Impaired ability to perform self-care activities, such as eating, grooming, dressing, and toileting, is one of the immediate impacts an individual likely experiences following his/her spinal cord injury (SCI). These activities, also known as activities of daily living (ADL), are among the major areas that occupational therapy (OT) addresses during rehabilitation.
Methods of optimizing functional abilities after SCI vary with the level and completeness of injury, as well as medical complications resulting from the injury. People with higher levels of injury (e.g. cervical level (C) 4 and above) will have severe functional limitations due to the absence of upper-extremity (UE) control. People with C5 and C6 levels of injury will have some muscle and somatosensory function at the elbow (flexion) and wrist (extension), which may increase their ability to perform some ADL, such as upper body dressing, grooming, and self-feeding, as well as limited mobility skills. Injury at C7 affords a person elbow extension and increased independence with ADL and mobility. Individuals with injuries below C7 generally retain hand function, which aids in the performance of ADL, but continue to have deficits in trunk control and balance. Those with higher thoracic (T1–T6) injuries also have balance dysfunction that may affect their ability to perform certain ADL (such as lower body dressing, bowel, and bladder management) and transfers; those with injuries below T6 generally will be independent with both upper and lower body-related ADL. These functional expectations also vary depending on whether the injury is complete or incomplete.1
Occupational therapists (OTs) select interventions based on level of injury and functional expectations with the goal of optimizing functional independence. Interventions focusing on ADL are critical for individuals to live independently and to decrease the burden of care for others. For patients who have decreased functional use of their UE, more OT time may be devoted to addressing basic ADL; for patients with lower levels of injury (e.g. T1 and below) OT interventions generally focus on more advanced skills such as home management and toileting.2
Improvement in function and increased independence in ADL are not the only goals of OT; goals also include improving community integration, promoting fuller participation in society, and satisfaction with life. OT also attempts to improve health status by educating patients with SCI about their risk for potential medical complications and teaching the skills necessary to avoid secondary conditions such as pressure ulcers and shoulder joint deterioration. Therefore, there is a wide range of outcomes that OT could reasonably be expected to influence.
Patient factors and individual goals warrant consideration when examining associations of OT treatment with outcomes as they can influence the choice of OT intervention.3
In two studies of patients with motor and sensory impairments due to stroke or SCI, investigators stressed the importance of considering multiple client (patient) factors during the OT treatment process.4,5
They suggested that OT services, and the environment in which they are provided, may impact on outcomes in SCI rehabilitation.
Relating OT treatments to outcomes is further complicated by the difficulty of distinguishing between improvements in function resulting from OT interventions and improvements in function due to natural recovery of neurological function. Since the majority of people with SCI experience some degree of neurological recovery during the rehabilitation process, an examination of cases with minimal neurological recovery can better identify functional improvement due to rehabilitation interventions provided by OT and by physical therapy.6
The SCIRehab study provides the opportunity to examine the relationship between OT interventions and a broad range of outcomes across the full range of people with SCI, and then to focus the relationship between OT interventions and functional outcomes within specific subgroups of people with particular needs. The multi-center SCIRehab investigation classified treatments provided during rehabilitation so that data reflecting the routine practice of care could be used in analyses to examine the choices of intervention type and dosage for patients with specific types of injuries.7,8
Clinicians from six sites worked together to develop a taxonomy for classifying and defining OT interventions typically delivered during inpatient rehabilitation.9
Descriptive analysis of 600 patients enrolled during the first year demonstrated that the choice of therapeutic interventions varied with level and extent of injury. For example, OTs spent more time with patients at C5–C8 levels of injury than any other patient group.10
Whether the specific choice of intervention leads to the highest functional outcomes after SCI when compared with others is not yet clear.
This article has two objectives. First, we examine associations of OT interventions and patient demographic and injury characteristics with outcomes at discharge from inpatient rehabilitation and at 1-year post-SCI for all patients enrolled in the SCIRehab study. Second, we examine the relationship between OT interventions and select functional outcomes within two homogeneous subgroups: motor complete low tetraplegia (C5–C8), and motor complete paraplegia (T1–T9).