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Purpose: To help enhance participation, the study aims to identify and document a comprehensive list of environmental barriers for people with SCI in the broad travel setting., Methods: Semi-structured interviews were conducted among four stakeholder groups: people with SCI ( n = 39), caregivers and family members of people with SCI ( n = 24), therapists who work with people with SCI ( n = 9), and travel professionals specializing in accessible travel ( n = 11)., Results: Five major categories of travel barrier emerged from the interviews: Partial Accessibility, Systemic Ignorance, Travel Hassles, Poor Service Performance, and Lack of Support. Detailed barriers in each category are described. The analysis of multi-stakeholder perspectives indicates while respondents with SCI offered the most specific information about the barriers, family members/caregivers were most concerned about the impact of systemic ignorance on their loved ones. Therapists focused on offering their clients tools to overcome barriers, and travel agents emphasized their limitations of serving customers with disabilities., Conclusion: Results of the study should help not only health and travel professionals better assist individuals to reintegrate into society after SCI, but also travel and hospitality businesses to better meet the accessibility needs of people with SCI.Implications for rehabilitationTravel is important to full participation in society for people after SCI.The study has identified five categories of barriers to travel participation after SCI: partial accessibility, systemic ignorance, travel hassles, poor service performance and lack of support.While traveling is important for participation in society for people with SCI, rehabilitation professionals should work together with policy makers, travel and hospitality businesses and agencies to lower the found barriers.

Objective: To examine associations of patient characteristics and treatment quantity delivered during inpatient spinal cord injury (SCI) rehabilitation with outcomes at 5 years post-injury and compare them to the associations found at 1 year post-injury., Design: Observational study using Practice-Based Evidence research methodology in which clinicians documented treatment details. Regression modeling was used to predict outcomes., Setting: Five inpatient SCI rehabilitation centers in the US., Participants: Participants were 792 SCIRehab participants who were > 12 years of age, gave informed consent, and completed both a 1-year and 5-year post-injury interview., Outcome Measures: Outcome data were derived from Spinal Cord Injury Model Systems (SCIMS) follow-up interviews at 5 years post-injury and, similar to the 1-year SCIMS outcomes, included measures of physical independence, societal participation, life satisfaction, and depressive symptoms, as well as place of residence, school/work attendance, rehospitalization, and presence of pressure ulcers., Results: Consistent with 1-year findings, patient characteristics continue to be strong predictors of outcomes 5-years post-injury, although several variables add to the prediction of some of the outcomes. More time in physical therapy and therapeutic recreation were positive predictors of 1-year outcomes, which held less true at 5 years. Greater time spent with psychology and social work/case management predicted greater depressive symptomatology 5-years post-injury. Greater clinician experience was a predictor at both 1- and 5 -years, although the related positive outcomes varied across years., Conclusion: Various outcomes 5-years post-injury were primarily explained by pre-and post-injury characteristics, with little additional variance offered by the quantity of treatment received during inpatient rehabilitation.

Background . In spinal cord injury, there are multiple databases containing information on functional recovery, but data cannot be pooled or compared due to differences in how function is measured. A crosswalk is needed to link or convert scores between instruments. Objectives . To create a crosswalk between the voluntary musculoskeletal movement items in the Functional Independence Measure (FIM®) and the Spinal Cord Independence Measure III (SCIM III) for spinal cord injury. Methods . Retrospective datasets with FIM® and SCIM III on the same people were used to develop (Swiss dataset, n = 662) and validate (US, n = 119, and Canadian datasets, n = 133) the crosswalks. Three different crosswalk methods (expert panel, equipercentile, and Rasch analysis) were employed. We used the correlation between observed scores on FIM® and SCIM III to crosswalked scores as the primary criterion to assess the strength of the crosswalk. Secondary criteria such as score distributions, Cohen's effect size, point differences, and subgroup invariance were also evaluated. Results . All three methods resulted in strong correlation coefficients, exceeding the primary criterion value of r = .866 (.897-.972). Assessment of secondary criteria suggests the equipercentile and Rasch methods produced the strongest crosswalks. Conclusions . The Rasch FIM®/SCIM III crosswalk is recommended because it is based on co-calibration of linearized measures, allowing for more sophisticated parametric analyses. The crosswalk will allow comparisons of voluntary musculoskeletal functional recovery across international databases using different functional measures, as well as different systems of care and rehabilitation approaches.

Study Design: This was a secondary analysis on an observational cohort study., Objective: To determine if serum albumin significantly associates with long-term neurological outcome (i.e., 1-year post-injury) in a contemporary cohort of individuals with spinal cord injury., Setting: Six rehabilitation centers across the United States., Methods: A secondary analysis of neurological outcomes and serum albumin concentrations was performed on data from the Spinal Cord Injury Rehabilitation study. Data was accessed from the Archive of Data on Disability to Enable Policy and research (ADDEP). The primary analysis applied unbiased recursive partitioning to examine the relationship between serum albumin, injury severity, and long-term outcomes. The analysis is accessible via https://rpubs.com/AnhKhoaVo/586028 ., Results: Serum albumin concentration was significantly associated with lower extremity motor scores (LEMS) and American Spinal Injury Association Impairment Scale (AIS) grade at admission to rehabilitation. Serum albumin concentrations alone were also significantly associated with change of LEMS and marked recovery (improvement of at least 2 AIS grades and/or recovery to walking) at 1-year post injury. However, after adjusting for admission to rehabilitation LEMS and AIS grade, serum albumin was not significant., Conclusion: The current study partially confirms our previous observations that serum albumin concentrations are associated with neurological outcome after spinal cord injury. As a crude prognostic biomarker, serum albumin concentration could be useful in cases where injury severity cannot be accurately assessed.

Objective: To evaluate the use of Participation Assessment with Recombined Tools-Objective (PART-O) in spinal cord injury (SCI) and compare it with the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF)., Design: Follow-up survey of inception cohort., Setting: Community., Participants: Individuals with SCI, rehabilitated at 2 large SCI Model Systems and enrolled in the SCI Model Systems National Database, who were due for routine follow-up (N=468; median age at injury, 29; median time post injury, 5 years)., Interventions: Not applicable., Main Outcome Measures: PART-O and CHART-SF., Results: Use of Rasch analysis identified an SCI-specific scoring of PART-O that demonstrated unidimensionality (first contrast eigenvalue of 1.76) with no misfitting items or disordered steps in any response categories. Person separation and reliability were 2.00 and .80, respectively. Unlike CHART-SF, PART-O had a relatively normal distribution with no floor or ceiling effects. Test-retest reliability PART-O administered 2-4 weeks apart was 0.97, with a reliable change index of 3.1 points on a 100-point scale. PART-O correlated 0.79 with the sum of 3 CHART-SF domains with similar content. The PART-O scoring was initially validated on a second data set., Conclusions: PART-O can be used successfully to measure participation in a population of people with SCI. A new method of scoring PART-O in SCI provides an initially validated, univariate interval measure of participation with good psychometric properties that has advantages over the CHART-SF legacy measure of participation., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop an environmental-barriers scale, Travel Restrictions Influencing Participation (TRIP), in the context of travel for people living with spinal cord injury (SCI)., Design: A mixed-method approach where, in the qualitative phase, items were developed and written based on results of interviewers with different stakeholder groups and, in the quantitative phase, survey data were collected to examine the psychometric properties of the scale., Setting: Home, work, and community settings., Participants: People living with SCI, caregivers/family members, therapists, and travel professionals (N=333)., Interventions: None., Main Outcome Measures: A 19-item TRIP scale that measures the travel barriers encountered by people with SCI., Results: Results from 83 semi-structured in-depth interviews with 4 stakeholder groups guided the writing of items in the TRIP scale. Seven cognitive interviews and an expert panel conducted reviews for content validity of the scale, and 19 items were included in the quantitative assessment of the scale. A total of 250 patients enrolled in the Rocky Mountain Regional Spinal Injury System was systematically selected to report their experience with each travel barrier. Item-response theory-based Rasch analysis revealed that TRIP has acceptable psychometric properties., Conclusions: The 19-item TRIP scale demonstrates promising psychometric properties for the scale to be used in clinical settings to quickly identify environmental barriers individuals with SCI encounter when traveling. It has the potential to assist with developing interventions that will improve the travel experience of individuals with SCI or to assist with strategies to overcome travel barriers., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Study Design: Secondary analysis of prospectively collected observational data., Objectives: To assess the representativeness of the Spinal Cord Injury Model Systems National Database (SCIMS-NDB) of all adults aged 18 years or older receiving inpatient rehabilitation in the United States (US) for new onset traumatic spinal cord injury (TSCI)., Setting: Inpatient rehabilitation centers in the US., Methods: We compared demographic, functional status, and injury characteristics (nine categorical variables comprising of 46 categories and two continuous variables) between the SCIMS-NDB (N = 5969) and UDS-PRO/eRehabData (N = 99,142) cases discharged from inpatient rehabilitation in 2000-2010., Results: There are negligible differences (<5%) between SCIMS-NDB patients and the population for 31 of the 48 comparisons. Minor differences (5-10%) exist for age categories, sex, race/ethnicity, marital status, FIM Motor score, and time from injury to rehabilitation admission. Important differences (>10%) exist in mean age and preinjury occupational status; the SCIMS-NDB sample was younger and included a higher percentage of individuals who were employed (62.7 vs. 41.7%) and fewer who were retired (10.2 vs. 36.1%)., Conclusions: Adults in the SCIMS-NDB are largely representative of the population of adults receiving inpatient rehabilitation for new onset TSCI in the US. However, users of the SCIMS-NDB may need to adjust statistically for differences in age and preinjury occupational status to improve generalizability of findings.

Objective: To determine whether antispasmodic medications are associated with neurological and functional outcomes during the first year after traumatic spinal cord injury (SCI)., Design/methods: Retrospective analysis of prospectively collected data from six inpatient SCI rehabilitation centers. Baseline-adjusted outcomes at discharge and one-year follow-up were compared using analysis of covariance between patients who received antispasmodic medication on at least 5 days during inpatient rehabilitation and patients who did not., Outcome Measures: Rasch-transformed motor subscore of the Functional Independence Measure (FIM); International Standards for Neurological Classification of Spinal Cord Injury motor scores, grade, and level., Results: Of 1,259 patients, 59.8%, 35.4%, and 4.8% were injured at the cervical, thoracic, and lumbosacral levels, respectively. 65.6% had motor complete injury. Rasch-transformed motor FIM score at admission averaged 23.3 (95% confidence interval (CI) 22.4-24.2). Total motor score averaged 39.2 (95% CI 37.8-40.6). 685 patients (54.4%) received one or more antispasmodic medications on at least 5 days. After controlling for demographic and injury variables at admission, Rasch-transformed motor FIM scores at discharge were significantly lower (P = 0.018) in patients receiving antispasmodic medications than in those who did not. This trend persisted in secondary analyses for cervical, thoracic, and lumbosacral subgroups. Multivariate regression showed that receiving antispasmodic medication significantly contributed to discharge motor FIM outcome. At one-year follow-up, no outcomes significantly differed between patients ON or OFF antispasmodics., Conclusions: Antispasmodic medications may be associated with decreased functional recovery at discharge from inpatient traumatic SCI rehabilitation. Randomized prospective studies are needed to directly evaluate the effects of antispasmodic medication on recovery.

Objective: The primary aim of this study was to examine and refine a modified measure of participation for adults with spinal cord injury (SCI) based on a conceptual model of participation., Method: This study involved secondary analysis of data from a larger study designed to identify a standard measure of participation for use in SCI research. The larger study recruited 634 community-dwelling adults with SCI from seven collaborating SCI Model Systems Centers, of whom 520 subjects (average age 45.1 ± 13.6 years, 76% were male) completed the survey that is the focus of the present analysis. Content review, confirmatory factor analysis (CFA), Rasch analysis, and precision analysis were employed to select the items for the modified participation measure., Results: Three participation domains were supported: Productivity, Social, and Community, that displayed good model-fit (CFI=0.984, TLI=0.982, RMSEA=0.043) in CFA and good item-fit (infit= 0.6 to 1.4) in Rasch analysis. Differential Item Functioning (DIF) was found in one item, however its magnitude was small. The precision of each scale was better for participants in the middle range of participation and was lower for participants with extremely low or high participation., Conclusion: The study results support the proposed three-dimensional construct of participation by demonstrating good model-fit and item-fit. Ongoing efforts are needed to expand the domain coverage and increase the precision of the instrument.

Objective: To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status., Design: Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury., Setting: Inpatient rehabilitation and community follow-up at 6 SCI treatment centers., Participants: Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation., Interventions: Not applicable., Main Outcome Measures: Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI)., Results: Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school., Conclusions: Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the application of practice-based evidence (PBE) methodology to spinal cord injury (SCI) rehabilitation in the SCIRehab study, and to summarize associations of patient characteristics and treatment interventions to outcomes., Design: Prospective observational study., Setting: Six SCI rehabilitation centers., Participants: Patients with traumatic SCI (N=1376) admitted for first rehabilitation., Interventions: Not applicable., Main Outcome Measures: FIM and residence at discharge, and FIM, residence, Craig Handicap Assessment and Reporting Technique, work/school status, Patient Health Questionnaire-9, Diener Satisfaction with Life Scale, rehospitalization, and presence of pressure ulcers at 1 year postinjury., Results: Patient demographic and injury characteristics explained significant variation in rehabilitation outcomes, particularly functional outcomes. Regression modeling also identified a large number of significant associations with outcomes when total time in each discipline was modeled and when models were developed for each discipline, examining time spent in the many specific interventions provided by each discipline., Conclusions: The application of PBE methodology in the SCIRehab study provided extensive information about the process of inpatient SCI rehabilitation. While patient demographic and injury characteristics explain substantial variation in rehabilitation outcomes, particularly functional outcomes, significant relations also were found between the type and quantity of treatment interventions delivered by each rehabilitation discipline and a broad range of outcomes., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate associations of nursing bedside education and care management activities during inpatient rehabilitation with functional, participation, and quality-of-life outcomes for patients with traumatic spinal cord injury (SCI)., Methods: In a prospective observational study, data were obtained by means of systematic recording of nursing activities by registered nurses (RNs), chart review and patient interview., Results: Greater patient participation in nursing activities is associated with better outcomes. More time spent by RNs in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) is associated with patient report of higher life satisfaction and higher CHART mobility at the one-year injury anniversary; more time providing psychosocial support is associated with higher CHART mobility and occupation scores and with greater likelihood of working or being in school at the anniversary. More time spent providing education about specific care needs is associated with several outcomes but not as consistently as might be expected., Conclusion(s): Higher levels of patient participation in nursing care activities is associated with multiple better outcomes, and hence, nurses should promote active patient participation during all aspects of care and interactions between themselves and patients with SCI. Time spent providing psychosocial support of patients and their families should be evaluated to ensure that other necessary education or care management interventions are not minimized. Note: This is the seventh of nine articles in the SCIRehab series.

Background/objective: Describe associations of patient characteristics and speech-language pathology (SLP) interventions provided during impatient rehabilitation for spinal cord injury (SCI) to outcomes at discharge and 1-year post-injury., Methods: Speech-language pathologists at six inpatient rehabilitation centers documented details of treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary. Cognitive, participation, and mood outcomes for a subsample of patients with traumatic brain injury (TBI) and cognitive-communication limitations (CCLs) were examined., Results: SLP treatment factors explain a small amount of variation in cognitive Functional Independence Measure (FIM), participation, and mood. Variation explained by treatment factors for cognitive outcomes at the time of discharge increased when the patient group was more homogeneous (patients with TBI and CCLs). More time in SLP cognitive-communication interventions had a negative relationship, while longer length of stay was positive. The added explanatory power was not seen for similar outcomes at 1-year post-injury., Conclusion: Patients with SCI who have the greatest need for interventions to address cognitive limitations due to TBI receive the most SLP cognitive-communication treatment and show the greatest amount of improvement during rehabilitation. Their cognitive functioning remained impaired at discharge; this likely accounts for the consistent finding that more hours of SLP cognitive-communication treatment is associated with lower cognitive FIM scores at discharge. Future research on individuals with dual SCI and TBI should include more comprehensive assessment of individual differences in cognitive performance in order to better examine the complex relationships between SLP treatments and outcomes. Note: This is the fifth of nine articles in this SCIRehab series.

Objective: To investigate associations of therapeutic recreation (TR) interventions during inpatient rehabilitation for patients with traumatic spinal cord injury (SCI) with functional, participation, and quality of life outcomes., Methods: In this prospective observational study, data were obtained from systematic recording of TR services by certified TR specialists, chart review, and patient interview., Results: TR interventions, including exposure to community settings and leisure activities, add to the variance explained (in addition to the strong predictors of injury classification, admission motor Functional Independence Measure (FIM), and other patient characteristics) in outcomes at the time of rehabilitation discharge (FIM, discharge to home) and at the 1-year injury anniversary (FIM, working or being in school, residing at home, and societal participation as measured by the Craig Handicap Assessment and Reporting Technique (CHART)). They also are associated with less rehospitalization and less pressure development after discharge. In addition, more time spent in specific TR activities during rehabilitation is associated with more participation in the same type of activities at the 1-year injury anniversary., Conclusion(s): Greater participation in TR-led leisure skill and community activities during rehabilitation is a positive predictor of multiple outcomes at rehabilitation discharge and the 1-year injury anniversary demonstrating that TR activities are associated with a return to a productive and healthy life after SCI. Further research should focus on the impact of TR on longer-term outcomes to determine whether relationships continue or change as persons continue to adapt to their life after SCI. Note: This is the fourth of nine articles in the SCIRehab series.

Background/objective: Describe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury., Methods: Occupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined., Results: OT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes., Conclusion: OT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings. Note: This is the third of nine articles in the SCIRehab series.

Context and Objective: To evaluate the effects of psychological interventions on rehabilitation outcomes, including residence and functional status at discharge, and residence, school attendance, or employment, and physical, social, occupational, and mobility aspects of participation 1 year after spinal cord injury (SCI)., Design: Prospective observational cohort study., Setting: Six inpatient rehabilitation facilities in the United States., Participants: Inpatients with SCI 12 years of age and older., Interventions: Usual rehabilitation care., Outcome Measures: Functional Independence Measure at rehabilitation discharge and 1-year injury anniversary; discharge destination and residence at 1-year anniversary; Craig Handicap Assessment and Reporting Technique, Diener Satisfaction with Life Scale, Patient Health Questionnaire, employment or school attendance, rehospitalization, and occurrence of a pressure ulcer at 1-year anniversary., Results: More time in psycho-educational interventions was associated with better function, discharge to home, home residence at 1 year, and the absence of pressure ulcers at 1 year. More psychotherapeutic sessions focusing on processing emotions and/or locus of control were associated with poorer function at discharge and 1 year, less physical independence and community mobility, lower satisfaction with life, and the presence of pressure sores at 1 year., Conclusions: Psychological services are an important component of comprehensive medical rehabilitation and tailored to patient needs and readiness to benefit from rehabilitation. Services focused on remediating deficits tend to be associated with negative outcomes, while services intended to foster adjustment and growth tend to be associated with favorable outcomes. Further research is needed to determine the optimal type and timing of psychological services during inpatient rehabilitation based on individuals' strengths and vulnerabilities. Note: This is the sixth in this third series of SCIRehab articles.

Background/objective: To examine associations of patient characteristics along with treatment quantity delivered by seven clinical disciplines during inpatient spinal cord injury (SCI) rehabilitation with outcomes at rehabilitation discharge and 1-year post-injury., Methods: Six inpatient SCI rehabilitation centers enrolled 1376 patients during the 5-year SCIRehab study. Clinicians delivering standard care documented details of treatment. Outcome data were derived from SCI Model Systems Form I and II and a project-specific interview conducted at approximately 1-year post-injury. Regression modeling was used to predict outcomes; models were cross-validated by examining relative shrinkage of the original model R(2) using 75% of the dataset to the R(2) for the same outcome using a validation subsample., Results: Patient characteristics are strong predictors of outcome; treatment duration adds slightly more predictive power. More time in physical therapy was associated positively with motor Functional Independence Measure at discharge and the 1-year anniversary, CHART Physical Independence, Social Integration, and Mobility dimensions, and smaller likelihood of rehospitalization after discharge and reporting of pressure ulcer at the interview. More time in therapeutic recreation also had multiple similar positive associations. Time spent in other disciplines had fewer and mixed relationships. Seven models validated well, two validated moderately well, and four validated poorly., Conclusion: Patient characteristics explain a large proportion of variation in multiple outcomes after inpatient rehabilitation. The total amount of treatment received during rehabilitation from each of seven disciplines explains little additional variance. Reasons for this and the phenomenon that sometimes more hours of service predict poorer outcome, need additional study. Note: This is the first of nine articles in the SCIRehab series.

Background/objective: Examine associations of type and quantity of physical therapy (PT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and at 1 year post-injury., Methods: Physical therapists delivering routine care documented details of PT interventions provided. Regression modeling was used to predict outcomes at discharge and 1 year post-injury for a 75% subset; models were validated with the remaining 25%. Injury subgroups also were examined: motor complete low tetraplegia, motor complete paraplegia, and American Spinal Injury Association (ASIA) Impairment Scale (AIS) D motor incomplete tetra-/paraplegia., Results: PT treatment variables explain more variation in three functionally homogeneous subgroups than in the total sample. Among patients with motor complete low tetraplegia, higher scores for the transfer component of the discharge motor Functional Independence Measure () are strongly associated with more time spent working on manual wheelchair skills. Being male is the most predictive variable for the motor FIM score at discharge for patients with motor complete paraplegia. Admission ASIA lower extremity motor score (LEMS) and change in LEMS were the factors most predictive for having the primary locomotion mode of "walk" or "both (walk and wheelchair)" on the discharge motor FIM for patients with AIS D injuries., Conclusion: Injury classification influences type and quantity of PT interventions during inpatient SCI rehabilitation and is a strong predictor of outcomes at discharge and 1 year post-injury. The impact of PT treatment increases when patient groupings become more homogeneous and outcomes become specific to the groupings. Note: This is the second of nine articles in the SCIRehab series.

Objective: To investigate associations of social work/case management (SW/CM) services during inpatient rehabilitation following spinal cord injury (SCI) and patient characteristics with outcomes., Design: Prospective observational cohort of individuals with SCI receiving inpatient rehabilitation., Setting: Six inpatient rehabilitation centers., Participants: 1032 individuals with traumatic SCI., Interventions: Not applicable., Main Outcome Measure(s): Type of residence at the time of rehabilitation discharge. Employment/school status, presence of a pressure ulcer, Patient History Questionnaire, Satisfaction with Life Scale, Craig Handicap Assessment and Reporting Technique (CHART) subscales, and rehospitalization at 1-year post-injury., Results: The intensity of specific SW/CM services is associated with multiple outcomes examined. More sessions dedicated to discharge planning for a home discharge and financial planning were associated positively with more discharge to home, while more sessions focused on planning for discharge to a location other than home, e.g. nursing home or long-term acute care facilities, have negative associations with societal participation outcomes (CHART Social Integration, Occupation, and Mobility scores) as well as with residing at home at the time of the 1-year injury anniversary., Conclusion(s): The intensity and type of SW/CM services are associated with outcomes at rehabilitation discharge and at 1-year post-injury. Discharge to home may require assistance from SW/CM in the area of discharge planning and financial planning, while discharge to non-home residence demands directed SW/CM services for such placement. Note: This is the eighth of nine articles of this SCIRehab series.

Objectives: To describe the calibration of the Spinal Cord Injury-Functional Index (SCI-FI) and report on the initial psychometric evaluation of the SCI-FI scales in each content domain., Design: Cross-sectional survey followed by calibration data simulations., Setting: Inpatient and community settings., Participants: A sample of participants (N=855) with traumatic spinal cord injury (SCI) recruited from 6 SCI Model Systems and stratified by diagnosis, severity, and time since injury., Interventions: None., Main Outcome Measure: SCI-FI instrument., Results: Item response theory analyses confirmed the unidimensionality of 5 SCI-FI scales: basic mobility (54 items), fine motor function (36 items), self-care (90 items), ambulation (39 items), and wheelchair mobility (56 items). All SCI-FI scales revealed strong psychometric properties. High correlations of scores on simulated computer adaptive testing (CAT) with the overall SCI-FI domain scores indicated excellent potential for CAT to accurately characterize functional profiles of adults with SCI. Overall, there was very little loss of measurement reliability or precision using CAT compared with the full item bank; however, there was some loss of reliability and precision at the lower and upper ranges of each scale, corresponding to regions where there were few questions in the item banks., Conclusions: Initial evaluation revealed that the SCI-FI achieved considerable breadth of coverage in each content domain and demonstrated acceptable psychometric properties. The use of CAT to administer the SCI-FI will minimize assessment burden, while allowing for the comprehensive assessment of the functional abilities of adults with SCI., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To develop a comprehensive set of patient-reported items to assess multiple aspects of physical functioning relevant to the lives of people with spinal cord injury (SCI), and to evaluate the underlying structure of physical functioning., Design: Cross-sectional., Setting: Inpatient and community., Participants: Item pools of physical functioning were developed, refined, and field tested in a large sample of individuals (N=855) with traumatic SCI stratified by diagnosis, severity, and time since injury., Interventions: None., Main Outcome Measure: Spinal Cord Injury-Functional Index (SCI-FI) measurement system., Results: Confirmatory factor analysis (CFA) indicated that a 5-factor model, including basic mobility, ambulation, wheelchair mobility, self-care, and fine motor function, had the best model fit and was most closely aligned conceptually with feedback received from individuals with SCI and SCI clinicians. When just the items making up basic mobility were tested in CFA, the fit statistics indicated strong support for a unidimensional model. Similar results were demonstrated for each of the other 4 factors, indicating unidimensional models., Conclusions: Though unidimensional or 2-factor (mobility and upper extremity) models of physical functioning make up outcomes measures in the general population, the underlying structure of physical function in SCI is more complex. A 5-factor solution allows for comprehensive assessment of key domain areas of physical functioning. These results informed the structure and development of the SCI-FI measurement system of physical functioning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To develop and compare 2 scoring algorithms for a measure of participation, the Participation Assessment with Recombined Tools-Objective (PART-O) based on the assumption that more participation is better versus an alternative that reflects balance in domains of participation., Design: Survey., Setting: Community settings., Participants: Three groups of participants under the age of 65 years were included: (1) persons with spinal cord injury, traumatic brain injury, stroke, and other disorders who are commonly treated in acute rehabilitation settings (n=220), and (2) participants from the general population who did (n=366) or (3) did not (n=284) self-report limitations indicative of a disability who participated in the 2006 Colorado Behavioral Risk Factor Surveillance System (N=870)., Interventions: Not applicable., Main Outcome Measure: PART-O., Results: We developed PART-O subscores using a consensus process and then evaluated them empirically. We combined subscores using 2 contrasting algorithms, one using average scores and the other reflecting the amount of participation and variation in participation across 3 domains. The algorithms for the total scores yielded normal distributions in all 3 samples and were equally sensitive to the impact of disability. While strongly correlated, about 30% of the variance of the 2 total scores was not shared., Conclusions: Two scoring algorithms for the PART-O illustrate contrasting perspectives of the construct of participation. The 2 algorithms may be used in future studies to expand our understanding of the construct of participation., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To reflect the perspectives of rehabilitation stakeholders in a measure of participation enfranchisement that can be used by people with and without disabilities., Design: Survey., Setting: Community settings., Participants: We pilot-tested a draft instrument with 326 adults who had sustained stroke, spinal cord injury, traumatic brain injury, or other disabling condition, as well as a general population sample. We administered a revised version of the instrument to a statewide sample drawn from the 2006 Colorado Behavioral Risk Factors Surveillance System that included persons with (N=461) and without (N=451) self-identified activity limitations., Interventions: None., Main Outcome Measure: Participation enfranchisement., Results: We used multidimensional scaling, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), followed by rating scale analysis to evaluate the psychometric properties of the instrument. EFA identified 3 participation enfranchisement factors that describe perceived choice and control, contributing to one's community, and feeling valued; the factors were supported marginally by CFA. Rating scale analysis revealed marginal person separation and no misfitting items., Conclusions: Participation enfranchisement constitutes a new, previously unmeasured aspect of participation-one that addresses subjective perceptions rather than objective performance-with items that are clearly distinct from more generalized satisfaction with participation. The 19 enfranchisement items describe aspects of participation that may prove useful in characterizing longer-term rehabilitation outcomes., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI)., Design: Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview., Setting: Inpatient and postdischarge rehabilitation programs., Participants: Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study., Interventions: Not applicable., Main Outcome Measures: Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews., Results: Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services., Conclusions: SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background/objective: Length of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs., Methods: Six hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline., Results: Average LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics., Conclusions: Variations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.

Purpose: This article aims to present a comprehensive conceptual model of the SCIRehab project, which merges the International Classification of Functioning, Disability, and Health (ICF) focus on outcomes with the practice-based evidence (PBE) research design, which focuses on process and also quantifies person and outcomes details. The SCIRehab methodology operationalised this conceptual model to implement the most data-intensive study of spinal cord injury to date. We discuss the conceptual and methodological contributions of SCIRehab and how this comprehensive research approach may complement randomised controlled trials., Methods: PBE methodology applied to the SCIRehab study used extensive clinician input to develop taxonomies of each discipline's interventions and an electronic point-of-care documentation system to capture extensive details of the rehabilitation process. Traditional medical record abstracting and follow-up surveys were used to capture details on patient characteristics and outcomes achieved by 12 months post-injury., Results: Not applicable., Conclusions: Although data collection is not complete, the SCIRehab project has made major contributions to rehabilitation research, including a comprehensive conceptual model of person, process and outcome domains; discipline-specific taxonomies of rehabilitation interventions; and an electronic documentation system to capture details of the rehabilitation process.

Background/objective: Limited research evidence is available to show the effectiveness of the many specific interventions provided in spinal cord injury (SCI) rehabilitation; what is available typically focuses on effects of the full rehabilitation package but not specific therapy interventions, medical procedures, patient education, or counseling. Given the problems of conducting randomized controlled trials (RCTs) in rehabilitation, practice-based evidence (PBE) research has been suggested as an alternative methodology for identifying which rehabilitation interventions are associated most strongly with positive outcomes, after controlling for patient differences. Using the PBE research methodology, the SCIRehab project attempts to "open the black box" of acute SCI rehabilitation, provide detailed information on treatments delivered by all rehabilitation disciplines, and contribute to outcomes-based guidelines for clinical decision-making., Methods: The SCIRehab project includes 1,500 patients with acute SCI, consecutively admitted to 1 of 6 US inpatient rehabilitation facilities. Details of the rehabilitation process are captured by clinicians from multiple disciplines documenting their interventions in handheld personal digital assistants after sessions with their patients. Outcome data are abstracted from medical records (clinical outcomes data) and obtained from patient interviews at 6 and 12 months after injury. Extensive patient, injury, and other treatment characteristics are abstracted from medical records. SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team., Results: SCIRehab is the first research project to collect detailed information on individual interventions offered by the full rehabilitation team. These findings are presented in a series of 9 articles., Conclusions: To date, SCIRehab's major contribution is a system for categorizing specific contributions of each discipline and a technology for documenting that detail. After data collection is complete, future manuscripts will relate those process elements to outcomes. The SCIRehab Project is an important step toward establishing outcomes-based guidelines for SCI rehabilitation.

Background/objective: Applying practice-based evidence research methodology to spinal cord injury (SCI) rehabilitation requires taxonomy (typology or classification) of rehabilitation interventions provided by every discipline contributing to SCI rehabilitation. The rehabilitation field currently lacks such taxonomy., Methods: SCIRehab project researchers and clinicians representing 7 rehabilitation disciplines from 6 US inpatient SCI rehabilitation facilities worked in discipline groups during 2 face-to-face meetings and weekly discipline-specific teleconferences for 9 months to identify key contributions of each discipline to SCI rehabilitation and to develop a classification of treatment interventions used by each discipline. These clinician groups were charged with designing documentation systems that collected enough details to describe treatment adequately while not imposing an unrealistic data collection burden on clinicians. Completed documentation systems were programmed onto handheld personal digital assistants (PDAs) to facilitate data entry by clinicians at the point of care., Results: Seven discipline-specific SCI rehabilitation taxonomies were developed that describe and quantify intervention activities (major categories of treatment offered by the discipline) and the activity-specific details (variables deemed important to fully describe the interventional process). Much treatment information is unique to each discipline; some is common across disciplines., Conclusions: The taxonomies provide a format with which clinicians document actual interventions performed with or for patients. The SCIRehab project has developed the first comprehensive multidisciplinary taxonomy for describing the details of the SCI rehabilitation process and designed a PDA-based documentation system based on that taxonomy that allows clinicians to describe the specifics of their interactions with their patients.

Background/objective: To test the hypothesis that apolipoprotein E (APOE) polymorphisms are associated with outcomes after spinal cord injury (SCI)., Methods: Retrospective cohort study, from rehabilitation admission to discharge., Participants: Convenience sample of 89 persons with cervical SCI (C3-C8) treated from 1995 through 2003. Median age was 30 years (range 14-70); 67 were male (75%) and 83 were white (93%)., Main Outcome Measures: American Spinal Injury Association (ASIA) motor and sensory scores, ASIA Impairment Scale (AIS), time from injury to rehabilitation admission, and length of stay (LOS) in rehabilitation., Results: Subjects with an APOE epsilon4 allele (n = 15; 17%) had significantly less motor recovery during rehabilitation than did individuals without an epsilon4 allele (median 3.0 vs 5.5; P < 0.05) and a longer rehabilitation LOS (median 106 vs 89 days; P = 0.04), but better sensory-pinprick recovery (median 5.0 vs 2.0; P= 0.03). There were no significant differences by APOE epsilon4 allele status in sensory-light touch recovery, likelihood of improving AIS Grade, or time from injury to rehabilitation admission., Conclusions: APOE epsilon4 allele was associated with differences in neurological recovery and longer rehabilitation LOS. Genetic factors may be among the determinants of outcome after SCI and warrant further study.

Background/objective: Few studies have examined the prevalence of visceral pain in persons with spinal cord injury (SCI), and virtually no studies have looked at the relationship between visceral pain and self-reported quality of life. We examined the frequency of reported visceral pain at 5, 10, and 15 years after injury to determine whether the presence of visceral pain is related to quality of life, and to determine to what extent visceral pain should be of concern to clinicians treating patients with SCI., Methods: Visceral pain and quality of life in persons with SCI were compared from a combined Craig Hospital and National Model SCI Systems database at 5 (N = 33), 10 (N = 132), and 15 (N = 96) years after injury., Results: The rates of visceral pain increased at each measurement (10% at year 5, 22% at year 10, and 32% at year 15); although these numbers reflect cross-sectional data, they do show a clear statistical change. Only a limited true longitudinal sample was available, but at 10 years after injury, individuals who had reported visceral pain at any time reported a significantly lower quality of life than those never experiencing visceral pain, F1,188 = 3.95, P < 0.05., Conclusions: Although visceral pain may not be as prevalent as the more researched neuropathic and musculoskeletal subtypes of pain, it may account for a higher percentage of people with SCI who report pain than previously recognized. More quantitative and longitudinal research is needed to examine the relationship of visceral pain with overall quality of life and to pursue interventions.

Objectives: To investigate environmental barriers reported by people with spinal cord injury (SCI), and to determine the relative impact of environmental barriers compared with demographic and injury characteristics and activity limitations in predicting variation in participation and life satisfaction., Design: Cross-sectional, follow-up survey., Setting: Individuals rehabilitated at 16 federally designated Model Spinal Cord Injury Systems of care, now living in the community., Participants: People with SCI (N=2726) who completed routine follow-up research interviews between 2000 and 2002., Interventions: Not applicable., Main Outcome Measures: The Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF), the Craig Handicap Assessment and Reporting Technique-Short Form, and the Satisfaction With Life Scale., Results: The top 5 environmental barriers reported by subjects with SCI, in descending order of importance, were the natural environment, transportation, need for help in the home, availability of health care, and governmental policies. The CHIEF-SF subscales accounted for only 4% or less of the variation in participation; they accounted for 10% of the variation in life satisfaction., Conclusions: The inclusion of environmental factors in models of disability was supported, but were found to be more strongly related to life satisfaction than to societal participation.

Objective: To assess the efficacy, across a range of disability groups, of the Craig Handicap Assessment and Reporting Technique (CHART), a measure of societal participation., Design: Cross-sectional analysis survey methodology. A total of 1110 community-based, nonhospitalized Coloradans with spinal cord injury, traumatic brain injury, multiple sclerosis, stroke, burn, or amputation were interviewed twice, 2 wks apart, using the CHART and a single administration of the FIM., Results: Across all impairment groups, the intraclass correlation for the total score and the subscales of CHART-R were high. In addition, the CHART-R discriminated among the impairment categories in a direction that parallels increasing disability., Conclusions: CHART may be an appropriate measure of handicap for a range of physical or cognitive impairments.

Objective: To assess the predictors of personal care assistance (PCA) use in people with spinal cord injury (SCI)., Design: Cross-sectional., Setting: Follow-up of individuals crossing their 1st, 5th, 10th, 15th, 20th, or 25th anniversary of injury who underwent their initial rehabilitation at a Spinal Cord Injury Model Systems center., Participants: A total of 2154 participants (2547 records) who met the inclusion criteria for the National Spinal Cord Injury Database and had valid values for the main outcome measures., Interventions: Not applicable., Main Outcome Measures: Daily hours of paid, unpaid, and occasional PCA services., Results: Differences in an interval version of the motor portion of the FIM trade mark instrument accounted for 26.3% of the variance in total PCA hours, Model Systems differences accounted for 9.3%, and no other predictor accounted for more than 2.1% of the variance., Conclusion: Activities of daily living functioning, as measured by the motor portion of the FIM, was the strongest predictor of PCA use among people with SCI., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objectives: To evaluate whether the risk of bladder cancer is greater in individuals with spinal cord injury (SCI) than in the general population and whether indwelling catheter (IDC) use is a significant independent risk factor for bladder cancer., Design: Historical cohort study in which subjects with SCI were stratified according to bladder management method and followed for the development of bladder cancer., Setting: A large rehabilitation hospital in the Spinal Cord Injury Model Systems., Participants: A total of 3670 patients with SCI who were evaluated for bladder cancer on at least 1 occasion by cystoscopy over a period of 1 to 47 years., Interventions: Not applicable., Main Outcome Measures: Bladder cancer occurring after SCI determined by diagnosis at our facility, by subject report, or by report of next of kin., Results: Twenty-one cases of bladder cancer were found in the 3670 study participants. The risk of bladder cancer for subjects with SCI using IDC is 77 per 100,000 person-years, corresponding to an age- and gender-adjusted standardized morbidity ratio (SMR) of 25.4 (95% confidence interval [CI], 14.0--41.9) when compared with the general population. After controlling for age at injury, gender, level and completeness of SCI, history of bladder calculi, and smoking, those using solely IDC had a significantly greater risk of bladder cancer (relative risk [RR] = 4.9; 95% CI, 1.3--13.8) than those using nonindwelling methods. Mortality caused by bladder cancer in individuals with SCI was significantly greater than that of the US population (SMR = 70.6; 95% CI, 36.9--123.3)., Conclusions: Bladder cancer risk and mortality are heightened in SCI compared with the general population. IDC is a significant independent risk factor for the increased risk of and mortality caused by bladder cancer in the SCI population., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)