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Rehabilitation Practices

Neurological and Functional Status

Several studies have identified patterns of neurological and/or functional improvement over the first few months post-injury. Most of these studies examine neurological and/or functional status and associated changes between rehabilitation admission and discharge. Table 4 summarizes various reports in the literature for neurological and/or functional status organized by jurisdiction and by the time period for which the data was collected. Data were only included if the underlying sample was deemed representative of an overall heterogeneous population of individuals with SCI (i.e., unselected sample of a single or multi-centre study).

Study Jurisdiction N, Trauma &/or Nontrauma

Outcome Measure and Sample Period

Neurological and/or Functional Change with Rehabilitation

Gupta et al. 2009; India (single centre)
N = 64
Nontrauma

AIS
BI 2005-2008

  1. AIS score showed significant neurological recovery during rehabilitation (p=0.001).
  2. # 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.
  3. BI scores showed significant functional recovery (p=0.000).

Moslavac et al. 2008; Croatia
(single centre)
N = 154
Trauma

AIS 1991-2001

  1. 49% were AIS A at admission -of these, 93% remained an A at discharge, 5% to C and 1% to D.
  2. 8% were AIS B at admission -of these, 38%remained B at discharge, while 31% of these improved to a C, 23% to a D and 8% to E.
  3. 21% were AIS C at admission – of these, 3% deteriorated to A, 9% remained C, 67% improved to D and 21% to E.
  4. 12% were AIS D at admission – of these, 26% remained D and 74% improved to E.
  5. 8% were AIS E at admission – all of these remained E.

DeVivo 2007; United States (multi-centre)
N = 24,333
Trauma

AIS

FIM 1973-2006

  1. For 2002-2006, among injuries that were initially neurologically complete, 15.1% became incomplete by discharge. Among ASIA B injuries, 45.2% improved at least one grade, whereas 54.3% of ASIA C injuries improved to at least ASIA D injuries. This suggests some gains in the likelihood of neurologic improvement over the past 30 years.
  2. Mean gain in FIM motor score decreased by 3.38 points during the past 20 years (p<0.01) although FIM efficiency increased (p<0.01) (discrepancy due to reduced LOS).
  3. FIM motor scores at admission & discharge decreased significantly during the past 20 years (p<0.0001).

Mϋslϋmanoğlu et al. 1997;
Turkey
NInitial=52 NFinal=10

AIS FIM

  1. Neurological assessments (Motor scores and light touch scores) showed increases from admission to discharge for those with incomplete injuries (p<0.001) but not complete injuries.
  2. FIM showed increases from admission to discharge for those with incomplete injuries (p<0.05) and those with complete paraplegia (p<0.05) but not complete tetraplegia.
  3. FIM scores (p<0.05), but not motor scores or light touch scores showed significant increases from discharge to 1 year post-discharge in a subsample of 10 with paraplegia.

Chan & Chan 2005; China (single centre)
N = 33
Trauma

FIM 2002

  1. All groups showed ↑ in FIM motor scores from admission to discharge but these were only significant for tetraplegia AIS D.
  2. All patient groups (i.e., levels and severity of injury) had similar FIM motor scores at discharge as noted by American Consortium for Spinal Cord Medicine (1999).

Pollard & Apple 2003; USA (single centre)
N = 95
Trauma

AIS
  1. Most gains in motor and sensory scores were found in first year. An average of 35 motor points (18% during acute care, 53% during rehabilitation, 8% during the remainder of the year) and 46 sensory points (46% during acute care, 46% during rehabilitation, 8% during the remainder of the year) were recovered.
  2. People with Brown Sequard and Central Cord injuries had more improvement in motor scores but not sensory scores than those with anterior cord (p=0.019).

Pagliacci et al. 2003; Italy (multi-centre)
N = 684
Trauma

AIS 1997-1999

  1. ↑ was associated with AIS B and C, shorter LOS, earlier admission and no complications (especially pressure sores).

Tooth et al. 2003; Australia (single centre)
N = 167
Trauma

FIM 1993-1998

  1. ↑ from 68.7 (admission) to 102.2 (discharge) due almost entirely to gains in motor FIM scores.
  2. Total FIM scores were lowest for those with complete tetraplegia and highest for those with incomplete paraplegia. Those with complete tetraplegia had the least change in FIM scores.

Catz et al. 2002; Israel (single centre)
N = 250
Trauma

Frankel 1962-1992

  1. ↑ in 27% of those admitted at A, B or C to D or E. None initially admitted as A were able to achieve D or E. 43% of those initially C ↑ to D and 11% to E. 47% of those initially D ↑ to E.

Celani et al. 2001; Italy (multi-centre)
N = 859
Trauma & Nontrauma

Frankel 1989-1994

  1. ↑ of at least 1 grade was seen in ~1/3 of those with traumatic SCI. Initial B and C had greatest probability of ↑. 76% of those initially at C and 67% of those initially at B ↑. With non- traumatic SCI, 64% of those initially at C and 44% of those initially at B ↑.

Sumida et al. 2001; Japan (multi-centre)
N = 123
Trauma & Nontrauma

FIM 1994-1997

  1. Compared earlier versus later admission to rehabilitation and showed ↑ FIM and FIM efficiency for the earlier group
  2. Greater proportion of persons ↑ by at least 1 AIS grade with earlier admission.
  3. Increasingly greater likelihood of ↑ by 1 AIS grade for initial AIS of B, C or D than A.

Marino et al. 1999; USA
(multi centre)
N = 3585
Trauma

AIS 1988-1997

  1. Increasingly greater likelihood of ↑ to D for initial AIS of C>>B>>A.

Mϋslϋman-oğlu et al. 1997; Turkey
(single centre)
N = 52
Trauma & Nontrauma

AIS FIM 1992-1995

  1. ↑ in ASIA motor scores and light touch scores for those with incomplete injuries but not complete injuries.
  2. FIM showed ↑ f for those with incomplete injuries and those with complete paraplegia but not complete tetraplegia.

DeVivo et al. 1991; USA (multi-centre)
N = 13,763
Trauma

AIS FIM 1973-1990

  1. Proportion showing ↑ were 10.3% (A), 45.2% (B), 55.9% (C), 7.3% (D) versus no change 89% (A), 50.3% (B), 41.5% (C), 90.5% (D) versus declined 4.5% (B), 2.6% (C), 2.0% (D)
  2. From 1973-1990 the proportion of incomplete patients increased from 40% to 55.2%.
  3. Average FIM gain was 37 (incomplete paraplegia, 36 (complete paraplegia), 34 (incomplete tetraplegia and 15 (complete tetraplegia).

Yarkony et al. 1987; USA
(single centre)
N = 711
Trauma

MBI 1973-1980

  1. ↑ in total scores & self-care and mobility subscores.
  2. Greater ↑ for incomplete versus complete and for those with paraplegia versus tetraplegia.

Burke et al. 1985; Australia
(single centre)
N = 262
Trauma

Frankel

  1. 31% of people improved, 66% remained unchanged, and 3% deteriorated. 23% initially complete became incomplete and 40% of those initially incomplete improved.

Discussion

The AIS represents an internationally recognized system for the classification of individuals with SCI, and as such, has been employed to characterize overall improvement in the neurological status of people with SCI (ASIA 2002). It is somewhat similar to earlier systems such as the Frankel grading classification system. The AIS is an ordinal 5 grade scale classifying individuals from “A” to “E” with “A” designating those with complete SCI and “E” designating individuals with normal sensory and motor function. Most notably, DeVivo (M. DeVivo, 2007), Pagliacci et al. (Pagliacci et al., 2003), Celani et al. (Celani, Spizzichino, Ricci, Zampolini, & Franceschini, 2001), Marino et al. (Marino, Ditunno, Donovan, & Maynard, 1999) and DeVivo et al. (De Vivo et al., 1991) employed large multi-centre databases and found that individuals with incomplete injuries (especially AIS B or C) were more likely to improve at least 1 grade over the course of rehabilitation. In particular, DeVivo et al. (De Vivo et al., 1991) reported that 45.2% and 55.9% of those initially admitted as AIS B and C respectively improved at least 1 AIS grade as compared to only 10.3% and 7.3% of individuals initially classified as AIS A or D respectively. Over the period of 1973-2006, DeVivo (M. DeVivo, 2007) reported that there was an 8.8% increase in likelihood that those classified as AIS A at admission would improve to AIS B at discharge. Other reports have presented similar findings and data culled from a sample of these investigations have been summarized in Figure 1. Figure 1 illustrates the proportion of persons assessed at each AIS (or Frankel) grade status (i.e., A, B, C or D) at discharge from rehabilitation relative to the proportion of people at each AIS level at rehabilitation admission for each of the studies (Burke et al., 1985; Catz et al., 2002; M. DeVivo, 2007; Marino et al., 1999; Pagliacci et al., 2003; Sumida et al., 2001). This provides an indication of the degree of neurological recovery that occurs over the period of rehabilitation. It should be noted that for each study (i.e., jurisdiction) the admission and discharge time points are variable relative to the time of injury although these all are typically within the first six months following injury. In addition, all datasets consisted of relatively unselected patients with traumatic SCI, other than the report by Sumida et al. (Sumida et al., 2001) which included patients with SCI of both traumatic and non-traumatic etiology.

Figure 1. Discharge or Frankel Grades for each initial admission AIS grade

As one can see, it is striking how similar these patterns of AIS conversion rates are across health systems (i.e., Australia, Israel, Italy, Japan, United States) with only Catz et al. (Catz et al., 2002) (i.e., Israel) providing somewhat disparate results. Overall, AIS A patients comprise from 40-50% of individuals admitted to SCI rehabilitation centres and a similar, but slightly reduced percentage of those are assessed AIS A at discharge. AIS B and AIS C patients comprise ~5-15% and ~10-30% respectively with moderate reductions in these percentages manifest at discharge. Conversely, those assessed AIS D comprise ~15-25% of those admitted which increases to ~25-35% by discharge.

The majority of patients assessed AIS A at admission remain so at discharge, whereas a much greater proportion of individuals assessed AIS B recovered significant motor function during rehabilitation so as to be assessed AIS C or D. The conversion rate is even greater for those assessed initially as AIS C but much less so for those assessed as AIS D.

These conversion rates appear similar across these studies and therefore provide a base for comparison with other findings. For example, Moslavac et al. (Moslavac, Dzidic, & Kejla, 2008) reported data for a centre-based study in Croatia at which all national cases of SCI resulting from road traffic accidents received rehabilitative care. In this case, although 49% of people were AIS A at admission and 93% of these remained AIS A at discharge, there was a tendency for greater proportions of persons making conversions to AIS D or E of those assessed with an incomplete injury at admission. Importantly, Wilde et al. (2020) found that interhospital transfer does not reduce functional recovery.

Similarly, many individuals also make significant functional gains during comprehensive inpatient rehabilitation. Most often, functional status has been assessed at admission and discharge from rehabilitation using the FIM (De Vivo et al., 1991; Muslumanoglu et al., 1997; Tooth et al., 2003)c(Chan & Chan, 2005) or MBI (Yarkony et al., 1987). Typically, functional gains are greater with rehabilitation for those with incomplete injuries as compared to complete injuries and for those with paraplegia as compared to those with tetraplegia (Chan & Chan, 2005; De Vivo et al., 1991; Muslumanoglu et al., 1997; Tooth et al., 2003). In particular, DeVivo et al. (1991) reported similar average FIM gains for those with incomplete and complete paraplegia and incomplete tetraplegia (i.e., 37, 36 and 34 respectively) but much reduced gains for those with complete tetraplegia (i.e., 15). For the most part increases seen in the FIM have been attributed to motor FIM changes with little change in cognitive FIM scores at least partly due to an apparent ceiling effect (Chan & Chan, 2005).

Conclusions

There is level 4 evidence that a significant proportion of people (~50%) initially assessed as AIS B and C will improve by at least one AIS grade in the first few months post-injury concomitant with inpatient rehabilitation. Fewer individuals (~10%) initially assessed as AIS A and D will improve by one AIS grade.

There is level 4 evidence that individuals make significant functional gains during inpatient rehabilitation, more so for those with complete and incomplete paraplegia and incomplete tetraplegia.

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