Advances in Disability Research

Advances in Disability Research Group Physical Therapy During Inpatient Rehabilitation for Acute Spinal Cord Injury: Findings From the SCIRehab Study Jeanne M. Zanca, Audrey Natale, Jacqueline LaBarbera, Sally Taylor Schroeder, Julie Gassaway, Deborah Backus

Background. Inpatient rehabilitation for spinal cord injury (SCI) includes the use of both individual and group physical therapy sessions. A greater understanding of group physical therapy use will help in the evaluation of the appropriateness of its use and contribute to the development of standards of practice.

Objective. This report describes the extent to which group physical therapy is being used in inpatient rehabilitation for SCI, identifies group physical therapy interventions being delivered, and examines patterns in the types of activities being used for people with different levels and completeness of injury (ie, injury groups).

Design. The SCIRehab Study is a 5-year, multicenter investigation that uses practice-based evidence research methodology.

Methods. Data on characteristics of participants and treatments provided were collected through detailed chart review and customized research documentation completed by clinicians at the point of care. The analyses described here included data from 600 participants enrolled during the first year of the project.

Results. Most of the participants (549/600) spent time in group physical therapy,

J.M. Zanca, PT, PhD, Department of Rehabilitation Medicine, Mount Sinai School of Medicine, 1425 Madison Ave, Box 1240, New York, NY 10029 (USA). Address all correspondence to Dr Zanca at: [email protected]. A. Natale, PT, DPT, Craig Hospital, Englewood, Colorado. J. LaBarbera, PT, Carolinas Rehabilitation, Charlotte, North Carolina. S.T. Schroeder, PT, Rehabilitation Institute of Chicago, Chicago, Illinois. J. Gassaway, MS, RN, Institute for Clinical Outcomes Research, Salt Lake City, Utah. D. Backus, PT, PhD, Shepherd Center, Atlanta, Georgia.

and 23% of all documented physical therapy time was spent in group sessions. The most common group physical therapy activities were strengthening, manual wheelchair mobility, gait training, endurance activities, and range of motion/stretching. Time spent in group physical therapy and the nature of activities performed varied among the injury groups.

[Zanca JM, Natale A, LaBarbera J, et al. Group physical therapy during inpatient rehabilitation for acute spinal cord injury: findings from the SCIRehab Study. Phys Ther. 2011;91:1877–1891.]

Limitations. Physical therapy use patterns observed in the 6 participating centers

© 2011 American Physical Therapy Association

may not represent all facilities providing inpatient rehabilitation for SCI. Research documentation did not include all factors that may affect group physical therapy use, and some sessions were not documented.

Published Ahead of Print: October 14, 2011 Accepted: July 11, 2011 Submitted: November 15, 2010

Conclusions. The majority of physical therapy was provided in individual sessions, but group physical therapy contributed significantly to total physical therapy time. Group physical therapy time and activities differed among the injury groups in patterns consistent with clinical goals.

Post a Rapid Response to this article at: ptjournal.apta.org December 2011

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI

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npatient rehabilitation for spinal cord injury (SCI) includes the use of individual physical therapy sessions, in which a patient works oneon-one with a clinician, and group sessions, in which multiple patients are brought together to participate in an activity under the supervision of one or more clinical staff members. In combination with individual physical therapy, group physical therapy may be used to address impairments, activity limitations, and participation restrictions that contribute to disability. Group physical therapy sessions are thought to enhance opportunities for peer support, allow practice of skills taught in one-on-one sessions, and improve the cost-effectiveness of treatment delivery.1–3 Several factors may affect the extent of use of group physical therapy, including characteristics and needs of patients, staffing patterns, and third-party payer requirements, which may vary from region to region.1 In the fiscal year 2010 inpatient rehabilitation facility prospective payment system final rule, the Centers for Medicare & Medicaid Services (CMS) expressed concern about the overuse of group therapy services and uncertainty about the amount of group therapy that would be appropriate for various groups of patients.4 In the final rule, the CMS described individual (one-on-one) therapy as the “standard of care” for inpatient rehabilitation facilities and recom-

Available With This Article at ptjournal.apta.org • Audio Podcast: “RCTs on Disability Intervention in Physical Therapy and Rehabilitation: Unique Challenges and Opportunities” symposium recorded at PT 2011, National Harbor, Maryland.

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mended that group therapy be used as an “adjunct” to individual therapy, not as a replacement for it. The CMS stated an interest in developing standards for the use of group therapy and acknowledged several comments that it received indicating that further research is needed to determine appropriate standards for the use of group physical therapy.4 As of the time of this writing, no specific policy changes had been made by the CMS with respect to group therapy use, but rehabilitation centers are carefully reviewing the content of the fiscal year 2010 final rule and considering its implications for future policies related to group therapy use. Little is known about the extent, nature, and potential benefits of group physical therapy use in inpatient rehabilitation, particularly for patients with SCI. In a recent study, van Langeveld et al5 examined interventions provided by physical therapists, occupational therapists, and sports therapists to patients with SCI during inpatient rehabilitation at 6 rehabilitation centers in Australia, Norway, and the Netherlands. Although the specific proportion of time spent in group physical therapy was not reported, the proportion of therapy time categorized as group therapy for all 3 disciplines combined ranged from 6% to 39% in the 3 countries studied. Other reports of group rehabilitation interventions are not specific to SCI rehabilitation but describe the use of group interventions to address impairments and activity limitations that contribute to disability. Gelsomino et al1 used staff interviews and observation of therapy sessions to gather descriptive information about the use of group physical therapy at 5 Midwestern rehabilitation facilities. All 5 facilities used group therapy at least some of the time, with considerable variations

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across facilities in the number of participants per group, types of groups offered, frequency and duration of group sessions, and billing policies. Gait or ambulation therapy groups were used at 4 facilities, “mat” groups were used at 3 facilities, and several other types of groups (cerebrovascular accident, SCI education, upper extremity, and wheelchair) were used by 2 facilities. Specific interventions provided in the groups were not described, and data on clinical outcomes were not collected. Other studies presented evidence for the benefits of group therapy. Periera et al2 evaluated the effects of outpatient group physical therapy on motor performance and activities of daily living in people with Parkinson disease. In that study, 5 patients participated in a series of thirty-five 60-minute outpatient sessions of group physical therapy held 3 times a week. The group sessions included mobility, balance, and strength-related activities, and group participants were allowed to observe each other and provide help and encouragement to one another. The group participants demonstrated statistically significant improvements in balance, gait, and performance of activities of daily living. Gauthier et al3 reported that, compared with people who had Parkinson disease but did not participate in group occupational therapy, those who had Parkinson disease and received group therapy demonstrated a significant decrease in bradykinesia and, perhaps more importantly, maintained their functional status after 1 year and reported a significant improvement in their psychological well-being. Both Parkinson disease and SCI are chronic diseases that have a tremendous impact on motor and sensory functions, functional abilities, and well-being. Thus, although these studies did not include people with December 2011

Group Physical Therapy During Inpatient Rehabilitation for Acute SCI SCI, their findings suggest that rehabilitation interventions provided in group sessions may reduce disability by improving function and that further study is needed to determine their benefits for people with SCI. A greater understanding of the current nature and extent of group physical therapy use in SCI rehabilitation is an important first step in evaluating the appropriate use of group physical therapy and the potential impact of policy changes that may occur with regard to the use of group physical therapy versus individual physical therapy. The 3 objectives of the present report are: (1) to describe the extent to which group therapy is being used in the inpatient SCI rehabilitation programs of 6 major inpatient rehabilitation facilities, (2) to identify the types of interventions that are being delivered in group sessions, and (3) to examine patterns in the types of activities used for people with different levels and completeness of injury. These analyses will provide a foundation for future work exploring the impact of group physical therapy on the prevention of disability after acute traumatic SCI.

Method The SCIRehab study uses practicebased evidence research methods,6 –12 an observational approach involving the collection of detailed data on rehabilitation interventions, characteristics of patients, and medical, functional, and psychosocial outcomes so that relationships among these factors may be studied.6,8,11,13–16 Data are collected through a combination of detailed chart review by trained data abstractors and completion of customized research documentation at the point of care by clinicians providing rehabilitation services to study participants. The SCIRehab Study is a 5-year, multicenter investigation that will include approximately 1,300 December 2011

patients. The analyses described here included data from 600 participants enrolled between August 2007 and September 2008, the first year of the SCIRehab Project. SCIRehab Facilities and Enrollment Criteria The Rocky Mountain Regional Spinal Injury System at Craig Hospital leads the SCIRehab Study and is joined by the Rehabilitation Institute of Chicago, the Shepherd Center, the National Rehabilitation Hospital, Carolinas Rehabilitation, and the Mount Sinai Medical Center. Project implementation support and data analyses are performed by the Institute for Clinical Outcomes Research. All patients (or their parents or guardians) gave informed consent or assent. Patients who were 12 years of age or older and admitted for initial rehabilitation after traumatic SCI were enrolled. The average rate of enrollment over the course of the entire SCIRehab study at all of the centers was 91% (range within centers⫽78%–95%). Collection of Data on Participants, Injuries, and Clinicians Injury groups. The International Standards for Neurological Classification of Spinal Cord Imjury17 was used to characterize the level and completeness of injury and to place study participants into 1 of 4 neurological injury groups. Participants with injuries classified as American Spinal Injury Association Impairment Scale (AIS) grade D were grouped together regardless of motor level of injury (AIS D group). The remaining pool of participants, with AIS grade A, B, and C injuries, was subdivided into 3 groups on the basis of motor level of injury at rehabilitation admission. These groups included participants with cervical injury levels 1 to 4 (high tetraplegia), those with cervical injury levels 5 to 8 (low tetraplegia), and those with paraVolume 91

plegia. These injury categories were selected because they were thought to create groups with different injury characteristics and functional expectations and were each large enough for comparative analyses. Illness severity and functional status. The severity of each participant’s complications and comorbidities was quantified with the Comprehensive Severity Index (CSI). Higher CSI scores indicate the presence of more physical symptoms that are considered “abnormal,” worse morbidity, and greater medical complexity.18 –22 The admission CSI score was based on a review of health status over the first 3 days of the rehabilitation admission. The maximum CSI score was based on a review of health status over the entire rehabilitation stay. The Functional Independence Measure (FIM) was used to describe the amount of assistance needed for the performance of specific motor and cognitive activities at rehabilitation admission and discharge.23,24 Length of stay (LOS). The rehabilitation LOS reflected the total time the participant spent in rehabilitation, as calculated by subtracting the first admission date from the last discharge date and then subtracting days spent out of the rehabilitation facility (such as in an acute care or other interim setting) before returning for completion of rehabilitation. This definition and calculation were chosen so that the LOS would correspond to days in the SCI unit, where service delivery was documented. Characteristics of clinicians. Clinical staff members who documented treatment sessions completed a clinician profile that included their years of SCI rehabilitation experience at the start of the project.

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Collection of Data on Physical Therapy Treatments An electronic documentation system was created to document the amount and nature of physical therapy interventions provided to study participants systematically and consistently at all of the participating centers. The documentation system included a taxonomy for classifying the types of rehabilitation interventions provided as well as additional details, such as time spent in each activity, level of assistance provided for functional activities, patient direction of care, family involvement, amount of missed therapy time, and the presence of factors affecting the conduct of the physical therapy session (such as fatigue or pain). The documentation system also included a field in which the documenting clinician could indicate whether he or she was completing documentation on behalf of another person (such as a student or aide under that clinician’s supervision or a covering therapist). The physical therapy taxonomy (including descriptions of activities included therein) and the documentation development process are described elsewhere.9,25 Clinicians providing care to participants with SCI documented each of their treatment sessions by using portable electronic devices that featured a customized software application containing the documentation system designed for the study.9 Therapy sessions were classified by the documenting clinician as either individual or group sessions, with “group” being defined as 2 or more participants being treated simultaneously by 1 clinician. Clinicians completed training in the use of the documentation system before the start of data collection, and quarterly reliability assessments were performed to assess the consistency of documentation across clini1880

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cians and identify areas in which further training was needed. Data collected with the handheld devices were monitored regularly by a study coordinator at each participating facility. To maximize the completeness of study documentation, entries were compared with the clinical documentation of services provided (such as chart entries, billing data, scheduling, or other clinical documentation) to identify missing sessions. Sessions that appeared to be missing from the study database were reported to therapists, supervisory staff, or both so that documentation could be completed. Internal checks for missing data were programmed into the data collection software to prevent required fields from being left blank. These and other measures taken to maximize the reliability and validity of data collected with the documentation system are described elsewhere.9 Data Analysis Time spent in physical therapy was calculated by summing all physical therapy session times documented during each participant’s rehabilitation stay. For purposes of analysis, educational sessions were considered to be a subset of group therapy, and clinic sessions (such as a seating clinic conducted by a physical therapist) were included as part of individual therapy. Total time spent in physical therapy was found to have a linear relationship with rehabilitation LOS, which varied from 2 to 259 days. Therefore, total minutes of treatment per week were calculated and considered to be the primary measure of physical therapy treatment intensity. For each participant, group minutes per week were calculated on the basis of the total minutes of group physical therapy over the rehabilitation stay and the participant’s rehabilitation LOS. (An analogous process was used to determine group minutes per week for each activity.) Group minutes per week

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for all 600 participants were averaged to determine mean group minutes per week (Tab. 1). The contribution of each group activity to the mean group minutes per week for all activities was assessed by dividing the mean group minutes per week for a given activity by the mean group minutes per week for all activities (to calculate the percentage of mean group minutes per week). Contingency tables, chi-square tests, and analyses of variance were used to test differences among the injury groups in characteristics of participants and therapy time (P⬍.05 was considered statistically significant), and post hoc analyses for continuous data were performed with the Duncan multiple range test. Pearson product moment correlations were calculated to assess relationships between individual physical therapy time and group physical therapy time (minutes per week). Ordinary least squares stepwise regression models were used to identify characteristics of participants and injuries associated with time spent in physical therapy activities. The strength of a regression model is determined by the R2 value, which indicates the amount of variation explained by the significant independent variables. Parameter estimates indicate the direction and strength of the association between each independent variable (predictor) and the dependent variable. Type II semipartial R2 values are reported here, indicating the proportion of the variance in the dependent variable that was uniquely associated with the predictor variable after controlling for all other variables in the model. The sums of the squared type II semi-partial R2 coefficients do not add up to the total R2 because common variance among predictors also contributes to the total R2.26,27 All independent variables were checked for collinearity, and if any pair was December 2011

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Number 12 0.5 (2.0)

1.0 (5.0)

1.1 (4.0)

1.4 (4.4)

2.8 (6.9)

3.2 (8.3)

3.8 (9.3)

4.2 (14.0)

5.2 (14.4)

7.1 (14.3)

8.6 (33.8)

17.3 (36.9)

43.6 (52.7)

101.1 (100.5)

Min/wk, X (SD)

10 (8)

11 (8)

14 (11)

27 (20)

25 (19)

25 (19)

39 (30)

47 (36)

35 (27)

34 (26)

11 (8)

22 (17)

75 (57)

109 (83)

No. (%) of Participants Performing Activity

0.2 (0.7)

0.5 (1.8)

0.8 (2.6)

1.0 (2.5)

1.3 (4.0)

2.0 (6.9)

4.2 (9.0)

9.0 (22.1)

2.9 (8.7)

4.4 (11.3)

3.1 (14.4)

3.9 (15.9)

26.5 (39.4)

60.6 (74.1)

Min/wk, X (SD)

C1–4 AIS ABC Group (nⴝ132)

17 (11)

9 (6)

19 (13)

28 (19)

37 (25)

35 (23)

37 (25)

42 (28)

59 (39)

59 (39)

6 (4)

57 (38)

113 (75)

145 (96)


0.4 (1.3)

1.0 (6.3)

1.2 (4.1)

0.9 (2.2)

1.6 (4.4)

1.8 (5.4)

3.3 (7.2)

5.8 (15.7)

2.6 (6.0)

10.6 (18.7)

3.3 (19.1)

9.0 (18.6)

37.0 (41.0)

79.6 (67.0)

Min/wk, X (SD)


39 (17)

20 (9)

29 (13)

47 (21)

88 (39)

70 (31)

40 (18)

18 (8)

92 (41)

83 (37)

15 (7)

148 (66)

162 (73)

208 (93)


0.9 (3.0)

0.8 (3.4)

1.4 (4.7)

1.9 (4.8)

4.5 (8.7)

4.8 (10.1)

4.2 (11.1)

1.3 (5.3)

9.4 (20.9)

5.7 (9.5)

4.3 (25.6)

35.8 (51.1)

47.1 (57.0)

123.5 (120.3)

Min/wk, X (SD)

Paraplegia AIS ABC Group (nⴝ223)

15 (16)

17 (18)

3 (3)

13 (14)

28 (30)

25 (27)

20 (21)

7 (7)

25 (27)

33 (35)

41 (44)

23 (24)

76 (81)

87 (93)


0.3 (0.9)

2.3 (7.8)

0.5 (3.2)

1.8 (7.0)

2.9 (7.5)

3.7 (8.4)

3.3 (7.8)

1.6 (6.3)

3.0 (7.3)

8.8 (17.7)

34.9 (64.0)

5.6 (17.3)

69.8 (63.6)

139.5 (99.0)

Min/wk, X (SD)

AIS D Group (nⴝ94)

Total mean minutes per week were averages calculated for all 600 participants, not just those who received one or more sessions of a particular activity in a group setting. Activities with mean group minutes per week of ⬍0.50 were excluded from the table. C1– 4⫽cervical injury levels 1 to 4 (high tetraplegia); AIS⫽American Spinal Injury Association Impairment Scale (AIS); ABC⫽AIS grades A, B, and C; C5– 8⫽cervical injury levels 5 to 8 (low tetraplegia); AIS D⫽AIS grade D. b Differences in mean minutes per week among injury groups were statistically significant at Pⱕ.05.

a

81 (14)

57 (10)

Bed mobilityb

Pre–gait training

b

115 (19)

178 (30)

155 (26)

136 (23)

65 (11)

b

Upright activitiesb

Education

Transfersb

Balance exercises

Classes

114 (19)

Power wheelchair mobility trainingb

209 (35)

211 (35)

Endurance activities

73 (12)

Range of motion/stretchingb

b

250 (42)

Gait trainingb

426 (71)

Manual wheelchair mobility trainingb

549 (92)

Strengthening exercisesb

Specific group physical therapy activities

All group physical therapy activitiesb

Activity


Overall SCIRehab Sample (Nⴝ600)

Time Spent in Group Physical Therapy Activities by Injury Groupa

Table 1.


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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Table 2. Participant and Injury Characteristics Associated With Time Spent in Group Physical Therapy During Rehabilitationa Time (min/wk) Spent in Group Physical Therapy During Rehabilitation Parameter Estimate

Independent Variable

Type II Semi-partial R2b

Role of the Funding Source This work was funded by the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, US Department of Education (grant H133A060103).

51.23

.02

Results

3.03

.03

Injury group: C1–4 ABC

⫺49.75

.03

Injury group: C5–8 ABC

⫺38.40

.02

Characteristics of Participants and Clinicians As in many studies of traumatic SCI, most (81%) of the 600 participants were men (Tab. 3). They ranged in age from 12 to 86 years, with a mean of 37.2 years. Fifty participants (8%) were minors (ⱕ18 years of age). Most of the participants were white (65%), spoke English as their primary language (95%), and had completed high school or higher levels of education (67%). Most were working at the time of injury (65%) and funded their care through private insurance (66%). The paraplegia injury group was the largest, with 223 participants; the low-tetraplegia, high-tetraplegia, and AIS D groups had 151, 132, and 94 participants, respectively. Statistically significant differences in the characteristics of the participants were found among the injury groups. Participants with high tetraplegia had the longest LOS, the most days from injury to rehabilitation admission, and the highest scores for illness severity, whereas participants in the AIS D group had the lowest values for all 3 of these variables. Admission FIM scores were typically highest in the paraplegia group and lowest in the hightetraplegia group (with the exception of the FIM cognitive score, which was highest in the AIS D group). Age at time of injury was greatest in the high-tetraplegia and AIS D groups. Differences in thirdparty payer, education level, employment status, BMI at admission, and injury etiology also were observed.

Race (Hispanic) Admission FIM cognitive score

⫺0.65

.03

2.89

.02

Employment status at time of injury (retired, unemployed, and otherc)

⫺37.69

.01

Body mass index ⬎40 kg/m2

⫺45.48

.01

Days from injury to rehabilitation admission Clinician experience index

a

Independent variables allowed into models were as follows: age at time of injury, male, married, race (white, black, Hispanic, and other), admission Functional Independence Measure (FIM) motor score, admission FIM cognitive score, illness severity score (Comprehensive Severity Index), injury group (C1– 4 ABC, C5– 8 ABC, paraplegia ABC, and AIS D—where C1– 4⫽cervical injury levels 1 to 4 [high tetraplegia]; ABC⫽American Spinal Injury Association Impairment Scale [AIS] grades A, B, and C; C5– 8⫽cervical injury levels 5 to 8 [low tetraplegia]; Para⫽paraplegia; and AIS D⫽AIS grade D), clinician experience index, traumatic etiology (vehicular, violence, fall, sports, medical/surgical complication, and other), work-related injury, days from trauma to rehabilitation admission, body mass index (⬎40, 30 – 40, and ⬍30 kg/m2), language (English, no English, and English sufficient for understanding), payer (Medicare, workers’ compensation, private, and Medicaid), employment status at the time of injury (employed, student, retired, unemployed, and other), and ventilator use at rehabilitation admission. b The total R2 value was .20. Semi-partial R2 values do not add up to the total R2 value because of a rounding error. c Other⫽homemaker, on-the-job-training, sheltered workshop, and unknown.

highly correlated (r⬎.75), only one of the pair was allowed to enter the models. The predictors used were sex, marital status, racial or ethnic group, traumatic SCI etiology, body mass index (BMI), English-speaking status, third-party payer, preinjury occupational status, score for maximum severity of illness (CSI), age, score for FIM motor items (FIM motor score) at admission, score for FIM cognitive items (FIM cognitive score) at admission, clinician experience index, and injury grouping (see footnotes of Tabs. 1 and 2 for details). The clinician experience index describes the average years of SCI rehabilitation experience of a clinician treating a particular participant and was calculated by weighting the experience of each clinician by the hours of treatment that each clinician provided. Independent variables were selected for inclusion on 1882

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the basis of the availability of data for analyses and the consensus recommendations of the interdisciplinary steering committee for the project. Regression analyses were repeated with variables symbolizing sites allowed to enter the model. Differences between the R2 value resulting from the initial model and that resulting from the model including sites were examined to determine the extent to which additional variance might be explained by site-related factors not accounted for in the initial model. Parameter estimates for the 2 models were compared to identify those that changed significantly (by ⬎50% of their value). Statistical analyses were performed with SAS version 9.2 (SAS Institute Inc, Cary, North Carolina).

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Most group sessions (97%) were documented by the clinician who December 2011

Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Table 3. Participant and Injury Characteristics by Injury Groupa Total Sample (Nⴝ600)



Paraplegia AIS ABC Group (nⴝ223)

AIS D Group (nⴝ94)

Length of rehabilitation stay, d, X (SD)b

54.6 (37.1)

74.1 (43.2)

64.9 (37.7)

44.9 (28.8)

33.6 (24.1)

Age at time of injury, y, X (SD)b

37.2 (16.6)

41.9 (17.0)

33.7 (15.6)

33.4 (14.2)

45.3 (18.5)

Characteristic

Sex (% men)

80.5

80.3

80.8

81.6

77.7

White

64.8

68.2

72.9

59.2

60.6

Black

21.5

19.7

16.6

24.7

24.5

Hispanic

8.0

7.6

6.0

9.9

7.5

Other

5.7

4.6

4.6

6.3

7.5

Race or ethnicity (%)

Primary language (%) English

95.0

96.2

97.4

93.7

92.6

Understands English

2.5

1.5

0.7

3.1

5.3

No English

2.5

2.3

2.0

3.1

2.1

Payer (%)b Medicare

6.8

9.1

3.3

4.0

16.0

Medicaid

18.0

13.6

21.2

22.0

9.6

Private insurance or payer

65.8

67.4

67.6

63.2

67.0

9.3

9.9

8.0

10.8

7.5

38.0

43.9

31.8

38.6

38.3

Workers’ compensation Marital status at time of injury (% married) Education (%)b Less than high school diploma

20.2

15.2

25.8

20.6

17.0

High school diploma or GED

46.5

56.1

42.4

48.0

36.2

More than high school diploma

27.0

25.0

26.5

25.6

34.0

6.3

3.8

5.3

5.8

12.8

Working

65.0

69.7

60.9

67.7

58.5

Student

16.2

8.3

23.2

16.1

16.0

Other

18.8

22.0

15.9

16.1

25.5

Vehicular

49.3

47.7

45.0

52.5

51.1

Violence

11.0

7.6

9.3

16.1

6.4

Sports

11.7

13.6

23.2

4.0

8.5

Fall or falling object

23.2

28.0

21.2

19.7

27.7

4.8

3.0

1.3

7.6

6.4

81.8

81.1

86.8

82.1

74.5

15.5

16.7

11.9

13.5

24.5

2.7

2.3

1.3

4.5

1.1

53.0 (14.8)

40.7 (6.8)

45.8 (7.8)

62.2 (12.8)

60.0 (17.3)

24.1 (12.1)

14.1 (2.3)

17.6 (5.5)

32.2 (10.4)

29.2 (15.1)

Other or unknown Employment status at time of injury (%)

Injury etiology (%)

b

b

Other Body mass index at admission (%)b ⬍30 kg/m2 30–40 kg/m

2

⬎40 kg/m2 Admission FIM total score, X (SD)b Admission FIM motor score, X (SD)b Admission FIM cognitive score, X (SD)

b

28.9 (5.6)

26.6 (6.4)

28.3 (5.2)

30.0 (5.1)

30.8 (5.2)

Admission CSI score, X (SD)b

21.2 (19.4)

29.2 (25.4)

20.8 (18.5)

20.0 (16.8)

13.3 (11.7)

Maximum CSI score, X (SD)b

40.2 (33.2)

58.3 (42.8)

41.8 (29.5)

36.1 (28.0)

22.0 (19.3)

Days from injury to rehabilitation admission, X (SD)b

31.7 (28.1)

42.1 (30.5)

33.0 (28.7)

31.5 (28.1)

15.5 (12.4)

a

C1– 4⫽cervical injury levels 1 to 4 (high tetraplegia); AIS⫽American Spinal Injury Association Impairment Scale (AIS); ABC⫽AIS grades A, B, and C; C5– 8⫽cervical injury levels 5 to 8 (low tetraplegia); AIS D⫽AIS grade D; GED⫽general equivalency diploma; FIM⫽Functional Independence Measure; CSI⫽Comprehensive Severity Index. b Differences among injury groups were statistically significant at Pⱕ.05.

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI group physical therapy differed significantly (P⬍.001) among the injury groups, with the smallest proportion observed in the high-tetraplegia group and the largest proportion observed in the AIS D group.

Figure 1. Variations in percentages of total physical therapy (PT) time spent in group therapy for injury groups. ABC⫽American Spinal Injury Association Impairment Scale (AIS) grades A, B, and C; C1– 4⫽cervical injury levels 1 to 4 (high tetraplegia); C5– 8⫽cervical injury levels 5 to 8 (low tetraplegia); D⫽AIS grade D.

directed the session. The average number of years of SCI rehabilitation experience of clinicians who documented group sessions was 6.0 (range⫽1.4 –9.9). Statistically significant differences were noted among the participating centers (P⬍.001). Frequency and Extent of Group Therapy Use Total physical therapy time. Clinicians documented 37,306 physical therapy sessions. Participants with SCI received a mean total of 55.3 hours (SD⫽35.1, median⫽ 45.8, range⫽1.6 –189.5) of physical therapy (individual therapy and group therapy combined) over the course of their rehabilitation stay. On average, participants received 7.4 hours of physical therapy (individual therapy and group therapy combined) per week. Group physical therapy time. Most of the participants (549/600, 92%) spent time in group physical therapy over the course of their rehabilitation stay (Tab. 1). Of these 549 participants, 36 received educational classes as their only type 1884

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of group therapy. Nearly one fourth of all documented therapy time (expressed in mean minutes per week) was spent in group sessions (23%, 101.1 min/wk). The amount of time spent in group physical therapy activities varied greatly among the participants (interquartile range [IQR]⫽25.5–144.6 min/wk, median⫽ 69.2). The mean minutes spent in group physical therapy per week differed significantly among the injury groups (P⬍.001), with the AIS D and paraplegia groups receiving more group physical therapy minutes per week than the tetraplegia groups. Proportion of total physical therapy time spent in group physical therapy. The proportion of total physical therapy hours during the LOS spent in group physical therapy activities was calculated for each participant in the sample. The median proportion of time spent in group physical therapy was 17%, with considerable interpatient variation (IQR⫽7%–30%). Considerable variation also was observed within the injury groups (Fig. 1). The proportions of total hours spent in

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Predictors of group physical therapy time (all activities combined). Regression analyses estimated that approximately 20% of the variation (variance) in group physical therapy time (mean minutes per week) could be predicted by a combination of characteristics of participants, characteristics of injuries, and experience of clinicians, although no single variable predicted greater than 3% of the total variance (Tab. 2). Characteristics associated with more time in group therapy included higher admission FIM cognitive score, Hispanic race, and more years of experience of clinicians. Characteristics associated with less time in group therapy included more days from injury to rehabilitation admission, cervical injury level, BMI of greater than 40 kg/m2, and employment status of “other” at the time of injury. When the site variables were allowed to enter the regression model, the total amount of variance predicted increased from 20% to 36%, and employment status was no longer a significant predictor in the model. The type II semi-partial R2 for the remaining predictor variables did not change by more than .01 after the addition of the site variables to the model, and no parameter estimates changed by more than 50%. Group session providers. Most of the group physical therapy sessions (91%) were provided by physical therapists; 6% and 1% of the sessions, respectively, were provided by students and aides, both of whom typically work under the supervision of physical therapists at the participating centers. Physical therapist assistants led 2% of the documented group therapy sessions. December 2011

Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Group Therapy Activities Overall sample. For all participants, the most common group physical therapy activities (based on the percentage of mean group minutes per week) were strengthening (43%), manual wheelchair mobility training (17%), gait training (9%), endurance activities (7%), and range of motion/stretching (5%), making up 80% of all time spent in group settings each week (Tab. 1). The proportion of participants spending time in a specific group physical therapy activity was largest for strengthening (71%); participants who engaged in strengthening spent an average of 61.3 min/wk in this activity (Fig. 2). Less than half of the participants spent time in manual wheelchair mobility training, endurance activities, or range of motion/ stretching, but those who did spent an average of 14.9 to 41.6 min/wk in these activities. A small proportion (12%) of participants spent time in gait training, but those who did spent an average of more than 1 h/wk in this activity (70.4 min/wk). Time spent in each group physical therapy activity varied considerably among the participants. For strengthening, minutes per week ranged from 0 to 289 (IQR⫽0 – 68 min/wk). Less than half of the participants engaged in manual wheelchair mobility training (IQR⫽0 –16, maximum⫽238 min/wk), range of motion/stretching (IQR⫽0 – 4, maximum⫽140 min/wk), or endurance activities (IQR⫽0 – 8, maximum 84⫽ min/wk). Fewer than 15% of the participants spent group physical therapy time in gait training (IQR⫽0 – 0, maximum⫽310 min/wk). Within injury groups. The types of group physical therapy activities in which time was spent differed among the injury groups (Fig. 3). Strengthening was the most common group physical therapy activity in all of the injury groups (range⫽ December 2011

Figure 2. Percentages of participants engaging in common group therapy activities and mean minutes that participants spent in each activity per week. ROM⫽range of motion.

Figure 3. Time spent in specific activities for injury groups. ABC⫽American Spinal Injury Association Impairment Scale (AIS) grades A, B, and C; C1– 4⫽cervical injury levels 1 to 4 (high tetraplegia); C5– 8⫽cervical injury levels 5 to 8 (low tetraplegia); D⫽AIS grade D; PT⫽physical therapy; WC⫽wheelchair.

38%–50% of mean group minutes per week). Other physical therapy activities addressed in group settings, particularly those related to mobility, varied among the injury groups. The proportion of group minutes spent in power wheelchair mobility training per week was largest for participants with tetraplegia, whereas manual wheelchair mobility training was most prominent for participants in the paraplegia group. Participants in the AIS D group spent a larger proportion of time in gait training than participants in any other injury group. Volume 91

Predictors of time spent in specific group physical therapy activities. Regression analyses indicated that characteristics of participants, injuries, and clinicians predicted 11% to 23% of the variance in minutes spent in the most common group physical therapy activities per week (Tabs. 4 and 5). The predictors of group therapy minutes per week that were statistically significant varied by activity but included injury group, admission FIM motor and FIM cognitive scores, age at time of injury, payer, experience of clinicians, race, primary language, days Number 12

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Table 4. Specific Group Physical Therapy Activities

a

Time (min/wk) Spent in Activitya

Activity

% of Participants Engaged in Activity

X

SD

Total R2

Manual wheelchair mobility

42

17.3

36.9

.23

Range of motion/stretching

35

5.2

14.4

.11

Strengthening

71

43.6

52.7

.16

Endurance activities

35

7.1

14.3

.17

Gait training

12

8.6

33.8

.18

Calculated for the total sample of 600 participants.

from injury to rehabilitation admission, employment status at the time of injury, score for illness severity, and work-relatedness of injury. The addition of site variables to the model increased the total amount of variance predicted by 9% to 17%, depending on the activity. Several variables that were significant predictors of time spent in 1 or more group activities in the initial regression model were no longer significant in the model that included sites: FIM motor score, clinician experience index, race (black, Hispanic, or white), and employment status (working or “other”). For the remaining variables, most type II R2 values remained within .01 of those in the initial model. The only predictor variable for which the parameter estimate changed by more than 50% after the addition of site variables was English-speaking status in the model for gait training, whose parameter estimate increased from 6.89 to 10.69. Relationship Between Group and Individual Minutes of Treatment per Week Correlation analyses for the overall sample indicated that group physical therapy time was not significantly correlated with individual physical therapy time (r⫽⫺.05, P⫽.26). Correlation analyses within injury groups revealed no significant cor1886

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relation between group physical therapy time and individual physical therapy time for the high-tetraplegia (r⫽.11, P⫽.21), low-tetraplegia (r⫽ ⫺.05, P⫽.53), and paraplegia (r⫽ ⫺.03, P⫽.69) groups. A small but statistically significant negative correlation was observed between group physical therapy time and individual physical therapy time for the AIS D group (r⫽⫺.22, P⫽.04), suggesting that participants who received more minutes of group physical therapy per week received fewer minutes of individual physical therapy per week and vice versa. For most activities, less than or equal to 20% of mean physical therapy minutes per week was spent in group therapy, with the exception of strengthening (51%), endurance activities (49%), manual wheelchair mobility training (47%), power wheelchair mobility training (33%), and gait training (29%).

disability experienced after SCI. Analyses of interventions provided to the first 600 participants enrolled in the study indicated that physical therapy was provided primarily as individual therapy but that group therapy contributed significantly to total therapy time. Most of the participants received at least 1 group therapy session, and nearly onefourth of all documented therapy time was provided in group sessions. The proportion of total hours of physical therapy provided in group sessions was less than 30% for 75% of cases. Van Langeveld et al5 did not report the proportion of therapy time provided in group sessions for physical therapy alone; therefore, direct comparison of the study findings is difficult. The percentage of time spent in group physical therapy sessions in the present study (23%) fell within the range reported by van Langeveld et al5 for physical therapy, occupational therapy, and sports therapy combined (6%–39%).

Discussion

One of the concerns expressed by the CMS in the fiscal year 2010 inpatient rehabilitation facility prospective payment system final rule was that some inpatient rehabilitation facilities were providing “essentially all” of their therapy in the form of group sessions.4 Although the findings of the SCIRehab Study cannot be generalized to all facilities that provide rehabilitation, they suggest that the majority of therapy is being provided in one-on-one sessions, in accordance with CMS recommendations.

Extent and Nature of Use of Group Therapy The SCIRehab Study provides a unique opportunity to examine current practices in the delivery of inpatient rehabilitation services to patients with acute traumatic SCI and to correlate these practices with outcomes related to impairments, activity limitations, and participation restrictions that affect the level of

Correlation analyses indicated that for most participants with SCI (those with injuries not classified as AIS D), there was not a significant negative correlation between individual therapy time and group therapy time; this finding suggested that, in general, there was not a “trade-off” between individual therapy and group therapy in which more group

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.03

Work-related injury

Illness severity score

Retired, unemployed, and otherb

Working

Employment status at time of injury

Days from injury to rehabilitation admission

White

Hispanic

Black

Race

Clinician experience index

Language (English)

Payer (Medicaid)

Age at time of injury

⫺0.17

⫺6.71

1.36

.01

.01

.03

2.71

4.86

0.44

⫺3.68

.01

.01

.02

.01

⫺28.58

⫺0.23

15.88

1.52

⫺25.42

.01

.01

.02

.02

.01

.04

3.56

0.08

⫺6.51

⫺0.07

4.67

0.66

.01

.03

.01

.02

.01

.04

⬍.01

1.56

.03

.02

0.10

Admission FIM motor score

Admission FIM cognitive score

20.76

⫺11.29

.02

.01

.04

6.77

0.27

6.11

4.46

.05

.13

Parameter Estimate

Type II Semi–partial R2

Endurance Activities

AIS D

⫺0.33

27.58

Parameter Estimate


Strengthening

C5–8 ABC

C1–4 ABC

Paraplegia ABC

Parameter Estimate


Range of Motion/Stretching

⫺0.11

⫺7.85

⫺1.30

6.89

28.34

Parameter Estimate

.01

.02

.03

.01

.11


Gait Training

Independent variables allowed into models were as follows: age at time of injury, male, married, race (white, black, Hispanic, and other), admission Functional Independence Measure (FIM) motor score, admission FIM cognitive score, illness severity score (Comprehensive Severity Index), injury group (C1– 4 ABC, C5– 8 ABC, paraplegia ABC, and AIS D—where C1– 4⫽cervical injury levels 1 to 4 [high tetraplegia]; ABC⫽American Spinal Injury Association Impairment Scale [AIS] grades A, B, and C; C5– 8⫽cervical injury levels 5 to 8 [low tetraplegia]; and AIS D⫽AIS grade D), clinician experience index, traumatic etiology (vehicular, violence, fall, sports, medical/surgical complication, and other), work-related injury, days from trauma to rehabilitation admission, body mass index (⬎40, 30 – 40, and ⬍30 kg/m2), language (English, no English, and English sufficient for understanding), payer (Medicare, workers’ compensation, private, and Medicaid), employment status at the time of injury (employed, student, retired, unemployed, and other), and ventilator use at rehabilitation admission. b Other⫽homemaker, on-the-job-training, sheltered workshop, and unknown.

a

Characteristic

Injury group

Parameter Estimate


Manual Wheelchair Mobility

Participant and Injury Characteristics Associated With Time Spent in Specific Group Physical Therapy Activitiesa

Table 5.


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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI physical therapy time being provided would result in less individual physical therapy time being provided. For participants with non–AIS D injuries, group therapy might have been taking place above and beyond the individual therapy being provided and might have acted as a tool to increase the total amount of therapy time being provided. For participants with AIS D injuries, a negative correlation was observed; this finding suggested that some trade-off might have been occurring between individual therapy and group therapy, although the extent of the trade-off was uncertain given the weak correlation. One possible clinical explanation for the negative correlation is that people with less severe motor impairments might require less one-on-one assistance for the performance of activities and might use group physical therapy sessions as an opportunity to practice skills learned in individual physical therapy sessions. Further study is needed to determine the effects of group physical therapy sessions on the content of individual physical therapy sessions and the extent to which inpatient physical therapy programs that include group physical therapy address advanced skills, such as mobility, that affect SCIrelated disability. Additional work is needed to determine which patterns of group physical therapy use are most appropriate for achieving desired outcomes related to impairments, activity limitations, and participation restrictions that influence the level of disability experienced after SCI. The nature of activities taking place in group physical therapy sessions was consistent with perceptions of what is clinically appropriate, in terms of both time spent in group therapy versus individual therapy and time spent in specific group activities within injury groups. The group physical therapy interven1888

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tions observed in this investigation included treatments that address impairments and activity limitations that contribute to disability after SCI. Strengthening, range of motion/ stretching, endurance activities, and wheelchair mobility training translated well to group settings because these activities required minimal supervision once the appropriate type of activity was selected by the therapist and the participant demonstrated the ability to perform the activity appropriately without oneon-one supervision. Variations in time spent in specific activities among injury groups fit with typical therapeutic goals and functional expectations for these groups, particularly with respect to mobility. Participants with tetraplegia spent a considerable portion of group time in power wheelchair mobility training, whereas participants with paraplegia engaged in manual wheelchair mobility training. Participants in the AIS D group, for whom return to walking was a major functional goal, spent much of their group time in gait training. The patterns of group activities taking place within injury groups suggested that participants’ needs associated with the nature and severity of injury were major drivers of treatment selection in group physical therapy sessions. Factors Affecting Use of Group Therapy Despite the fact that detailed data on characteristics of injuries, participants, and clinicians were available for analyses, only 20% of the variance in the total treatment time spent in group therapy was explained by these variables, and no more than 3% of the variance was explained by any 1 variable (Tab. 2). The variance predicted by single variables for specific types of group activities was somewhat higher (maximum⫽13%), but the total variance explained for any 1 activity remained low (ⱕ23%) (Tabs. 4 and 5).

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Although a considerable portion of the variance in total group therapy time remained unexplained, several factors did emerge as predictors of more time (minutes per week) spent in group therapy. Participants with higher FIM cognitive scores received more treatment in group sessions, possibly because of their ability to cognitively process instructions provided during individual sessions and apply it to generalized scenarios in group settings. People with a dual diagnosis of brain injury and SCI or with other diagnoses affecting cognition may perform better with oneon-one instruction. An association of more years of experience of clinicians with more group therapy time was found. Clinicians at facilities participating in the present study reported that per-diem and managerial staff members, who tend to have more years of experience at their facilities, frequently serve as group leaders; this factor may have contributed to the emergence of this association. They also noted, however, that the person leading the group was not necessarily the clinician who recommended group therapy for the patient. Hispanic race also was associated with more group therapy time, but the clinical significance of this predictor is unclear, particularly given that primary language did not emerge as a significant predictor of group therapy time. Several factors were associated with fewer minutes spent in group physical therapy activities per week. Participants with cervical injuries received fewer minutes of group physical therapy per week. Depending on the specific level of injury and motor function spared, people with tetraplegia may require 1:1 or 2:1 assistance for each movement and therefore may be served most appropriately in individual treatment sessions. A BMI of greater than 40 kg/m2 also was associated with fewer group physical therapy minDecember 2011

Group Physical Therapy During Inpatient Rehabilitation for Acute SCI utes per week. No significant differences among BMI categories with respect to mean minutes of missed therapy per week were found (data not shown). This finding suggested that people with a high BMI may receive less group physical therapy because they are scheduled for less group physical therapy. Other factors, such as the need for 2:1 assistance or the availability of overhead lift systems, may contribute to the use of less group therapy for participants with obesity. More time from injury to rehabilitation admission also was associated with less group session time. It is possible that participants in the latter situation have greater medical instability, making them better candidates for individual therapy; however, this explanation is not supported by data related to injury severity (CSI) because the CSI score was not found to be a significant predictor of total group therapy time (Tab. 2). Employment status was another significant predictor, although the clinical significance of this finding is unclear. Several factors, including an individual’s drive or motivation, problemsolving abilities, body awareness, comorbidities, and body composition, are factored into treatment plans, and all of these factors may affect choices about the use of group therapy. As in other practice-based evidence studies, the participating sites were expected to differ in factors that might affect therapy time received. The analyses were designed to examine the relationships between specific characteristics and therapy time directly whenever possible, without respect to site, because it was the characteristics themselves (such as experience of clinicians, illness severity, and race) that were of interest. Although great care was taken to measure and include all factors of interest in the analyses, it is likely that some, as-yet-unspecified December 2011

factors also affected therapy time received. To assess the extent to which additional predictive power might be added by unspecified factors that varied by site, regression analyses were repeated with variables symbolizing the sites allowed to enter the model. An increase in the R2 for the model after the addition of the site variables indicated the extent to which additional factors not accounted for in the initial analyses might explain the variance in therapy time received. Explained variance increased by 16% for overall group therapy time and increased by 9% to 17% for specific group therapy activities, indicating that additional variance (beyond that associated with significant predictors identified in the initial model) might be explained by unspecified factors that appeared to be related to sites. It is difficult to determine whether the explanatory power added by these factors reflects differences in practice patterns among sites or differences in underlying characteristics of participants or therapists among sites that were not accounted for by the data that were collected and analyzed. Several variables, such as admission FIM motor score, experience of clinicians, race, and employment status, did not retain significance in one or more of the regression models after the addition of the site variables. The loss of significance of certain variables indicated that these factors were significant predictors of therapy time but also differed among sites or were correlated with site variables, such that the variance they explained became embedded in the site variables when they were added to the models. In general, semipartial R2 and parameter estimate values for factors that remained significant in both models did not change dramatically after the addition of the site variables, suggesting

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that their effects were independent of site affiliation. Even with the addition of the site variables, the total amount of variance explained for overall group physical therapy time and time spent in specific group activities remained less than 50%. Other factors, such as whether a sufficient number of patients with similar needs is present at a given time to form a therapy group, may contribute to decisions about group therapy use. The availability of staff support and equipment also may determine whether skills are best addressed individually or in a group setting. Further study is needed to fully understand the factors that contribute to the development of individual patient care plans for group therapy use. Limitations The data collected in the present study may not represent the use of group therapy across the United States because of the relatively small number of centers involved. The inclusion of a larger number of centers would more fully reflect the degree to which group therapy is used in rehabilitation for people with SCI. All data on interventions provided were collected along with the clinical documentation required by each facility. Measures to cross-check entries with clinical documentation were put in place at each facility, and efforts were made to capture and enter missing data for sessions so that the data would be as complete as possible. Despite these efforts, it was expected that some sessions would not be represented in the study database. However, the data were reviewed periodically by clinical staff representatives at each facility, and patterns of interventions observed were reported to be consistent with their understanding of typical practice patterns at Number 12

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI their facility. Variability among clinicians in how they classified activities also might have affected the data collected, but steps were taken throughout the project to maximize consistency among clinicians. These steps included completing documentation on written case scenarios and providing feedback and education on any issues observed to maximize the consistency of documentation.9 Although great care was taken to develop a documentation system that was as comprehensive as possible, some data relevant to group therapy use were not captured. The amount of detail for group interventions was more limited than that for individual interventions because clinicians were given the option to document group therapy by using an abbreviated documentation form that was less descriptive than that used for individual therapy.25 This option was instituted to manage documentation burden and make it more feasible for clinicians to document interventions when multiple participants were included in a group session. The number of participants in the therapy groups was not recorded, nor was information recorded for other people who were participating in the group physical therapy sessions and who may have had conditions other than SCI. Information about staffing patterns (which may include ratios of staff members to patients, use of physical therapists versus physical therapist assistants, and staff coverage policies) was also limited. Several dynamic conditions, such as patient census, staff vacancies, and staff absences because of illness or other issues, affected staffing on any given day. Although data about the clinicians providing treatment to the study participants were collected in an effort to describe staff, the data collected were not sufficient to provide a complete assess1890

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ment of staffing patterns. Further study of factors such as group composition and staffing patterns is needed to evaluate their effects on group therapy use and treatment outcomes. The practice-based evidence approach was used to collect detailed information about several factors of interest and allowed multiple independent variables to enter predictive models to examine relationships between these factors and therapy time. Although this strategy was helpful in identifying factors that may have affected the use of group physical therapy, type I errors were possible and should be considered in the interpretation of findings. Consideration of the clinical significance of the factors identified and the results of further analyses will enhance the understanding of factors that affect the use of group physical therapy.

Conclusions The aim of this report was to enhance the understanding of the extent and nature of the use of group therapy in inpatient rehabilitation for acute traumatic SCI. Most of the inpatient physical therapy at the participating centers was provided in individual physical therapy sessions, but most participants received group physical therapy, and group therapy contributed significantly to total therapy time. Minutes of group physical therapy received per week varied considerably among the participants. Participants in the AIS D or paraplegia group tended to receive more group physical therapy, in terms of both mean minutes per week and the proportion of total physical therapy hours spent in group physical therapy. The nature of activities taking place within injury groups fit with the functional expectations for these groups. In general, the observed patterns of use of group physical therapy suggested that the majority of physical

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therapy was provided in individual sessions and that participants’ needs associated with the nature and severity of injury were major drivers of treatment selection in group physical therapy sessions. Further research is needed to understand the relationship between the use of group physical therapy and outcomes so that guidelines for the use of group physical therapy may be formulated. Future analyses will examine function-, activity-, and participation-related outcomes that affect disability to determine which rehabilitation practices are most highly associated with the prevention of disability after acute traumatic SCI. Dr Zanca, Ms Natale, and Ms Gassaway provided concept/idea/research design. All authors provided writing. Dr Zanca, Ms Natale, Ms LaBarbera, Ms Gassaway, and Dr Backus provided data collection. Dr Zanca and Ms Gassaway provided data analysis. Dr Zanca, Ms Natale, Ms Gassaway, and Dr Backus provided project management. Dr Backus provided fund procurement. Dr Zanca provided participants, facilities/equipment, and institutional liaisons. Dr Zanca, Ms LaBarbera, Ms Schroeder, and Dr Backus provided consultation (including review of manuscript before submission). Special thanks are given to Mr Randall Smout for assistance in data analysis and to Dr Gale Whiteneck, Ms Jessica Nicolosi, Ms Elise Coulson, Ms Kristen Casperson, and Dr Marcel Dijkers for helpful feedback during manuscript preparation. Institutional review board approval for this observational study was obtained at each facility participating in the SCIRehab Study. The results of this study were presented at the Combined Sections Meeting of the American Physical Therapy Association; February 9 –12, 2011; New Orleans, Louisiana. A poster presentation of the findings was given at the Annual Conference of the American Spinal Injury Association; June 4 – 8, 2011; Washington, DC. This work was funded by the National Institute on Disability and Rehabilitation Research, Office of Special Education and

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Group Physical Therapy During Inpatient Rehabilitation for Acute SCI Rehabilitative Services, US Department of Education (grant H133A060103). DOI: 10.2522/ptj.20100392

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9 Gassaway J, Whiteneck G, Dijkers M. Clinical taxonomy development and application in spinal cord injury research: the SCIRehab Project. J Spinal Cord Med. 2009; 32:260 –269. 10 Whiteneck G, Gassaway J, Dijkers M, Jha A. New approach to study the contents and outcomes of spinal cord injury rehabilitation: the SCIRehab Project. J Spinal Cord Med. 2009;32:251–259. 11 Horn SD, DeJong G, Ryser DK, et al. Another look at observational studies in rehabilitation research: going beyond the holy grail of the randomized controlled trial. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S8 –S15. 12 DeJong G, Hsieh CH, Gassaway J, et al. Characterizing rehabilitation services for patients with knee and hip replacement in skilled nursing facilities and inpatient rehabilitation facilities. Arch Phys Med Rehabil. 2009;90:1269 –1283. 13 Conroy B, Zorowitz R, Horn SD, et al. An exploration of central nervous system medication use and outcomes in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S73–S81. 14 James R, Gines D, Menlove A, et al. Nutrition support (tube feeding) as a rehabilitation intervention. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S82–S92. 15 Hatfield B, Millet D, Coles J, et al. Characterizing speech and language pathology outcomes in stroke rehabilitation. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S61–S72. 16 Horn SD, DeJong G, Smout RJ, et al. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Arch Phys Med Rehabil. 2005; 86(12 suppl 2):S101–S114. 17 Marino R. Reference Manual for the International Standards for Neurological Classification of Spinal Cord Injury. Chicago, IL: American Spinal Injury Association; 2003.

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18 Horn SD, Sharkey S, Rimmasch H. Clinical practice improvement: a methodology to improve quality and decrease cost in health care. Onc Issues. 1997;12:16 –20. 19 Horn SD, Sharkey PD, Buckle JM, et al. The relationship between severity of illness and hospital length of stay and mortality. Med Care. 1991;29:305–317. 20 Ryser DK, Egger MJ, Horn SD, et al. Measuring medical complexity during inpatient rehabilitation after traumatic brain injury. Arch Phys Med Rehabil. 2005;86: 1108 –1117. 21 Averill RF, McGuire TE, Manning BE, et al. A study of the relationship between severity of illness and hospital cost in New Jersey hospitals. Health Serv Res. 1992;27: 587– 606. 22 Clemmer TP, Spuhler VJ, Oniki TA, Horn SD. Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit. Crit Care Med. 1999;27:1768 –1774. 23 Fiedler RC, Granger CV. A measurement of disability and medical rehabilitation. In: Chino N, Melvin J, eds. Functional Evaluation of Stroke Patients. Tokyo, Japan: Springer-Verlag; 1996:75–92. 24 Fiedler RC, Granger CV, Russell CF. UDS(MR)SM: follow-up data on patients discharged in 1994 –1996 —Uniform Data System for Medical Rehabilitation. Am J Phys Med Rehabil. 2000;79:184 –192. 25 Natale A, Taylor S, LaBarbera J, et al. SCIRehab Project series: the physical therapy taxonomy. J Spinal Cord Med. 2009;32: 270 –282. 26 Partial and semipartial correlations. Available at: http://www.uoregon.edu/ ⬃stevensj/MRA/partial.pdf. Published 2003. Accessed July 25, 2011. 27 Stevens J. Intermediate Statistics: A Modern Approach. 2nd ed. Mahwah, NJ: Lawrence Erlbaum Associates Inc; 1999.

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