The Journal of Spinal Cord Medicine

ISSN: 1079-0268 (Print) 2045-7723 (Online) Journal homepage: http://www.tandfonline.com/loi/yscm20

Predictors of functional outcomes in adults with

traumatic spinal cord injury following inpatient
rehabilitation: A systematic review

Faisal AlHuthaifi, Joseph Krzak, Timothy Hanke & Lawrence C. Vogel

To cite this article: Faisal AlHuthaifi, Joseph Krzak, Timothy Hanke & Lawrence C. Vogel
(2016): Predictors of functional outcomes in adults with traumatic spinal cord injury following
inpatient rehabilitation: A systematic review, The Journal of Spinal Cord Medicine, DOI:
10.1080/10790268.2016.1238184

To link to this article: http://dx.doi.org/10.1080/10790268.2016.1238184

Published online: 17 Nov 2016.

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Review
Predictors of functional outcomes in adults
with traumatic spinal cord injury following
inpatient rehabilitation: A systematic review
Faisal AlHuthaifi 1, Joseph Krzak 2,3, Timothy Hanke 2, Lawrence C. Vogel 3
1
Midwestern University, College of Health Sciences, Doctor of Health Sciences Program, Downers Grove, IL, USA,
2
Midwestern University, College of Health Sciences, Physical Therapy Program, Downers Grove, IL, USA, 3Shriners
Hospitals for Children®- Chicago, Chicago, IL, USA

Context: Despite functional improvements during rehabilitation, variable functional outcomes were reported
when patients with Spinal Cord Injury (SCI) return to society. Higher functioning individuals at discharge can
experience a decrease in independent mobility (i.e. Motor Functional Independence Measure (mFIM) Score)
by one-year follow-up. However, functional gains after discharge have also been reported and associated
with recovery.
Objective: To identify, categorize and rank predictors of mFIM score for patients with SCI following inpatient
rehabilitation, both at the time of discharge and at one-year follow-up.
Methods: Data sources included CINAHL, PubMed, ERIC, Google Scholar, and Medline for literature published
from February 2000 to February 2015. Quality and risk of bias of included studies was assessed using the Risk of
Bias Assessment Instrument for Prognostic Factor Studies (QUIPS). Significant predictors of mFIM score were
categorized using the domains of the International Classification of Function and Disability model ICF and
ranked based on how frequently they were significant predictors of mFIM score.
Results: Twenty-seven predictors of mFIM score spanning the ICF domains were identified among seven
studies. At discharge, variables in the Body Structure and Function domain were the most consistent
predictors of mFIM score. At one-year follow-up, variables in the Activity and Participation domain were the
most consistent predictors of mFIM score. Contextual factors were the least frequent predictors at both
discharge and one-year follow-up.
Conclusion: This systematic-review assists clinicians setting realistic goals that maximize functional
independence at the time of discharge and after reintegrating to society.
Keywords: FIM, mFIM, Spinal cord injury, Predictors, Rehabilitation, Motor outcomes, ICF, Follow-up

Introduction mostly directed at therapeutic activities to improve func-

Rehabilitation is an essential component of the overall tional mobility and independence.1,3 Examples of activi-
care of individuals following spinal cord injury (SCI).1 ties commonly trained during inpatient rehabilitation
Rehabilitation can be defined as “an active and include wheelchair skills, transfers, bed mobility, and
dynamic process by which a disabled person is helped self-care.4
to acquire knowledge and skills to maximize physical, The ultimate goal of the interdisciplinary team is to
psychological and social function.”2 It is a process that facilitate functional independence.2,5 Achievement of
maximizes functional ability and minimizes disability this goal is often measured using quantitative outcome
and handicap. Effective rehabilitation is best conducted measures,1 such as the Functional Independence
by actively involving well-integrated teams of specialists Measure (FIM), a widely-used outcome measure of dis-
working in an interdisciplinary fashion in all stages of ability and the level of assistance required for an individ-
the process.2 In the rehabilitation setting, efforts are ual with SCI to perform activities of daily living.6 It can
be used to determine the magnitude of functional sever-
Correspondence to: Faisal K. Alhuthaifi, 400 E South Water St. #2008
Chicago, IL 60601 USA. Email: [email protected] ity, the effectiveness of an intervention or the effect of

© The Academy of Spinal Cord Injury Professionals, Inc. 2016

DOI 10.1080/10790268.2016.1238184 The Journal of Spinal Cord Medicine 2016 1
Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

time on functional outcomes for individuals in a rehabi- and health, and its interaction with contextual factors
litation setting. The FIM has been widely used for the (environmental and personal).25–27 Functional mobility
assessment of patients with SCI.5,7,8 It contains 18 func- influences an individual’s ability to participate in activi-
tional tasks: thirteen motor (mFIM) and five cognitive. ties within the community.28 Thus, functional outcome
Each task is rated on a seven-point ordinal scale ranging is an ideal area to study for individuals with SCI as it
from total independence (7/7) to complete dependence represents a measurement of disability across the conti-
(1/7).6 The FIM is commonly administered in a rehabi- nuum of care including both discharge from inpatient
litation setting upon admission and at discharge. It is rehabilitation and at follow-up. To date, there are no
becoming more common in clinical and research systematic reviews that identify, categorize, and rank
arenas to additionally administer the FIM during sub- predictors of functional mobility in SCI population fol-
sequent follow-up visits after discharge. lowing rehabilitation.
Despite functional improvements in the rehabilitation The objective of the current systematic review was to
setting, variable motor outcomes have been reported identify, categorize and rank predictors of functional
when patients return to society after discharge.9 outcomes for patients with SCI following inpatient reha-
Outcome studies of individuals with SCI at one-year bilitation, both at the time of discharge from inpatient
follow-up demonstrated that higher functioning individ- rehabilitation and at one-year follow-up. We anticipate
uals at discharge could experience a significant decrease that variables ( predictors) in the body structure and
in independent mobility.9–11 For people with chronic function and the level of activity and participation are
SCI, increases in secondary conditions such as pressure important domains influencing functional outcomes in
ulcers and urinary tract infection were associated with a rehabilitation settings. However, we anticipate that
decline in function over time.12 In contrast, functional additional variables such as contextual factors following
gains after discharge have been associated with recovery rehabilitation may alter functional outcomes (recovery).
from injury, even one year after injury.5,12 As a result of The results of this study will help clinicians to set realis-
such variability in post-discharge of motor outcome tic goals to maximize functional independence not only
levels, researchers are beginning to describe rehabilita- at the time of discharge but also after individuals inte-
tion as a “continuum” that includes both inpatient grate back into society and though-out their lifespan.
and post-discharge services within the first year post-
injury.13 The authors emphasized not only the impor- Methods
tance of considering the effects of both inpatient and The manuscripts used in the current systematic review
post discharge services when examining long-term out- was identified using the Preferred Reporting Items for
comes but also identifying additional patient specific Systematic Reviews and Meta-Analyses (PRISMA)
factors which can impact functional mobility across guidelines.29
the continuum of care.13
Functional outcomes after discharge can be influ- Eligibility criteria
enced by sociodemographic factors1,14–18 and injury The review includes retrospective, prospective and longi-
related characteristics3,19–23 including age, sex, race, tudinal cohort studies that were written in English.
cause of SCI, level and severity of neurologic impair- Additional criteria include studies that used: 1) individ-
ment, and the presence of traumatic brain injury.24 As uals with traumatic SCI, 2) International Standards for
a result of this complexity, it is important to identify Neurological Classification of SCI as the primary
specific predictors of functional outcomes. By identify- method of neurological assessment,30 3) the motor
ing these predictors, clinicians will be able to maximize FIM score as a primary outcome at discharge and/or
functional independence not only at the time of dis- one year follow-up assessment, 4) statistical modeling
charge but also after individuals integrate back into techniques to identify predictors of functional outcomes
society and though-out their lifespan. One tool that (e.g. regression) and 5) studies that took place in
can be used to facilitate not only identification of predic- inpatient rehabilitation settings 6) Studies included
tors but also categorize them is to apply the domains of factors independently associated with mFIM.
the International Classification of disability and Exclusion criteria consist of studies that focused on par-
Functioning (ICF) model. ticular body function other than functional outcomes
The ICF model is a classification of health and (e.g. respiratory management, pain, or depression),
health-related conditions that was developed by World and studies that did not use statistical techniques,
Health Organization (WHO) and published in which explicitly identify predictors of functional out-
2001.25,26 The model describes functioning, disability comes (e.g. group comparisons).

2 The Journal of Spinal Cord Medicine 2016

 Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

Information resources representing the strength of the full regression model

A systematic search was performed using CINAHL, was obtained at both discharge and follow-up.
PubMed, ERIC, Google Scholar, and Medline for Identified predictors were then categorized based on the
literature published from February 1, 2000 to February domains of the ICF (Body Structure/ Function, Activity
1, 2015. and participation, contextual factors). Each predictor was
assign to an ICF domain independently by two reviewers
Search Strategy (FA and JK). ICF domains were assigned based on the
To build the initial article selection, a combination of units of measurement used in the original studies. For
search terms related to “FIM”, “mFIM”, “Predictors”, example, hours spent on PT mobility training, was
“Mobility”, “SCI”, “Follow-up”, “Motor FIM”, assigned to the activity and participation domain. In the
“Functional”, and “Spinal cord” were utilized. event of disagreement between two reviewers, a third
Furthermore, relevant papers from a previous scoping reviewer was assigned so that consensus could be reached.
search were sought to retrieve additional keywords. After the predictors had been identified and categor-
Every search term has been reviewed to ensure relevance ized, individual variables within each ICF domain were
within the scope of the research question. The authors per- ranked. The ranking was performed based on how fre-
formed an expanded search to identify articles potentially quently the variable was identified as a significant pre-
missed through the electronic searches, including grey lit- dictor of mFIM score across the included studies both
erature and unpublished studies. at discharge and at one year follow-up.
All references obtained using the search strategy
were imported into Endnote X7 (Thomson Reuters,
Philadelphia, PA, USA). The relevant studies were Results
screened for eligibility. Two authors (FA and JK) Data sources and search outcomes
screened the title and the abstract. Full text of all articles The PRISMA flow chart of the total search and study
considered relevant after the initial title and abstract selection is shown in Figure 1. Two reviewers retrieved
screening were retrieved and assessed for eligibility. Any
remaining non-eligible articles were excluded. Reasons
for exclusion were documented.

Quality assessment of the selected articles

Following full review of the remaining manuscripts, the
methods of all included studies were evaluated for risk of
bias. Quality and risk of bias assessment of the studies
was performed using the approach outlined by the
Risk of Bias Assessment Instrument for Prognostic
Factor Studies (QUIPS).31

Data Collection and Analysis

The following data was extracted from the included
papers using evidence summary templates: author(s),
year of publication, title, journal, study location, year
of data collection, sample size in the hospital setting,
sample size at follow-up, length of follow-up, character-
istics of the study population (age, sex, level of injury at
admission, and neurological classification), definition of
outcomes and predictors, and results (associations
between predictor variables and functional outcomes,
and characteristics of predictor variables, if available).
Identified predictors of mFIM at discharge and
follow-up were selected from the eligible studies based
on whether or not the outcome variables were signifi-
cant using regression analysis in the original studies. Figure 1. Preferred reporting items for systematic review and
Additionally, the coefficient of variation (R2) meta-analysis. (PRISMA) Search strategy diagram

The Journal of Spinal Cord Medicine 2016 3

Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

a total of 107 articles from six key databases (CINAHL, included: participation, attrition, prognostic factor
PubMed, ERIC, Google Scholar, Medline and the measurement, confounding measurement, outcome
Cochrane Library). After applying the inclusion criteria measurement, and statistical analysis and reporting
in the first stage of the review process, seventy-six studies (Table 2).31 All samples in the included studies represented
did not meet the inclusion criteria on the basis of the the population of interest on key characteristics, limiting
study title and abstract. Of the thirty-one remaining potential bias of the observed relationship between predic-
studies, twenty-four were further excluded after the full tors and mFIM scores. The follow-up rate across seven
text was comprehensively examined. Reasons for exclu- studies ranged from 85.3% to 100%.32–37 The percentage
sion are presented in Table 1. of patients who returned for follow-up was unclear for
Of the remaining seven studies, five included both dis- one of the studies.1
charge and one year follow-up mFIM scores, while two There was a moderate to high level of bias due to the
studies included only mFIM at one year follow-up. Thus, presence of confounding variables. The included studies
the literature search generated a total of seven articles for did not consistently state how the confounding variables
inclusion in the current systematic review.1,32–37 were accounted for in the data analysis section. Only
The level of evidence for one retrospective cohort and three out of the selected studies identified severity, age
one prospective study was Level IV. The five remaining and level of injury as confounding variables.33,35,37
studies qualified as Level III evidence since they were Also, one study showed residual confounding effects
prospective studies with high follow-up percentages by using large age groups that were not adequately
(≥ 85%) and integrated regression techniques in the adjusted for in the analysis.37
analysis to adjust for confounding variables (Table 2).38 The statistical analyses included in the selected studies
were appropriate in limiting invalid or false results.
Quality Assessment Furthermore, the outcomes of interest in the reported
The six categories of the QUIPS were used to evaluate the studies were adequately measured to limit any potential
included studies for potential bias. The six categories bias.

Table 1 Reasons for exclusion of the selected articles

Study Reason for exlusion

Akmal et al., 2003 ASIA classification was not used as the primary method of neurological assessment.
Chan et al., 2013 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Cohen et al., 2012 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Eastwood et al., 1999 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Fisher et al., 2005 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Fyffe et al., 2014 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Horn et al., 2013 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Kennedy et al., 2011 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment (Independent
variables included psychological factors.)
Kirshblum et al., 2011 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Kozlowski et al., 2013 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Lee et al., 2014 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Lugo et al., 2007 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
McKinley et al., 2004 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Muslomanoglu et al., Study did not use statistical techniques to explicitly identify predictors of motor outcomes did not use
1997 statistical techniques to explicitly identify predictors of motor outcomes changes o any independent
variables *
Pershouse et al., 2012 Study did not use statistical techniques to explicitly identify predictors of motor outcomes did not use
statistical techniques to explicitly identify predictors of motor outcomes changes to any independent
variables *
Putzke et al., 2003 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Riggins et al., 2011 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Rodakowski et al., 2014 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Sipski et al., 2004 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Spooren et al., 2011 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Weitzenkamp et al., Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
2002
Wilson et al., 2012 Study did not use statistical techniques to explicitly identify predictors of motor outcomes
Yasar et al., 2015 Motor FIM score is not the primary outcome at discharge and/or one follow-up assessment
Yilmaz et al., 2005 Study did not use statistical techniques to explicitly identify predictors of motor outcomes changes to any
independent variables

4 The Journal of Spinal Cord Medicine 2016

 Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

Table 2 Risk of bias assessment for the selected studies (QUIPS)

Biases Level Summary

Participation Low All samples in the included studies represented the population of interest on key
characteristics.
Attrition Moderate to high No evidence on attempts to collect information from drop outs.
Prognostic factor Low to moderate Proportion of the study sample is not adequate for 2 studies.
measurement
Confounding measurement Moderate to High Potential confounders are not appropriately accounted for, resulting in potential bias.
Outcome measurement Low Adequately measured to sufficiently limit potential bias.
Statistical analysis and Low Appropriate in limiting potential presentation of invalid or false results.
reporting

On the contrary, moderate to high risk of bias due to and 70% at one year follow-up (Fig. 3). The neurologic
attrition was identified among the included studies. Five level of injury was consistently identified as a predictor
out of the seven selected studies did not provide infor- of mFIM across all studies. The most common mechan-
mation about attempts to collect information on partici- ism used to categorize neurologic level of injury was
pants who dropped out. In addition, the selected studies dividing individuals into 5 groups: (1) AIS ABC (2)
did not provide insight into the potential impact of sub- C1-4 AIS ABC, (3) C5-8 AIS ABC, (4) paraplegia
jects lost to follow-up on study results and conclusions. AIS ABC, and (5) all AIS D. The results show that
Loss to follow-up is a common characteristic associated AIS ABC, paraplegia AIS ABC, C5-C8 AIS ABC
with increased risk of bias in cohort studies.39 were consistent predictors of mFIM at both discharge
Acceptable guideline for follow-up rate has been reported and follow-up.1,32–34,36,37 Other variables including tet-
in the literature.39 Among the included studies the raplegia C1-C4 with AIS ABC, comprehensive severity
response rate on follow-up was acceptable (>85%); index (CSI), and AIS D showed variation in predicting
the rate minimizes the risk of bias due to attrition. The mFIM at discharge and at one year follow-up.
selected studies used clearly defined, valid and reliable Secondary complications such as pressure ulcer were
measurements overall, adequate to limit potential bias. found to be a predictor of mFIM only at discharge
but were not at follow-up.
Predictors of mFIM scores at discharge and at
one-year follow-up
The adjusted R2 values for the individual full regression Predictors related to activity and participation
models ranged from 0.59 to 0.73 at discharge and 0.25 domain
to 0.51 at one year follow-up. We identified 27 predic- Predictors categorized to the Activity and Participation
tors among the individual studies spanning the ICF domain primarily emphasized functional status upon
domains (Table 3A and Table 3B). Figure 2 shows the admission and time spent participating in rehabilitative
number of identified predictors categorized using the activities. None of the included studies used standar-
ICF domains. When examining the variables within dized participation-based outcomes as predictors of
the seven selected studies, six of the seven studies had motor FIM score. The predictive variables in the
ten or more predictors of mFIM score.1,32–36 One Activity and Participation domain were significant
study only identified three.37 Furthermore, of the six 82.3% of the time at discharge and 76.2% of the time
studies with ten or more predictors, all had variables at one year follow-up (Fig. 3). Patient’s mFIM score
that spanned the ICF domains of interest (e.g. Body upon admission and hours spent on PT mobility train-
Function and Structure, Activity and Participation, ing including gait mobility were consistently identified
and Contextual Domain). Across 27 predictors included as predictors of mFIM at both discharge and at one-
in the 7 studies, there were 8 predictors within the Body year follow-up. Hours spent on wheelchair mobility,
Structure/Function domain (30%), 9 within Activity upright activities, and strengthening activities were pre-
and Participation (33%) and 10 in the Contextual dictors of mFIM only at discharge. Inpatient recreation
domain (37%). therapy, social work, case management services were
not predictors of mFIM at discharge but were consistent
Predictors related to body structure and function predictors of mFIM at a one-year follow-up. In
domain addition, hours spent participating in OT sessions were
Predictive variables in the Body Structure/Function consistently a predictor of mFIM only at one-year
domain were significant 84% of the time at discharge follow-up.

The Journal of Spinal Cord Medicine 2016 5

6

Faisal AlHuthaifi et al.

The Journal of Spinal Cord Medicine

Table 3A. Prediction marker of motor outcomes at discharge

Predictors of functional outcomes in adults with traumatic spinal cord injury

Times Parameter % of times
Backus, Cahow, Horn, Teeter, Welson, used in prediction parameter was
Predictor ICF Domain 2013 2011 2013 Hsieh, 2013 Tian, 2013 2012 2014* models significant

Discharge R 2
----> No Data R2 =0. 65 No Data R2 =0.73–0.670 R2 = 0.585 R2 =0.65 NR
ASIA ABC Body No Data S No Data X X S S 3 100%
All para Structure/ No Data S No Data S X S X 3 100%
Function (for all age gr except
2016

≥60)
C5–C8, grades A–C No Data X No Data S X S X 2 100%
secondary complication No Data X No Data X S X X 1 100%
(only Para A-C)
C1-C4 gradesA-C No Data X No Data S X S X 2 50%
ASIA D No Data NS No Data S X S NS 3 33. 30%
(all age except
age ≥ 60)
Comprehinsive severity No Data S No Data S S NS X 4 75. 00%
index (CSI) (for all age gr exceptonly C5–8, A–C and
(16–44) grade D
Time spent in inpatient Activity/ No Data X No Data S S S X 3 100%
PT Participation Participation (for age group ≥60) (only C1–4 and para
A–C)
Time spent in inpatient No Data X No Data S S X X 2 100%
OT services (h) (for age group 45–60) (only Para A–C)
Admission mFIM No Data S No Data S S S X 4 100%
(except Grade D)
Time spent in wheelchair No Data X No Data X X S X 1 100%
mobility – manual (h)
Time spent in gait No Data X No Data X X S X 1 100%
mobility training (h)
Time spent in PT mobility No Data X No Data S X X X 1 100%
training (h) age gr (16–44) only
Time spent in No Data X No Data X X S X 1 100%
strengthening
Activities (h)
Time spent in Upright No Data X No Data X X S X 1 100%
activities (h)
Time spent in inpatient No Data NS No Data NS NS X X 3 0%
TR/SW/CM/SLP
service (h)
 Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

Predictors related to contextual domain

Predictive variables were significant 64% at discharge

33. 30%
100%

100%

100%

100%

100%
50%

33%
and 57% on follow-up (Fig. 3). Age, LOS and delayed

0%

0%

0%
admission to rehabilitation were consistent predictors
of mFIM at discharge and 75% of the time at follow-
up. Sex, level of education, use of ventilator at admis-
sion, payers, and employment showed inconsistency in
predicting mFIM at discharge and at one year follow-
up. Patient’s Body Mass Index was a predictor of
1

1
2
1
3

1
mFIM at discharge; however, it failed to consistently
predict mFIM at follow-up. Ethnicity was not a predic-
tor of mFIM at either discharge or at one year follow-
up. Language barrier was only predictor at one year
years)
(<65
X

X
x
x

follow-up

Discussion
NS

NS

NS
X

X
X

X
The purpose of the current systematic review was to
identify, categorize and rank predictors of functional
outcomes for individuals with SCI following rehabilita-
(only AIS grade D)

(only gr Para A-C)

(only gr. C 5–8)

(only Para A-C)
sig only C1-4

tion. Twenty-seven variables spanning each domain of

(only C1–4)

the ICF model were able to predict mFIM scores at dis-

NS

NS

NS
X

charge and/or at one year follow-up. Different domains

had more influence on mFIM score at various times
during the rehabilitation process. Together, this infor-
mation will help clinicians to set realistic goals to maxi-
(only age gr 16–39)
(for age gr. 30-44)
(for 16–29 yr only)

mize functional independence not only at the time of

(for age ≥ 45)
(for all age gr
except ≥ 60)

discharge but also after individuals integrate back into

NS
S

X
X
X
S

society and though-out their lifespan.

Among the twenty-seven predictors of mFIM score,
variables spanning the ICF domains were identified as
being more consistently significant at discharge and/or
No Data
No Data

No Data
No Data
No Data
No Data

No Data

No Data

No Data

No Data

No Data

follow-up: ten variables at both discharge and at one

year follow-up, five only at discharge, and two only at
follow-up. Additionally, two variables showed variabil-
ity at discharge but were consistent at follow-up, seven
X
S

S
X

X
x

variables were inconsistent predictors of mFIM score

at both discharge and one year follow-up, and one vari-
No Data
No Data

No Data
No Data
No Data
No Data

No Data

No Data

No Data

No Data

No Data

able was not significant at either discharge or at one year

follow-up. Variables related to the Body Structure and
Function domain were the most consistent predictors
of mFIM score at discharge, and those related to the
Contextual

Activity and Participation domain were the most con-

sistent predictors at one year follow-up. Aside from
age, variables related to the Contextual domain were
the least consistent predictors of mFIM score at both
Payer (private insurance)

discharge and follow-up. These findings demonstrate

that a particular domain of the ICF can have greater
Days from trauma to

Education >12yr

influence on functional outcomes at different stages of

Ventilator use at

the rehabilitation process. For example, the amount of

admission

Employment

Language

time spent on manual wheelchair propulsion training

Ethnicity
rehab

was a predictor of mFIM score 100% of the time at

LOS

Age

BMI

Sex

discharge but was not a predictor (0%) at one year

The Journal of Spinal Cord Medicine 2016 7

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Faisal AlHuthaifi et al.

The Journal of Spinal Cord Medicine

Table 3B. Prediction marker of motor outcomes at one-year follow-up

Times Parameter % of times

Backus, Cahow, Horn, Teeter, Welson, used in prediction parameter was
Predictor ICF Domain 2013 2011 2013 Hsieh, 2013 Tian, 2013 2012 2014* models significant

Predictors of functional outcomes in adults with traumatic spinal cord injury

One-year Follow-up 2
R ----> R2= 0.49 R = 0.51
2
R =0.
2
R = 0.630–0.580
2
R2 = 0.250 R2 = 0.51 NR One-year follow-up
516
ASIA ABC Body S S S S X S S 6 100%
Structure/ (Only for age
Function 16–29)
All para X S X S X S X 3 100%
(all age except age
≥60)
2016

C1-C4 grades A-C X X X S X S X 2 100%

C5-C8 grades A-C X X X S X S X 2 100%
(all age except age
≥60)
Comprehensive Severity S S X S NS NS X 5 60%
Index (CSI) (for age gr 30–44)
AIS D NS NS S X X S NS 5 40%
ventilator used at rehab X X NS NS S X X 3 33. 30%
admission (only para)
(Airway/respiratory
management)
Secondary X X X X NS X X 1 0%
complications
Admission mFIM Activity/ S S S S S S X 6 100%
Participation (only C1–8)
Time spent in inpatient S X X NS S S X 4 75%
PT participation (h) (only C1-8)
Time spent in inpatient S S X S S X X 4 100%
TR/SW/CM/SLP (for age gr 45–59) (only C5–8) *SW
service (h)
Time spent in inpatient X X X S NS X X 2 50. 00%
OT service (h) (for age group
30–44)
Time spent in PT X X X S X X X 1 100. 00%
mobility training (h) (Only for age
16–29)
Time spent in gait X X X X X S X 1 100%
training (h)
Time spent in upright X X X X X NS X 1 0%
activities
Time spent in X X X X X NS X 1 0%
Strengthening
activities (h)
Wheelchair mobility – X X X X X NS X 1 0%
manual (h)
 Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

follow-up. Conversely, time spent participating in

Recreational Therapy, Social Work, and Case

33. 30%

0. 00%
100%

100%

100%

50%

50%
25%
75%

75%

50%
Management was a predictor of mFIM score only at
one year follow-up. The common language of the ICF
as a model of health and disability was applied to clas-
sify the ranked variables across domains. Identifying
individual variables within each domain allows for the
evaluation of the relationships among variables within
each domain, as well as, the relationship between vari-
1
3

4
4

3
2
4

1
4

ables in different domains.28,40,41

The value of the coefficient of determination (R2) is
meaningful for conceptualizing the degree of association
between full regression models and the mFIM scores.42
years)
(<65
X

X
X

X
X

X
x

As shown in the results, the decrease in R2 from dis-

charge to follow-up indicates that the predictive capa-
bilities of these models were variable and reduced over
time. This variability suggests that not only are there
NS
NS
X
X

X
X

X
S

additional variables affecting functional outcomes fol-

lowing discharge from rehabilitation, but more frequent
(onlyPara gr A-C)

clinical evaluations following discharge are indicated to

(for all levels)

(onlyPara gr
(only para+

(only C1–4)
(only para)
Grade D)

identify the need for further intervention.

A–C)
NS

NS
NS

S
S

S
X

S
S

Body structure/function domain

Predictors in the Body Structure and Function domain
(for age gr. 16–44)
(for age gr 30–60)

showed that injury category levels C5–C8, paraplegia

ABC, and combined paraplegia and tetraplegia injury
NS

NS
NS

X
S

X
X

levels AIS ABC were the most consistent predictors of

mFIM at discharge and follow-up. It has been demon-
strated in previous studies that mFIM is strongly associ-
ated with the neurological level of the individual’s SCI.
NS

NS
NS

However, the level of injury alone cannot fully capture

S

X
X

X
S

the spectrum of functional capability following rehabili-

tation. For patients in the AIS A, B, and C levels, the
NS

likelihood of future ambulation is very limited.

NS

X
X
X
S

X
x

Individuals in the AIS D level appeared to be indepen-

dent of the neurological level of injury due to the pres-
ence of motor function below the level of injury.
NS
NS
X

S
X
x

Individuals with AIS D come to rehab with a basic

goal to further improve functional independence that
may be translated to future ambulation. Overall,
Contextual

Studies showed that the number of ambulatory patients

with AIS D is four times as many compared in AIS A,
B, and C levels.43 However, studies also showed that
individuals in the AIS D level might be affected by
impairments including spasticity, muscle weakness,
Ventilator used at rehab

(Airway/respiratory

and neuropathic pain.1 These factors may add to the

Days from trauma to

inconsistency of the results and also limit independent

management)
Payer (private

mobility at discharge and at one year follow-up.

insurance)

admission
Employment

Language

Education

Similar findings were identified in the current systematic

Ethnicity
rehab

review where the overall predictive value of an AIS D

LOS

Age

BMI
Sex

injury was inconsistent following rehabilitation.

The Journal of Spinal Cord Medicine 2016 9

Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

Figure 2. Number of predictors in each selected study. (Colour online)

Activity/participation domain process of rehabilitation, a patient’s participation can sig-

Variables in the Activity and Participation domain nificantly affect functional outcomes. These findings are
including Admission FIM score, PT participation score, consistent with a previous study which showed that
and hours spent on PT mobility training (including patients sharing the same level of injury who participated
ambulation training) were the most consistent predictors more during rehabilitation sessions reported higher func-
of mFIM. The result indicates that within the interactive tional outcomes.1,44 The study further concluded that
patient participation is a significant element of successful
SCI rehabilitation and must be enabled, encouraged and
tailored to every individual with SCI in the rehabilitation
settings. In Teeter et al., higher levels of intrinsic and
extrinsic motivation were identified as possible patient
characteristics associated with high functional improve-
ment following rehabilitation.1 Individuals who are
more responsive to rehabilitation are likely to have sup-
portive personal features that enhance activity and par-
ticipation levels, as well as, mFIM scores.1,44
Although other inpatient services such as Recreation
Therapy, Social Work, and Case Management were
not significant predictors of mFIM scores at discharge,
they were consistent predictors at one year follow-up.
This suggests that the skills and knowledge obtained
from these professionals are more impactful on indepen-
dent functional mobility when they can be applied in a
community setting.

Contextual Domain
Figure 3. Rate of significant predictors in the ICF domain at Overall, variables in the Contextual domain were less
discharge and at one year follow-up. (Colour online) likely to predict mFIM scores at discharge and at

10 The Journal of Spinal Cord Medicine 2016

 Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

follow-up. However, it is important to consider the another, given the differences in culturally associated
direct effect of contextual factors on the identified factors, accessibility to cost-effective resources and sup-
predictors, themselves, of functional outcome. For porting means during and following rehabilitation.
example, the time spent in participating in the various
rehab intervention activities can be actually conditioned Clinical relevance
by contextual factors such as patient/therapist goals, The findings in this study allows clinicians to set more
motivation, scheduling. However, in other studies, con- realistic goals to maximize functional independence not
textual factors were found to be more strongly associ- only at the time of discharge but also after individuals
ated with measures of life satisfaction than measures integrate back into the community and though-out their
of the Activity and Participation domain (as measured lifetime. Also, the findings in the current systematic
by mFIM, Craig Hospital Inventory of Environmental review can help prioritize services received as a patient
Factors, and Craig Handicap Assessment and prepares for discharge and guide discharge planning to
Reporting Technique).45–47 ensure that post-discharge services are available once a
In the current systematic review, variables in the con- patient reintegrates back into the community.
textual domain showed that age at injury, LOS, and
delayed admission to rehabilitation were the most con- Study limitations and future direction
sistent predictor of mFIM. The findings are consistent There are a number of limitations were encountered in
with other studies on the positive influence of rehabilita- the current systematic review that warrant discussion.
tion LOS on functional achievements as determined by First, the mapping of predictors into the ICF domains
improvement in mFIM.48–51 These results suggest that was not entirely straightforward. By way of explanation,
admission to rehabilitation following SCI should be there is a risk of decreased reliability in the process of
expedited and discharged should be considered based identifying which domain the predictor relate to.25 In
on the attainment of goals. At the time of discharge con- an effort to minimize this risk, multiple expert opinions
sideration of physical, psychological and environmental were carried to confirm the accuracy of placement of
constraints within the community must be considered the predictors into its correct domain. Second, although
to minimize the effect of the contextual barriers on many studies showed that the Spinal Cord Independence
functional gains achieved during rehabilitation. Measure (SCIM) is the gold standard in serving as a
Nevertheless, predictors such as LOS can be influenced common tool for assessment of individuals with SCI,
by external factors like governmental policies, health its application in clinical practice has not yet been
system administration and financial considerations that fully embraced. In addition, the SCIM has undergone
in return may affect mFIM during and following two major revisions in 2001 and 2007. The current
rehabilitation. version is the SCIM-III. Consequently, there is insuffi-
Older age at injury can negatively affect functional cient data in the literature to fully utilize the SCIM-III
outcomes from discharge to one year follow-up. as an outcome measure for the purpose of this systema-
Although results from other studies found that neuro- tic review. However, future studies should utilize the
logical recovery to be independent of age, the findings SCIM-III assessment tool to improve reliability and sen-
further demonstrated that neurological improvement in sitivity measures of functional outcomes during and
elderly population fails to be translated into equivalent after rehabilitation.
functional mobility gains.52 Lack of functional mobility Although contextual ( personal and environmental)
gains was mainly associated with age-associated factors are essential to the framework of the ICF, they
conditions such as reduced cardiovascular capacity, have yet to be fully classified. This is a current limitation
endurance, and various chronic health conditions of the ICF, as personal and environmental factors are
(cardiovascular disease, osteopathic disorder).53,54 This critical to the process and outcome of the rehabilitation
suggests that facilitating tailored interventions for a par- for individuals with SCI. The ICF has also been criti-
ticular age population will help to accommodate their cized for its inability to clearly portray change of
specific needs and serve the overall goal of health-related factors over time.2
rehabilitation. The included studies did not explicitly include formal
Race and ethnicity were not identified as predictors of outcomes measures of participation. The included
mFIM score. This suggests that changes in mFIM may studies measured the activity and participation
not possibly emerge from racial and ethnic differences. through time spent in participating in rehabilitative
However, it is expected that ethnic group’s results from activities. Based on the current literature, it is still ques-
these studies may vary from one environment to tionable as to whether the number of hours is a valid

The Journal of Spinal Cord Medicine 2016 11

Faisal AlHuthaifi et al. Predictors of functional outcomes in adults with traumatic spinal cord injury

parameter for measuring activity and participation, as Conflict of Interest: No author has a conflict of interest
this perspective overlooks the association of subjective with the material presented.
character of experience with factors related to the con-
Ethics approval None.
textual domain. Given the importance of participation
to people with SCI, it is crucial that clinicians and Disclosures None.
researchers have access to outcome measures that accu-
rately measure participation in ways that are both theor-
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