Neurological level effect on the discharge functional status of spinal cord injured persons after rehabilitation

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Neurological Level Effect on the Discharge Functional Status of Spinal Cord Injured Persons After Rehabilitation James W. Middleton, MBBS, George Truman, BSc (Hons), Timothy J. Geraghty, MBBS ABSTRACT. Middleton JW, Truman G, Geraghty T. Neurological level effect on the discharge functional status of spinal cord injured persons after rehabilitation. Arch Phys Med Rehabil 1998;79:1428-1432.

Objective: To determine the relation between neurological level and functional status, measured by individual Functional Independence Measure (FIM) item scores, at discharge after rehabilitation in individuals with acute spinal cord injury (SCI). Design: A cohort of spinal cord injured individuals (ASIA Impairment Scale grades A, B, and C) were classified in groups for analysis of variance (ANOVA) according to neurological level at discharge (C1-4, C5, C6, C7-8, T1-6, T7 and below). Setting: A 20-bed SCI rehabilitation unit. Patients: One hundred twelve individuals admitted between January 1993 and December 1996. Intervention: Multidisciplinary rehabilitation program. Main Outcome Measures: FIM item scores at discharge after rehabilitation. Results: ANOVA and post hoc testing showed significant differences and a systematic change in discharge FIM item scores between adjacent neurological groupings for the tetraplegic and TI-6 paraplegic groups for all the self-care items and between the high and low paraplegic groups for the mobility items. A systematic relation was also seen between lesion level and discharge FIM score for the sphincter control items but not for the locomotion and cognitive items. Conclusions: The finding of an inverse relationship between FIM score and neurological level for certain motor items supports clinical observations that functional performance in spinal cord injured individuals is reduced with greater neurological impairment. However, results for the locomotion and cognitive subscale items indicate a need for other measures, in addition to the FIM, for outcome measurement in SCI.

© 1998 by the American Congress of Rehabilitation Medicine and the American Academy of" Physical Medicine and Rehabilitation HE FUNCTIONAL Independence Measure (FIM) is becoming more widely used for functional assessment in rehabiliT tation. It was developed in 1987 as the functional assessment component of the Uniform Data System for Medical Rehabilitation minimum data set/ The FIM was designed to measure severity of disability and to determine burden of care in performing core life activities across a range of impairments. In

From the Moorong Spinal Injuries Unit, Royal Rehabilitation Centre Sydney (Dr. Middleton); the Rehabilitation Studies Unit, The University of Sydney and Royal Rehabilitation Centre Sydney (Mr. Truman); and the Spinal Injuries Unit, Royal North Shore Hospital (Dr. Geraghty), Sydney, Australia. Submitted for publication January 6, 1998. Accepted in revised form June 29, 1998. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to James W. Middleton, MBBS, Director, Moorong Spinal Injuries Unit, Royal Rehabilitation Centre Sydney, Victoria Road Ryde 2112 Australia. © 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7911-479553.00/0

Arch Phys Med Rehabil Vol 79, November 1998

addition to assessment of functional outcomes and evaluation of rehabilitation programs, 2"3the FIM has also been used to predict care needs and develop case mix models for funding. 4,5 It demonstrates good reliability6'7 and overall high internal consistency 7,s and has face, content, and construct validity for various impairment groups. 3.6,8'9 The American Spinal Injury Association (ASIA) has recommended the FIM be adopted as a universal functional measure for spinal cord injury (SCI) because of its well-defined guidelines, simplicity, and ability to measure relevant functional aspects, l° ASIA, however, has acknowledged some limitations of the FIM, noting that its validity for subpopulations of SCI has not yet been demonstrated.l~ It is generally accepted that as the neurological level of the spinal cord lesion becomes more caudal, the degree of functional independence increases. Functional goals and expected outcomes are based on knowledge of the sequential organization of spinal segments and the capacity of spared muscle groups to perform specific activities of daily living (ADL). 12-15 Of course, the level of function ultimately achieved by an individual will also be influenced by a variety of medical and nonmedical factors, including age, body size and weight distribution, presence of contracture, severity of spasticity, presence of associated injuries, motivation, family support, living arrangements, premorbid lifestyle, vocation, educational background, and financial status. 13 Compared with other impairment groups, relatively little research has examined the use of FIM in individuals with SCI. 8"16'17These studies have mostly used the total FIM or FIM motor score to compare patients and groups of patients. Dodds and colleagues s showed that the FIM could clearly discriminate between complete paraplegic and tetraplegic groups; however, they were unable to demonstrate distinct differences along the continuum from high tetraplegia to low paraplegia, particularly when incomplete lesions were included. Data from the NIDRR Model Spinal Cord Injury Systems 18 have shown clear differences in total FIM and FIM motor scores at discharge for different neurological levels in spinal cord-injured individuals with Frankel A, B, and C but not Frankel D impairments. Is No differences were found, however, for the FIM cognitive score. To date little has been documented concerning the effect of neurological level on performance of specific ADL tasks. The purpose of this study was to determine the relation between neurological level and discharge functional status measured by individual item scores of the FIM in acute spinal cord injured individuals after rehabilitation. The following hypotheses were tested: (1) FIM motor items will show a systematic change with neurological level, and (2) FIM cognitive items will show no systematic change with neurological level.

METHODS FIM scores and neurological status (motor level and impairment classification according to ASIA standards) II at discharge were obtained retrospectively by review of the medical records of 167 patients admitted to the Moorong Spinal Unit between

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DISCHARGE FUNCTIONAL STATUS IN SCI, Middleton

Table 1: Patient Demographics Level

Age, yrs (mean ± SD) Sex (M/F) % Traumatic Days f r o m onset to admission (median) LOS in days (mean ± SD) FIM total on admission (mean ± SD) FIM total on discharge (mean ± SD) FIM motor on admission (mean _+ SD) FIM m o t o r on discharge (mean ± SD)

C1-4 (n = 11)

C5 (n = 19)

C6 (n = 24)

C7-8 (n = 7)

T1-6 (n = 13)

T7 and Below (n - 38)

39.4 ± 17.3 10/1 82 129 131 ± 47 51 ± 5 58 ± 10 17 ± 3 24 ± 10

37.6 ± 21.8 16/3 100 74 143 _+ 52 52 ± 6 62 ± 13 18 _+ 5 28 ± 12

36.2 + 19.7 17/7 100 81 158 ± 97 55 _+ 6 71 ± 15 21 ± 5 37 _+ 15

34.3 _+ 13.6 3/4 100 66 129 _+ 47 64 ± 6 89 ± 19 30 ± 6 54 ± 19

42.8 -+ 14.0 8/5 69 89 85 ± 27 82 ± 17 100 -+ 16 48 ± 16 66 ± 15

43.7 _+ 19.0 34/4 92 72 89 ± 50 86 ÷ 13 110 ± 11 51 _+ 13 75 + 11

January 1, 1993, and December 31, 1996, for rehabilitation after acute SCI. ASIA classification was performed by two of the authors, both experienced SCI rehabilitation specialists. The FIM was scored at discharge by nursing and allied health professionals who had undergone accredited FIM training. Approval from the Human Ethics Committee was not sought or considered necessary because collection of the FIM already occurred routinely within the rehabilitation center as part of an established minimum data set and clinical indicator.

Inclusion/Exclusion Criteria One hundred twelve individuals with ASIA Impairment Scale (AIS) grades A, B, and C were included for analysis. From a total of 167 patients, 42 patients with useful motor sparing (AIS grade D) were excluded from further analysis because of a significantly different neurological recovery and functional profile in this group. 18 Ten patients were excluded because of associated significant traumatic brain injury, multiple fractures, or psychiatric disorder. Three patients were excluded because of incomplete or missing data. Patients with AIS grades A, B, and C were combined into one group 18 and then subdivided according to neurological level into the following groups for analysis: C1-C4, C5, C6, C7-C8, T1-T6, and T7 and below. Demographic details are shown in table 1.

neurological levels was between the C6 and the C7-8 groupings. No significant differences were found between any levels for FIM cognitive scores. Self-care items. One-way ANOVA tests showed significant differences for all self-care items (table 2). In general, scores for self-care items showed that patients with higher level lesions (ie, cervical lesions) scored lower on all the items than patients with lower level lesions. Furthermore, there is a possible hierarchical relationship between items, which is most clearly seen in the C5 and C6 groups. Feeding appears to be the easiest item and toileting the most difficult because they have the highest and lowest mean scores, respectively. In tetraplegic patients, most post hoc comparisons for self-care items showed a systematically increasing score from C1-4 through to C7-8 levels and significant differences between adjacent neurological level groups. However, in the paraplegic group, none of the self-care items differentiated between the high and low level groups. Figure 1 shows the mean discharge scores for self-care items. Sphincter control items. One-way ANOVAs showed significant effects (table 2), but in contrast to the self-care items, differences were not necessarily found between adjacent neurological level groups. Post hoc tests showed that for the bladder and bowel control items, both paraplegic groups and the low tetraplegic (C7-C8) group scored higher than the other tetraplegic groups. Neither of the items differentiated between the high

Statistical Analysis One-way analysis of variance (ANOVA; neurological level) was performed on FIM motor score, FIM cognitive score, and each FIM item. When a significant main effect was found, post hoc tests (least significant difference) were performed. Because of multiple tests of significance, a conservative a level of .003, calculated by the Bonferroni method, was chosen. ~9 Although a nonparametric method of analysis (eg, KruskalWallis) would seem most appropriate for this study, ANOVA was chosen because of the absence of a suitable nonparametric post hoc procedure to test differences between neurological groups. ANOVA was performed using raw and transformed data in an effort to improve normality of the data. ANOVAs with transformed data produced the same results as those without. Statistical analysis was performed using SSPS. 2°

RESULTS Motor and Cognitive Subscales FIM motor scores were found to increase systematically with more caudal neurological level. However, one-way ANOVA showed that the only significant difference between adjacent

Table 2: Results on One-Way ANOVA Tests Item Feeding

Grooming Bathing Dressing upper body Dressing lower body Toileting Bladder Bowel Bed transfers Toilet transfers Tub transfers Walk/Wheelchair Stairs

Comprehension Expression Social interaction Problem solving Memory

F

df

p

44.26 51.45 49.29 44.42 50.34 33.47 17.82 39.57 25.60 21.64 25.79 2.94 0.75 0.46 1.84 1.43 1.30 0.70

5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111 5,111

<.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 NS NS NS NS NS NS NS

Arch Phys Med Rehabil Vol 79, November 1998

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DISCHARGE FUNCTIONAL STATUS IN SCI, Middleton

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Fig 1. Effect of neurological level on mean discharge FIM self-care item scores. (Error Bars have been removed from all figures for clarity.)

and low paraplegic groups. Figure 2 shows the mean discharge scores for bladder and bowel control items. Mobility items. One-way ANOVAs showed significant differences for all transfers (table 2). As for the self-care and sphincter control items, scores for mobility items showed that patients with higher level lesions scored lower on all items than patients with lesions at a lower level. Bed transfers were seen to be easier than either toilet or tub transfers. Post hoc tests showed no differences between the tetraplegic groups but showed differences between higher tetraplegic (CI-4, C5, and C6) and paraplegic patients as well as differences between the two paraplegic patient groups. Figure 3 shows the mean discharge scores for the mobility items. Locomotion items. Figure 4 shows the mean discharge scores for the two locomotion items. One-way ANOVAs showed no significant effects for these items (table 2).

C6 C7-8 Ti-6 T7&below Neurological Level

Fig 3. Effect of neurological level on mean discharge FIM mobility item scores,

Communication and social cognition items. One-way ANOVAs showed no significant effects for the five communication and social cognition items (table 2). The mean discharge FIM score for each of these items was between 6 and 7, and results are not presented graphically. DISCUSSION Measurement of functional outcomes is an integral part of any goal-orientated, multidisciplinary rehabilitation program and requires suitable assessment tools. The FIM, consisting of 18 items that rate the level of independence in self-care activities, sphincter control, mobility, locomotion, communication, and social cognition, has been shown to contain two fundamental subscales of items, one measuring motor and the other measuring cognitive function. 7,16,21Although the FIM is a suitable tool for many impairment groups, various authors have questioned whether it is as suitable for particular impairments, including SCI and traumatic brain injury (TBI). 11,22

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Fig 2. Effect of neurological level on mean discharge FIM sphincter control item scores. Arch Phys Med Rehabil Vol 79, November 1998

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DISCHARGE FUNCTIONAL STATUS IN SCI, Middleton

Clinical experience in SCI reasonably supports a theoretical construct that disability will increase with greater neurological impairment (ie, higher neurological level of lesion). ~2 The results of the present study confirm the previous finding that FIM motor score increases systematically with more caudal neurological level. 18 However, FIM motor score does not adequately discriminate between adjacent neurological levels. The study also shows a systematic relationship between neurological level and many of the individual FIM item scores at discharge. Profiles for individual FIM self-care items in patients with tetraplegia and high paraplegia clearly show an inverse relation between neurological level and FIM item score with a hierarchical offset depending on item difficulty. Feeding appears to be the easiest item, with grooming, dressing upper body and bathing intermediate, and dressing lower body and toileting the most difficult items. A similar and consistent hierarchy of difficulty among the self care items has been found with Rasch analysis examining FIM item for individuals with SCI.16,23 Both the sphincter control items showed a somewhat restricted range of scores, which may explain their limited ability to differentiate between adjacent levels. In higher level tetraplegia, there is a floor effect, caused by permanent catheter or condom drainage. Results for the mobility items confirmed those expected through clinical experience. Differences in ability to perform transfers would be expected between the tetraplegic and paraplegic patient groups and the significant differences seen between paraplegic patient groups (T1-6 versus T7 and below) in all transfers may reasonably be attributed to greater motor and sensory function in those with lower neurological levels. Our results, suggesting that bed transfers were easier to perform than either toilet or tub transfers, again confirm previous findings relating to item difficulty. ~6,23 This probably reflects greater difficulty in performing transfers combining vertical as well as horizontal components. Not unexpectedly, the locomotor category in individuals with SCI was largely insensitive to neurological level. There was a floor effect in the stair item, with most individuals scoring 1 at discharge. In contrast, there was a ceiling effect for wheelchair locomotion, with most individuals scoring 6 on this item, whether they were higher level tetraplegic patients controlling motorized wheelchairs or paraplegic patients in manual wheelchairs. The results for the cognitive subscale items found in this study, showing ceiling effects across all neurological groupings, further question the utility of these items for assessment of cognitive status in SCI. 24 Davidoff and coworkers 25 have previously highlighted this ceiling effect and the inability of the FIM communication and social cognition items to differentiate a range of cognitive capabilities in areas such as concentration, memory, problem solving, and mental flexibility, evident on formal neuropsychological testing of spinal cord injured individuals. While generally showing similarly high FIM cognitive scores at discharge, analysis of data from the model systems in a larger number of patients showed a slight reduction in FIM cognitive scores for the high level tetraplegic (C 1-3, C4) patient groups. TM Ditunno and associates TM suggested that this may be attributable to an increased frequency of associated TBI in this group. Apart from the FIM, other instruments used to measure self-care functioning in spinal cord-injured individuals have included the modified Barthel Index (MBI), 14'15'26the Quadriplegia Index of Function (QIF), 27 and more recently the Spinal Cord Independence Measure (SCIM). 28 The MBI has been

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widely used for ADL measurement in many impairment groups, including those with SCI; however, it is generally considered less useful than the FIM. 3'29 The QIF was specifically designed for assessment of self-care status in tetraplegia and is more closely related to upper limb strength and more sensitive than FIM for measurement of feeding ability. 3° However, other self-care items, such as upper and lower limb dressing and the motor subscale items including bladder and bowel management, transfers, and wheelchair locomotion, were not studied. Despite some demonstrated advantages, the QIF has not gained wide acceptance. The SCIM has been reported not only to correlate quite highly with FIM, but also to be more sensitive to changes in function of spinal cord injured individuals during rehabilitation. Catz and colleagues 28 weighted tasks according to the perceived impact on everyday functioning of poor sphincter control and poor mobility. The FIM was conceptualized on the basis of the burden of care, and therefore it is not surprising that the results of this study show the ability of various individual FIM items, particularly self-care and mobility items, to discriminate reasonably between different neurological levels. Unlike some activities assessed by the FIM, locomotion is greatly influenced by the environment in which it is performed. Currently the FIM wheelchair locomotion item does not reflect well the skills required for independence in the community. Although this study showed a "ceiling" for wheelchair locomotion and no difference between spinal cord injured individuals with different neurological levels, this is only likely to be true when it is tested on a level surface. Architectural barriers, changes in surface such as thick carpet at home, or inclines/ declines and curbs encountered outdoors may substantially alter both performance and burden of care for spinal cord injured individuals in the community. Dodds and colleagues 8 have recommended either creation of separate ambulation and stair subscales or addition of more items that assess locomotionrelated disability. The discriminative power of the FIM, as well as its sensitivity, may be enhanced by expansion of the wheelchair locomotion item to encompass more complex and advanced wheelchair mobility skills and adaptation of the stair climbing item to measure ability to ascend/descend ramps in a wheelchair. An important aspect of self-care functioning that is not measured by the FIM is an individual's ability to direct others to perform or assist in his or her care and help prevent complications. 9 This is of most significance to persons with high tetraplegia. Addition of an item assessing "self-care direction" may permit documentation of improvement in function in individuals with high tetraplegia that cannot be made with physical function items. Finally, consideration of the FIM cognitive subscale for SCI reveals several issues. Firstly, the present items appear to be unable to detect adequately the neurocognitive sequelae of TBI in individuals with SCI. 25 This is important because it is known that there is a significant incidence of TBI in association with SCI. 31 Secondly, there are important aspects of "cognition" not examined by the FIM. These include areas of psychological function such as psychosocial adjustment, adaptive coping style, and self-efficacy, which often improve, even in individuals with high tetraplegia, in whom physical function may change little if at all. This study has focused on the capacity of the FIM to discriminate between individuals with different levels of neurological lesion; it has not investigated responsiveness of the FIM for evaluation of change during rehabilitation. 32 This issue also warrants examination. Arch Phys Med Rehabil Vol 79, November 1998

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DISCHARGE FUNCTIONAL STATUS IN SCI, Middleton

CONCLUSION The demonstration of an inverse relation between neurological level and discharge functional status in certain FIM motor items supports clinical findings with spinal cord injured individuals that functional performance is reduced as neurological impairment increases. The marked ceiling and floor effects evident in the locomotion and cognitive items suggest that there is a need for additional measures to improve discrimination in the assessment of functional outcomes in spinal cord-injured individuals. Acknowledgment: The authors thank Professor Dennis Smith and Associate Professor Ian Cameron for their support and assistance, and staff members of Moorong Spinal Injuries Unit and the Medical Records Department, Royal Rehabilitation Centre, Sydney, for their assistance with data collection. References 1. Hamilton BB, Granger CV, Sherwin FS, Zielezny M, Tashman JS. A uniform national data system for medical rehabilitation. In: Fuhrer MJ, editor. Rehabilitation outcomes: analysis and measurement. Baltimore (MD): Brooks; 1987. p. 137-47. 2. Keith RA, Granger CV, Hamilton BB, Sherwin FS. The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil 1987;1:6-18. 3. Granger CV, Cotter AC, Hamilton BB, Feidler RC, Hens MM. Functional assessment scales: a study of persons with multiple sclerosis. Arch Phys Med Rehabil 1990;71:870-5. 4. Disler PB, Roy CW, Smith BP. Predicting hours of care needed. Arch Phys Med Rehabil 1993;74:139-43. 5. Lee L, Goor E, Kennedy C, Walters S, Kirby L. Non-acute casemix in the Illawarra. J Qual Clin Pract 1994;14:23-30. 6. Hamilton BB, Laughlin JA, Granger CV, Kayton RM. Interrater agreement of the seven level functional independence measure (FIM) [abstract]. Arch Phys Med Rehabil 1991 ;72:790. 7. Stineman MG, Shea JA, Jette A, Tassoni CJ, Ottenbacher KJ, Feidler R, et al. The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories. Arch Phys Med Rehabil 1996;77:1101-8. 8. Dodds TA, Martin DP, Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehabil 1993;74:531-6. 9. Heinemann AW, Kirk P, Hastie MA, Semik P, Hamilton BB, Linacre JM, et al. Relationships between disability measures and nursing effort during medical rehabilitation for patients with traumatic brain injury and spinal cord injury. Arch Phys Med Rehabil 1997;78:143-9. 10. Ditunno JF, Young W, Donovan WH, Creasey G. The international standards booklet for neurological and functional classification of spinal cord injury. Paraplegia 1994;32:70-80. 11. Maynard FM, Bracken MB, Creasey G, Ditunno JF, Donovan WH, Ducker TB, et al. International standards for neurological and functional classification of spinal cord injury. Spinal Cord 1997;35: 266-74. 12. Bedbrook GM. The care and management of spinal cord injuries. New York: Springer Verlag; 198 I. 13. Staas WE Jr, Formal CS, Gershkoff AM, Freda M, Hirshwald JF, Miller GT, et al. Rehabilitation of the spinal cord-injured patient. In: DeLisa JA, editor. Rehabilitation medicine. Philadelphia: JB Lippincott; 1988. p. 635-59.

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