Rehabilitation After Spinal Cord Injuries: The Sooner, the Better

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REHABILITATION AFTER SPINAL CORD INJURIES: THE SOONER, THE BETTERNew research shows earlier rehabilitation following traumatic spinal cord injuries may lead to better outcomes

Newswise — SACRAMENTO, CALIF. — Early rehabilitation following a traumatic spinal cord injury may lead to better functional outcomes for patients at the time of their discharge and in the subsequent year, according to research presented this week at the Association of Academic Physiatrists Annual Meeting in Sacramento, Calif.

Approximately 12,000 Americans experience traumatic spinal cord injuries each year. While the number of Americans who experience these injuries has not significantly increased or decreased in recent decades, the average length of stay in acute-care and rehabilitation settings after these injuries has declined dramatically. However, the length of stay in acute-care settings still varies widely, and this could potentially be due to underlying illnesses and medical needs separate from the spinal cord injury.

Those who fall into longer acute-care stays, and begin rehabilitation later, may miss a window of opportunity to take advantage of neuroplasticity, or the brain’s ability to adapt to neurological changes and fine tune itself to meet the patient’s needs. This critical time period led researchers from Johns Hopkins, the University of Alabama at Birmingham and Northwestern University to examine patients’ outcomes after being discharged from rehabilitation as well as one year after their injury to determine if earlier rehabilitation can positively affect those outcomes when compared to rehabilitation later in the recovery process.

“We were interested in whether earlier rehabilitation would be associated with improved outcomes,” explains Lead Investigator in the study, Kurt Herzer, MSc; a fellow in the Medical Scientist Training Program at Johns Hopkins School of Medicine. “In other areas of medicine, we tend to recognize that the time between an acute health event and treatment matters. For example, many patients are familiar with the adage that ‘time is muscle’ following a heart attack, and that delays in treatment increase the likelihood of damage to the heart. Our study is interested in a similar type of relationship between time and outcomes, but extending to the post-acute care setting — the time from spinal cord injury to rehabilitation.”

Herzer’s team conducted a retrospective study using data from the Spinal Cord Injury Model Systems – a network of federally funded facilities that has collected data on demographic and clinical characteristics for approximately 13 percent of all spinal cord injury cases in the United States since 1973.

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REHABILITATION AFTER SPINAL CORD INJURIES: THE SOONER, THE BETTER 2

Herzer’s team looked at data for 3,937 people who sustained a traumatic spinal cord injury between the years of 2000 and 2014. The patients were, on average, 41.5 years old at the time of their injury and were admitted to a Spinal Cord Injury Model System facility within 24 hours of sustaining the injury. The majority of those studied were white males (62.8 percent of the population was white and 79.2 percent was male) and nearly 17 percent had the most severe level of spinal cord injury (C1-C4), which includes paralysis in the hands, arms, trunk and legs.

The researchers looked at the number of days between the injury and admission to inpatient rehabilitation. They also looked at various measures to evaluate each patient’s outcome. These included the Functional Independence Measure (called FIM) motor score — which assesses physical disability — at discharge and one-year post injury; discharge to a private residence; and the Craig Handicap Assessment and Reporting Technique (called CHART) to assess physical independence and mobility at one-year post injury.

As they reviewed the data, the researchers took into consideration severity of illness, which could impact the time a person stayed in acute care. Additionally, they looked at Medicare data for terminally ill patients within different regions of the United States to better understand providers’ practice patterns within a given region and their likelihood of using acute care more versus less aggressively regardless of patients’ health statuses. “This additional information gave us the opportunity to improve our ability to make inferences about the relationship between time from injury to rehabilitation and subsequent outcomes,” explains Herzer of the Medicare data reviewed. Ultimately, Herzer’s team found, for patients suffering from spinal cord injuries, earlier rehabilitation was associated with modest improvements in functioning and physical independence. More specifically, they found the average time to rehabilitation was 19 days during the time period studied. When they accounted for patients’ health statuses, they found a 10 percent greater time to rehabilitation was associated with a relative decline of four percent in the FIM motor score and 5.3 percent in the CHART physical independence score at one-year post injury. Finally, they found no association between longer time to rehabilitation and the likelihood of being discharged to a private residence, one-year FIM motor score or the CHART mobility score.

“This study shows, following spinal cord injury, patients might benefit from entering inpatient rehabilitation at the earliest, clinically appropriate opportunity,” says Herzer of the results. “Patients and caregivers can discuss with their medical teams the plan and timing for transfer to rehabilitation and any concerns they may have about delays. Healthcare providers could similarly consider the value of additional days in the hospital as it relates to their treatment plans.”

The researchers caution that this observational study using data from the Spinal Cord Injury Model Systems has limitations, and additional research is needed to establish a cause-and-effect relationship between timing of rehabilitation and outcomes. Additionally, Herzer notes an opportunity to identify possible solutions that could improve the likelihood that patients receive earlier rehabilitation. He says this will likely require improved communication between hospital providers and rehabilitation professionals, better education of hospital providers about the possible benefits of earlier rehabilitation, and enhanced discharge planning across the care continuum.

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Editor’s Note: This project was completed as part of the Association of Academic Physiatrists’ Rehabilitation Research Experience for Medical Students. Others participating in the study were Yuying Chen, MD, PhD, Allen W. Heinemann, PhD, and Marlis González-Fernández, MD, PhD.

###The Association of Academic Physiatrists (AAP) is the only academic association dedicated to the specialty of physiatry in the world. AAP is an organization of leading physicians, researchers, in-training physiatrists, and others involved or interested in mentorship, leadership, and discovery in physiatry. AAP holds an Annual Meeting, produces a leading medical journal in rehabilitation, AJPM&R, and leads a variety of programs and activities that support and enhance academic physiatry. To learn more about the Association and the field of physiatry, visit our site at physiatry.org and follow us on Twitter using @AAPhysiatrists. To learn more about the 2016 AAP Annual Meeting, visit http://www.physiatry.org/AAP2016.

Abstract

Association Between Time-to-Rehabilitation and Outcomes Following Traumatic Spinal Cord InjuryKurt Herzer, MSC; Yu-Ying Chen, MD, PhD; Allen Heinemann, PhD; Marlis González-Fernández, MD, PhDObjectives: The benefits of earlier rehabilitation following traumatic spinal cord injury (SCI) remain uncertain. The objective of this study was to examine the relationship between time-to-rehabilitation (TTR) following SCI and rehabilitation outcomes, as measured at discharge and 1-year post injury.

Design: We conducted a retrospective study using data from 23 Spinal Cord Injury Model Systems across the United States. Patients experiencing a traumatic SCI between 2000 and 2014, who were 18 years or older, and who were admitted to a Model System within 24 hours of injury, comprised our study population (N = 3,937). TTR was measured as the number of days between injury and admission to inpatient rehabilitation. Pre-specified outcome measures included the Functional Independence Measure (FIM) motor score at discharge and 1-year post injury (Rasch-transformed), a dichotomous measure of discharge to a private residence, and the Craig Handicap Assessment and Reporting Technique (CHART) Physical Independence and Mobility scores (scaled 0-100) at 1-year post injury. Instrumental variables regression was used to reduce confounding from unobserved severity of illness/comorbidities. All models controlled for sociodemographic and injury characteristics (including injury severity), FIM motor score at admission, and rehabilitation length of stay.

Results: After adjusting for health status, a 10% increase in TTR was associated with a 1.50 lower FIM motor score at discharge (95% CI, -2.43 to -0.58; P=0.001) and a 3.92 lower CHART Physical Independence score at 1-year post injury (95% CI, -7.66 to -0.19; P=0.04). Compared to the mean FIM motor score (37.5) and CHART Physical Independence score (74.7), these represent relative declines of 4.0% and 5.3%, respectively. There was no association between longer TTR and the likelihood of discharge to a private residence, 1-year FIM motor score, or the CHART mobility score.

Conclusions: Efforts to promote earlier rehabilitation following traumatic SCI may improve patients’ functional status at discharge.