Factors affecting rehabilitation participation in patients with spinal cord injury

Spinal cord injury (SCI) results in severe disability affecting patients, their families, populations, and medical systems as a whole.¹ Patients with spinal cord injuries need comprehensive, multidisciplinary, and patient-focused rehabilitation services to recover motor and sensory abilities, regain strength and balance, and relearn essential skills for daily living tasks. Rehabilitation offers both physical and psychological benefits for individuals with spinal cord injuries, such as increased motivation, hope, self-confidence, and acceptance.²

The demographic, clinical, and sociocultural characteristics of patients may affect their participation in rehabilitation. Patients with SCI face medical problems such as pain, spasticity, sensory and motor deficits, urinary tract and pulmonary infections, incontinence problems, sexual dysfunction, and decubitus ulcers.³ During the rehabilitation period, psychosocial challenges should be addressed together with medical issues.²

Low participation in inpatient rehabilitation is a common and relevant prognostic factor in rehabilitation outcomes. However, despite the increasing awareness of this factor, few studies have evaluated rehabilitation participation in patients with SCI.^4-6 These studies did not collectively assess the clinical and psychosocial factors influencing rehabilitation participation, nor did they examine the impact of new rehabilitation technologies on participation in rehabilitation.

Our study aims to investigate the factors affecting rehabilitation participation in patients with SCI using multiple parameters. Awareness of these factors is important for the management of patients with SCI. We believe that our study sheds light on future research. Results of our study may be usefull for improving rehabilition strategies for better outcomes.

Methods

This prospective clinical study involved patients with spinal cord injuries who were hospitalized at Ankara City Hospital’s Physical Treatment and Rehabilitation Hospital between March 2021 and March 2022. The study complied with the Declaration of Helsinki and was approved by the Institutional Ethics Committee (Approval Number: E2-21-109, 10.02.2021). It was conducted as part of a specialty thesis research.

The study was conducted using face-to-face interviews. The inclusion criteria were: 1) disabling sequelae from SCI; 2) age 18 years or older; 3) ability to tolerate at least 2 hours of rehabilitation daily; 4) cooperative behavior; 5) no need for mechanical ventilation; 6) having general health insurance Exclusion criteria included: 1) additional neurological disorders; 2) cognitive impairment; 3) unstable medical condition; 4) non-vertebral fractures.

All patients took part in an inpatient rehabilitation program that lasted 2 to 3 hours per day, 5 days a week. The program included range of motion exercises, progressive resistance training, balance and coordination exercises, transfer and ambulation training, as well as occupational therapy.

Patients were also trained in locomats (Hocoma; Zurich, Switzerland) and mechanical balance exercise stations (Neuroforma-Meden-Inmed; Koszalin, Poland) when appropriate. Bladder and bowel management, along with treatment for pressure sores, was also administered. Psychiatric counseling was available.

Upon admission, demographic and clinical data were collected, including age, body mass index (BMI), educational background, marital status, employment status, cause of injury, and motor score. The level of impairment is determined by the American Spinal Injury Association Impairment Scale (AIS).⁷ Additionally, the duration since the injury and bladder and bowel control were recorded. For non-traumatic SCI patients, “time since injury” was determined by the onset of neurological symptoms. The length of stay (LOS) was also documented.

Patient participation in the rehabilitation program was measured using the Pittsburgh Rehabilitation Participation Scale (PRPS). It was completed by the therapist and attending physician. The scale evaluates patient engagement in therapy sessions, with scores ranging from 1 (refusal or no participation) to 6 (excellent participation). Patients who scored below 4 in 25% of the rehabilitation program were categorized as “low” participants, while the remaining individuals were classified as “high” participants.⁵ Depressive symptoms were assessed using the Beck Depression Scale (BDS), a self-report questionnaire originally created by Beck et al. This scale comprises 21 multiple-choice questions that address depressive symptoms. Each question offers four response options. A total score of 21 and above indicates depression.⁸

The presence of neuropathic pain was assessed using the Douleur Neuropathic 4 Questions (DN4) questionnaire.⁹

Pain intensity was evaluated using the Visual Analog Scale (VAS). Participants were instructed to indicate their overall pain level by marking the appropriate point on the scale from 0 to 10.¹⁰

The Turkish-validated form of the Spinal Cord Independence Measure (SCIM) was used to assess patient independence. It evaluates function across three key areas: (1) self-care, including activities such as eating, bathing, and grooming.¹¹ Finally, individuals were classified based on their BMI as normal weight, overweight, and obese.¹²

Results

This study included a total of 87 patients with SCI, consisting of 29 women (33.3%) and 58 men (66.7%), with a mean age of 44.9±17.0 years. Fifty-seven point five percentage of the patients had primary school education. 56.3% of the patients were employed before SCI this frequency of employment dropped to 3.4% after SCI. Of the patients, 65.5% had traumatic etiologies and 34.5% had non-traumatic etiologies. Nearly half of the patients (48.3%) had normal weight. Of these patients, 78.2% had paraplegia and 21.8% had tetraplegia. Median motor score according to ABS classification was 60 (50-78) [median (25-75% IQR)]. More than half of the patients had urinary incontinence (67.8%). The median time since the injury was 12 (3-26) [median (25-75% IQR)] months. Approximately one-third of the patients (31.0%) were dependent on wheelchairs, while nearly another third (28.7%) were able to walk indoors. Median LOS in the rehabilitation service was 54 (40-73) [median (25-75% IQR)] days. Among the patients, 11.5% were found to have depression. Neuropathic pain was detected in most of the patients (70.1%). Thirty One percentage of the patients showed low participation and 69% of the patients showed high participation in the rehabilitation program (Table 1).

There were no significant differences between participants with low and high participation regarding age, gender, educational level, marital status, cause of injury, BMI, urinary incontinence, employment status, and functional status. Additionally, the duration since injury and length of stay (LOS) were comparable between the 2 groups (p=0.139 and p=0.151, respectively). Neuropathic pain was more prevalent in the low-participant group (85.2% vs. 63.3%), but this difference did not reach statistical significance (p=0.071). The low-participant group also had a higher percentage of tetraplegic patients (37.0% vs. 15.0%, p<0.001). The motor score was significantly lower, and the BDS score was significantly higher in the low-participant group, with motor scores of 50 (33-58) compared to 70 (52.5-84) [median (25-75% IQR)], and BDS scores of 11 (6-19) compared to 7 (4-12) [median (25-75% IQR)] (p<0.001 and p=0.019, respectively). Furthermore, a greater number of patients in the high-participant group engaged in locomat training and mechanical balance training (38.3% vs. 7.4% and 35% vs. 0%, p=0.007 and p<0.001, respectively) (Table 2).

Results from the multivariate logistic regression analysis indicated that patients with lower participation had lower motor scores (OR: 0.926, 95% CI: 0.892-0.964) (p<0.001), lower rates of locomotor training (OR: 0.007, 95% CI: 0.013-0.471) (p=0.006), higher instances of neuropathic pain (OR: 7.458, 95% CI: 1.451-38.321) (p=0.016), and higher BDS scores (OR: 1.085, 95% CI: 1.004-1.174) (p=0.040) compared to those with higher participation (Table 3).

The SCIM scores at admission and discharge were compared between the low and high-participation groups. Both groups showed significant improvements in SCIM scores (p<0.001 for both). However, the increase in SCIM scores was significantly greater in the high-participation group compared to the low-participation group (p=0.030) (Table 4).

Discussion

This study investigated the factors affecting rehabilitation participation in patients with SCI. Lower motor scores, tetraplegia, higher BDS scores, and neuropathic pain were associated with lower participation in the rehabilitation program. Patients trained in locomats and mechanical balance devices showed higher participation rates. The high-participant group showed more improvement in the independence measures.

Low participation in inpatient rehabilitation was found in nearly one-third of the patients (31%). The percentage of patients with lower participation was similar to that reported in a study in Italy (33.88%) but higher than that reported in the USA (20.66%).^5,6 Differences in countries’ health policies may have contributed to these results. In Turkey, similar to Italy, inpatient rehabilitation beds are reserved only for patients with severe disabilities. In addition, differences in study populations and methodologies may have led to diverse results.

Neuropathic pain is a frequently observed negative prognostic factor in patients with SCI.^9,13 In our study, neuropathic pain was detected in 70% of the patients. Patients were diagnosed with neuropathic pain according to the DN4 questionnaire, which made our results more reliable. Neuropathic pain has been reported to negatively affect sleep and activity in patients with SCI.¹³ Neuropathic pain can hinder participation due to its negative impact on patients’ psychological well-being, sleep quality, and overall quality of life. Neuropathic pain was found to be negatively correlated with higher physical activity in SCI literature.¹⁴ Consistent with these findings, our study indicated that neuropathic pain was linked to reduced participation in rehabilitation programs. To improve pain management, an interdisciplinary team approach should be implemented, political and organizational interventions should be monitored and adjusted, and family members/caregivers should be involved in all these stages.¹⁵

Depression is another common and challenging complication in SCI patients. Depression was found to be linked to increased disability in patients with spinal cord injuries.¹⁶ Depression has also been reported to interrupt rehabilitation and negatively affect participation in rehabilitation.² In accordance with these studies, BDS scores were notably higher in the low-participant group compared to the high-participant group, and the presence of depression was linked to reduced participation in our study. Psychiatric counseling is necessary when depression is suspected in SCI patients. Additionally, better integration of social life, family support, and return to work should be encouraged. A recent observational cohort study highlighted the importance of diagnosing depression in the early stages following SCI and advocated for enhancing psychological care and rehabilitation management during the initial phase after SCI.¹⁶

In our study, nearly 60% of the patients were employed before SCI. However, only 3.4% of the patients went on working after SCI. Reemployment after SCI is strongly recommended in the literature.¹⁷ The patients with SCI need to be supported by their families, governments, and social environment to work after SCI. In a recent study by Barclay et al¹⁸ providing peer support early in rehabilitation helped patients develop hope for their future and fostered the expectation of returning to work.

A significantly higher percentage of patients were tetraplegic in the lower participation group. In addition, higher motor scores were associated with lower participation in the rehabilitation programs. Low motor scores were previously defined as poor prognostic criteria for SCI.¹⁹ Patients with higher motor scores are more independent in transfers and ambulation and better tolerate exercise. In a large-scale study, injury severity was identified as the SCI-related characteristic with the greatest discriminative power.²⁰ Individuals with complete tetraplegia faced the most significant restrictions and thus require special attention in rehabilitation settings. This group is the most vulnerable within the SCI community due to their difficulties with daily activities and mobility.²¹

In our study, the difference in SCIM scores was significantly greater in the group with higher participation. Previous studies have reported that higher disability and dependence are associated with lower participation in rehabilitation programs.^5,6 Patients with higher activity levels and higher independence in activities of daily living were better adapted to the rehabilitation program. The SCIM difference is also a measure of rehabilitation success. Independence in activities of daily living and the ability to adapt to real-life situations should be taken into account. Early active rehabilitation is recommended in patients with SCI.³ Also, safe and effective rehabilitation programs outside the hospital setting should be developed to increase rehabilitation participation, functional independence, and overall recovery.²²

Training with locomat and mechanical balance devices was found to have a positive impact on participation in our study. One reason for this may be that patients with higher motor scores and neurological injury levels receive these additional treatments. Assistive rehabilitative devices have been shown to improve motor scores, functional independence, and quality of life.²³ A recent meta-analysis found that robotic assistance led to enhancements in activities of daily living, muscle strength, and walking ability. The same study suggested that robot-assisted gait training was beneficial for individuals with SCI, with good outcomes without important adverse events.²⁴ In another study reported from Austria, robot-assisted gait training was found to be feasible and highly accepted by patients undergoing neurological rehabilitation.²⁵ Unfortunately, the effective implementation of technological innovations in rehabilitation settings remains limited. It is estimated that only about 10% of patients have access to the assistive devices needed for rehabilitation, with this disparity being even more pronounced in economically disadvantaged countries.²⁶ The use of assistive technologies should be promoted and expanded in all rehabilitation settings.