% to 18.8%, AIS B from 20.3% to 7.8% and AIS C/D from 48.4%to 73.4% between admission and discharge.
  5. 90% of patients reported at least one complication during rehabilitation.
  6. Most common medical complications were UTI (50.0%), spasticity (35.9%), urinary incontinence (31.3%) and pressure ulcer (25.0%).

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. LOS =55.8 days (7-413 days).
  2. FIM motor scores during rehabilitation from 40.8 to 67.1, cognitive FIM showed no change due to initial ceiling effect.
  3. 17.7% overall and 26.9% over the age of 70 were discharged to a nursing home.
  4. Those subjects male, younger, more mobile, more independent bowel and bladder function and less severe AIS grades were more likely to be discharged home.
  5. Major non-traumatic classifications were tumour (32.9%), degenerative (25.7%), vascular (14.3%) and other (27.1%).

Citterio et al. (2004); Italy
Case Series NInitial=323, NFinal=323

Population: Non-traumatic SCI: Mean age=55yr; Level of injury: cervical=72, thoracolumbar=251; Severity of injury: complete=79, incomplete=244; Etiology of injury: inflammatory=63, vascular=81, neoplastic=81, degenerative=60, other=38.
Intervention: No intervention. Patients with non-traumatic SCI involved in rehabilitation were recruited and clinical data was analyzed.
Outcome Measures: LOS, AIS grade, complications, discharge destination.

  1. Mean LOS was 73.5 days; patients having complete cervical lesions had significantly (p<0.0026) longer mean LOS (107.9 days).
  2. No significant difference was seen in LOS between men and women.
  3. AIS grade B was significantly related to longer LOS (p<0.0001).
  4. Living outside the rehabilitation centre district was related significantly to longer LOS (p<0.016).
  5. Having at least 1 complication on admission was significantly related to longer LOS, pressure ulcers (p<0.03) or DVT (p<0.014).
  6. 73% of patients were discharged home.
  7. 20% of patients were transferred to other hospitals for specialized rehabilitation.
  8. 3.3% of patients were admitted to nursing homes.
  9. Discharge to home was predicting by marital status, incompleteness of lesion, clinical improvement, efficient bowel and bladder management, absence of pressure ulcers and longer LOS.

Van der Putten et al. (2001); England, UK
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. LOS =31.5 days (9-184 days).
  2. Higher FIM motor score was associated with lower score on admission and reduced time between onset-admission (overall predictive model).
  3. 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.

McKinley et al. (1996); USA
Case Series
NInitial=32, NFinal=20

Population: Non-traumatic SCI secondary to neoplastic cord compression admitted over 5yr within a single centre; Mean age=64yr; Gender: male=18. Female=14.
Intervention: No intervention. Outcomes associated with rehabilitation care were assessed.
Outcome Measures: Medical complications, AIS, LOS, bladder function, FIM, Discharge destination. All collected at admission to and discharge from rehabilitation. Level of ambulation and dressing ability assessed at 3-15mo post-discharge.

  1. LOS =27 days (7-54 days).
  2. People showed significant  in 9 FIM categories (0<0.005) associated with mobility and self-care during rehabilitation.
  3. 11 individuals improved from AIS C to D at discharge.
  4. 27/32 were discharged home, 4 transferred for medical reasons (and died within 2mo) and 1 died before discharge.
  5. Of 20 people with assessed at 3-15 mo follow-up, 16 had maintained mobility and dressing function as compared to discharge. However, 12/20 had eventually died at a mean of 101 days post-discharge.

Discussion

Studies examining nontraumatic SCI typically make use of retrospective case series designs describing rehabilitation outcomes directly (Citterio et al. 2004; McKinley et al. 1996; van der Putten et al. 2001; New et al. 2005; New 2006) or involve case control designs employing matching techniques to make comparisons with traumatic SCI while controlling for such things as age and level and completeness of injury (McKinley et al. 1999; McKinley et al. 2001; McKinley et al. 2002, 2008). As noted above, those with nontraumatic SCI were more likely to be older, female, have paraplegia and have an incomplete injury than those with traumatic SCI (McKinley et al. 1996; McKinley et al. 2001; McKinley et al. 2002; New 2005). No difference in age, marriage, education, socioeconomic factors, LoS and functional outcome was reported for a case control analysis originating from India (Gupta et al 2008, N=76)

Patients with nontraumatic SCI were primarily discharged home after rehabilitation (Citterio et al. 2004; McKinley et al. 1996). Citterio et al. (2004) found that discharge to home was predicted by many factors including: marital status, completeness of injury, clinical improvement, efficient bowel and bladder management, and absence of pressure ulcers. Another important predictor was shown to be a longer length of stay. This was due to the finding that there is an increased probability of functional and neurological improvement after longer hospital stay.

Ones et al. (2007) and Yokoyama et al. (2006) showed no significant difference in LOS between individuals with traumatic vs. nontraumatic spinal cord injury. Conversely, when direct comparisons of traumatic and nontraumatic SCI of various etiologies have been conducted using matching procedures, it is clear that shorter rehabilitation LOS was seen for those with nontraumatic SCI (McKinley et al. 2001; Osterthum et al 2009). In addition, this shorter LOS was associated with reduced hospital charges for both an overall and a per diem basis (McKinley et al. 2001). These findings were replicated with similar studies examining subsets of those with nontraumatic SCI including those with stenosis (McKinley et al. 2002) and those with neoplastic cord compression (McKinley et al. 1999) although this was not the case for a review involving infection-based SCI (McKinley et al. 2008). Most of these findings have been established with data from the US Model Systems, although at least two reports from other jurisdictions have reported longer rehabilitation LOS (van der Putten et al. 2001; New 2005).

None of the studies employing matching procedures noted differences in discharge destinations for those with nontraumatic SCI as compared to those with traumatic SCI (McKinley et al. 1999; McKinley et al. 2001; McKinley et al. 2002). although New et al. (2005) did note that within nontraumatic subjects, those individuals male, younger, more mobile, more independent with bowel and bladder function and having less severe AIS grades were more likely to be discharged home. In addition, the relatively poor prognosis and low survival rate of those with neoplastic cord compression has specific implications for discharge disposition (McKinley et al. 1996) although no specific differences were noted in a matched comparison (McKinley et al. 1999).

Comparing the rehabilitation of individuals with traumatic SCI with or without concomitant TBI, Bradbury et al (2008) reported no significant differences in LOS and FIM change score. However the presence of dual diagnoses was deemed to result in clinical but not statistically significantly greater costs associated with the FIM change score.

All studies reviewed employed the FIM to assess the functional status of individuals and generally demonstrated improved function with rehabilitation. Typically, motor FIM scores were employed or in the event total FIM scores were used it was acknowledged that changes were due primarily to the motor FIM subscale given a ceiling effect associated with the cognitive FIM subscale (McKinley et al. 1999; New 2005). There was conflicting evidence in admission and discharge FIM scores between traumatic and nontraumatic SCI groups. A study by Ones et al. (2007) found patients with traumatic SCI had significantly lower admission FIM scores than those with nontraumatic SCI. However, other studies found no such trend (McKinely et al. 1999; McKinely et al. 2001). FIM discharge scores were shown to be lower in the nontraumatic SCI population than traumatic (McKinely et al. 1999; McKinely et al. 2001) while Ones et al (2007) showed no such difference. When examining only those with stenosis vs those with traumatic SCI, those with nontraumatic SCI had higher FIM scores on admission, similar scores on discharge, resulting in reduced change scores and lower efficiency (McKinley et al. 2002). On the other hand, those with neoplastic cord compression demonstrated similar FIM scores on admission, reduced scores on discharge, resulting in reduced change scores but no difference in efficiency (McKinley et al. 1999).

McKinely et al. (1999) and McKinely et al. (2001) found no significant difference between traumatic vs. nontraumatic SCI populations in FIM efficiency. However, Ones et al. (2007) showed a significantly higher FIM efficiency for persons with a traumatic as compared to a nontraumatic etiology. Given this and other conflicting findings in these studies it seems that it is especially important to appreciate the heterogeneity inherent in rehabilitation outcomes of persons with nontraumatic etiologies. In particular, much variation might be expected, especially between centre-based reports with relatively small sample sizes and which include various nontraumatic etiologies within a single nontraumatic grouping. Future research should focus on large scale, case control methodologies employing subject matching strategies that control for potential confounding variables or that examine the effect of potential mediating variables. It is also important to consider logical subgroups based on specific etiologies of nontraumatic SCI.

Van der Putten (2001) assessed a variety of factors using multiple linear regression techniques in order to predict those most associated with increases in FIM motor scores during rehabilitation. They included 100 consecutively admitted patients with nontraumatic SCI with rehabilitation periods of > 1 week. The primary factors associated with improved motor FIM scores accounting for 54% of the variance were having a lower score on admission and reduced time between symptom onset to admission. Age, specific diagnostic subgroup (i.e., space-occupying, vascular, spondylosis, inflammation or hereditary), or lesion level did not improve the prediction significantly.

Conclusions

There is level 4 evidence that those with nontraumatic SCI are more likely to be older, female, have paraplegia and have an incomplete injury as compared to those with traumatic SCI.

There is level 3 evidence that those with nontraumatic SCI have generally reduced rehabilitation LOS, reduced hospital charges but similar discharge destinations as compared to those with traumatic SCI.

There is conflicting level 3 evidence that individuals with nontraumatic SCI have lower FIM efficiencies than those with traumatic SCI, although many studies are comparing persons with different etiologies of nontraumatic SCI.

There is level 3 evidence that individuals with traumatic SCI with or without concomitant TBI have similar LoS and achieve similar FIM motor scores, but associated costs were higher in those with dual diagnosis.

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