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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 149-155

Rehabilitation length of stay among traumatic paraplegics – A retrospective analysis


1 Senior Resident (Academics), Department of Physical Medicine and Rehabilitation, AIIMS, Rishikesh, Uttarakhand, India
2 Professor and Head, Department of Physical Medicine and Rehabilitation, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Associate Professor, Department of Physical Medicine and Rehabilitation, King George's Medical University, Uttar Pradesh, India
4 Additional Professor, Department of Physical Medicine and Rehabilitation, King George's Medical University, Uttar Pradesh, India
5 Department of Community Medicine, King George's Medical University, Uttar Pradesh, India

Date of Submission01-Sep-2022
Date of Decision05-Nov-2022
Date of Acceptance21-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Dr. Mohit Kishore Srivastava
Department of Physical Medicine and Rehabilitation, AIIMS, Veerbhadra Road, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijprm.JISPRM-000179

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  Abstract 


Introduction: In patients with traumatic spinal cord injury (SCI), a complex interplay of sociodemographic and injury-related factors can impact on outcomes such as rehabilitation length of stay (r-LOS), functional status, and discharge following rehabilitation procedures. Every year 2.55 lakhs of people suffer from SCI globally. Objectives: To describe the r-LOS in patients with traumatic paraplegia and associated correlates. Materials and Methods: A retrospective study was conducted among traumatic paraplegics admitted in the rehabilitation unit of a government tertiary care hospital of Lucknow, Uttar Pradesh, between January 1, 2016, and December 31, 2017. All medical records of traumatic paraplegics fulfilling the inclusion criteria were used for data extraction and analysis. A data-gathering instrument was developed and was thereafter used to capture the relevant information from the patients' individual medical records. Results: Mean and median duration of r-LOS was 98.4 ± 37.2 and 98.3 (31.3) days, respectively. Significant predictors were age, employment status, location of residence, operation, and complications at/during hospitalization (P < 0.05). More than half (55.6%) of the traumatic paraplegic patients were of neurological category A. Among those who had r-LOS > 98 days, 94.2% had pressure ulcers in the sacral region, followed by 85.7% ischial and majority were grades 3 and 4. Conclusion: The most common cause of injury was falls from height. Pressure ulcer was the most common complication of paraplegics. Age, employment status, and location of residence were the epidemiological factors, while the history of operation and pressure ulcers were the clinical factors affecting the length of hospital stay.

Keywords: Length of stay, pressure ulcers, rehabilitation, traumatic paraplegics


How to cite this article:
Srivastava MK, Gupta AK, Yadav G, Kumar D, Mishra SR, Jauhari S. Rehabilitation length of stay among traumatic paraplegics – A retrospective analysis. J Int Soc Phys Rehabil Med 2022;5:149-55

How to cite this URL:
Srivastava MK, Gupta AK, Yadav G, Kumar D, Mishra SR, Jauhari S. Rehabilitation length of stay among traumatic paraplegics – A retrospective analysis. J Int Soc Phys Rehabil Med [serial online] 2022 [cited 2023 Feb 1];5:149-55. Available from: https://www.jisprm.org/text.asp?2022/5/4/149/363884




  Introduction Top


In patients with traumatic spinal cord injury (SCI), a complex interplay of sociodemographic and injury-related factors can impact on outcomes such as rehabilitation length of stay (r-LOS), functional status, and discharge following rehabilitation procedures.[1] Every year 2.55 lakhs of people suffer from SCI globally. Majority of them is caused by road traffic accidents and falls from height.[2]

Following a traumatic SCI (TSCI), patients go through a rehabilitation process comprising three consecutive phases: acute hospitalization, intensive functional rehabilitation (IFR), and community integration. This spectrum of care targets to improve patients' quality of life by enhancing functional recovery.[1] Most of the functional recovery occurs within the first 6 months following the TSCI, which is the phase of hospitalization and acute care and IFR.[3] The optimization of the clinical improvement of patients during the initial stages is thus of utmost importance to emphasize efficient functional rehabilitation and ultimately upgrade long-term functional outcomes.[4]

Discharge outcomes mostly depend on the level of injury and its severity. More extensive sensory and motor involvement are seen in spinal cord lesions, which are more rostral, and hence functional independence of the patient decreases.[1]

Previous works have shown that longer acute care length of stay (LOS) and the occurrence of medical complications during the early rehabilitation phase negatively affect the process of IFR and long-term functional outcome, even when adjusted for important confounding variables such as the level and severity of the SCI.[2],[4],[5] Occurrence of a pressure injury (PI) is one of the most common and preventable complications following TSCI, a serious complication that has the potential to delay or alter functional, psychological, and social well-being outcomes.[3] The acute hospitalization phase of rehabilitation represents the period with the highest PI risk.[3],[6]

Spinal cord injuries in our institute follow a protocol of assessment, physical therapy in the form of a range of motion, stretching, and strengthening as required. Management of pressure injuries, and a comprehensive bladder and bowel rehabilitation, forms the mainstay of treatment and rehabilitation of spinal injuries at our centre.

As a prolonged rehabilitation hospital stay is required, the risk of severe complications is increased. Due to the reduced functional independence, the burden of care after discharge also increases, along with these due to the loss of productivity of patients, various neurological sequelae spinal cord lesions cause a heavy financial burden on affected patients and their families.[4] Therefore, special efforts should be made to improve rehabilitation outcomes and to prevent complications and related medical problems, which was the rationale behind this study.

Objectives

To study the r-LOS among traumatic paraplegics and identify the associated demographic and clinical factors.


  Materials and Methods Top


Study design and setting

A retrospective study was conducted among the traumatic paraplegics admitted to the Rehabilitation Unit of the Department of Physical Medicine and Rehabilitation of a government tertiary care health facility in Lucknow. Being the capital city of Uttar Pradesh, India, this unit is the only rehabilitation center providing services to the whole state. The study was done for 2 years, i.e., from January 1, 2016, and December 31, 2017.

Inclusion criteria

All traumatic paraplegics with no history of readmission to the Department of Physical Medicine and Rehabilitation, tertiary care center, Lucknow, with no previous history of the visit to any other rehabilitation center, with no history of treatment from another consultant/medical team, with complete medical records and no previous SCI were included in the study.

Exclusion criteria

  • Tetraplegia (their r-LOS differs from that of the paraplegics)
  • Non TSCI
  • Previous history of SCI
  • History of readmission
  • History of admission to another hospital for the same
  • Rehabilitation was planned by another medical team.


Data collection

A quantitative approach was utilized. The records of traumatic paraplegics discharged from the hospital between January 1, 2016, and December 31, 2017, were reviewed to collect the data. All medical records of traumatic paraplegics fulfilling the inclusion criteria were used for data extraction and analysis. A data-gathering instrument was developed and was thereafter used to capture the relevant information from the patients' individual medical records. Information collected included demographic data, information relating to the injury, occurrence of medical complications, and R-LOS in the hospital. A total of 177 medical records of patients discharged between January 2016 and December 2017 from the Department of Physical Medicine and Rehabilitation of the Medical College were reviewed for data extraction, and finally, 108 medical records of patients who fulfilled the inclusion criteria were selected for statistical analysis. Telephonic consent was obtained from the patients or their families for including their records [Figure 1].
Figure 1: Flow diagram depicting the selection of patients with traumatic SCI. SCI: Spinal cord injury

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Variables

The outcome variable, r-LOS, was obtained from the dataset and examined in the current study. r-LOS was calculated as the number of days in the hospital from the day of the patient's first admission to the Rehabilitation Unit for IFR to the date of discharge from the unit. The day of admission was considered day 0. The outcome variable was r-LOS. The predictor or exposure variables were composed of sociodemographic and clinical variables. The main sociodemographic variables were age, gender, employment status, socioeconomic status, and location of residence. The main clinical variables were the cause of injury, associated comorbidities, neurological category (AIS grading), and complications at/during admission to the rehabilitation unit, history of treatment during the acute phase, MBI, WISCI, and SCIM scores at the time of admission to rehabilitation unit.[1],[2],[3],[4],[5],[6]

We also obtained information regarding the location of the patients' residence as compared to the admitting hospital and named it as the location of residence. We further dichotomized this variable as "in the same city" which means the residence of the patient was in the same city, in which the rehabilitation center was located and "in another city" which means that the residence was not in the same city, in which the rehabilitation center was located. All predictor variables were obtained from the dataset. All sociodemographic and clinical variables were categorical variables.

Ethical clearance

Ethical clearance was obtained from Institutional Review Board, Tertiary Care Centre, Lucknow (2289/Ethics/'R. Cell-17).

Data analysis

All statistical analyses were performed using licensed Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois, USA) SPSS version 23.0. Descriptive statistics, including mean, standard deviation, and frequencies expressed as percentages, were used to present information regarding sociodemographic and clinical characteristics. The cut-off for r-LOS was set at the median value. Values equal to the median, or lower, indicated a short r-LOS, while higher than the median pointed to a long r-LOS. Cross tabulations were done for the predictor variables, and Chi-square test was applied. P < 0.05 was considered statistically significant. Univariate regression analysis was performed to examine the association between r-LOS and the demographic and clinical factors. Variables with P < 0.05 were put through binomial multivariate regression analysis. The potential confounders were socioeconomic status, level of neurological injury, and cause of injury. The effect modifiers were gender and associated comorbidities. Multivariate regression analysis was performed after adjusting all the confounders.


  Results Top


The mean age of study participants was 35.6 ± 12.5 years. The mean and median r-LOS (r-LOS) was 98.4 ± 37.2 and 98.3 (31.3) days, respectively. Majority (40.7%) of the TSCI patients were in the age group of 1530 years. Males (84.3%) were the most affected. More than half (59.3%) of the patients were employed. 77.8% of patients were from another city. The most common cause of traumatic spinal cord injury was fall from height as majority (74.1%) of the patients had reported the same. Most of the patients (55.6%) were of ASIA grade A. The most common complication observed at/during hospitalization was pressure ulcer (48.1%). About 83.3% of patients were managed operatively [Table 1]. More than half (57.4%) of the patients had r-LOS of ≤98 days [Figure 2].
Figure 2: Duration of R-LOS among the study participants (N = 108). R-LOS: Rehabilitation length of stay

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Table 1: Characteristics of the study participants

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Among the patients 15-30 years of age, approximately two-thirds (63.6%) had r-LOS >98 days and this association was statistically significant. Similarly, a significant association was observed for variables such as gender, employment status, location of residence, neurological category, operation, and complications at/during hospitalization with the r-LOS in the hospital (P < 0.05). On comparing the mean values of functional scores at the time of hospital admission with r-LOS, a statistically significant association was seen (P < 0.05). Socioeconomic status and associated comorbidities were not affecting the LOS as it was not statistically insignificant. Hence, they were not included in the regression analysis [Table 2].
Table 2: Factors affecting the rehabilitation length of stay among traumatic paraplegics

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Patients of age <35 years had almost ten times greater r-LOS than those of age ≥35 years. Employed patients had approximately six times more r-LOS than unemployed patients. Those who had undergone the operation had two times more r-LOS than those who were on conservative treatment. Patients with pressure ulcers had six times more r-LOS than those with other complications at/during hospitalization. Patients residing in the same city had lesser r-LOS than those living in another city. Significant predictors were age, employment status, location of residence, operation, and complications at/during hospitalization (P < 0.05) [Table 3].
Table 3: Multivariate regression analysis of factors affecting the rehabilitation length of stay among the traumatic paraplegics

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The study depicts the location and grading of pressure ulcers which was a determinant of r-LOS. Among those who had r-LOS >98 days, 94.2% had pressure ulcers in the sacral region, followed by 85.7% ischial, 60% in the heel region and none in the occipital area. Among those who had r-LOS >98 days, 18.2% had grade 1 pressure ulcers, followed by 30% had grade 2, 82.8% had grade 3, and all had grade 4 ulcers (100%) [Table 4].
Table 4: Location and grading of pressure ulcer based on rehabilitation length of stay

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  Discussion Top


TSCI poses a severe toll on the life of the patient as well as his family members. Promoting efficient IFR is crucial for improving functional outcomes in the clinical evolution of a TSCI patient. As the prevention of PI during acute hospital care and so to reduce r-LOS, medical and rehabilitation units must equally contribute to facilitate the rehabilitation process.[3]

In our study, the mean age of study participants was 35.6 ± 12.5 years, with the majority being in the age group of 1530 years. Males were affected more than females (84.3%). In a cohort study of 112 patients conducted by Alito et al.,[7] mean age was 60 ± 14.8 years, with 81% males affected. Another study's mean age was 49 years, with a higher percentage of males affected (72%).[8] The higher incidence of traumatic spinal cord injuries among males can be attributed to the fact that they belong to the working class and many injuries are occupation driven.[7],[8],[9]

Our study showed that falls from height (74.1%) and road traffic accidents (25.9%) are the cause of traumatic paraplegics. The LOS was significant for age and the cause of injury was found to be significant in our study (P < 0.0001 and 0.002, respectively). Other significant factors were gender, employment status, neurological category, surgery done for the same, complications such as pressure ulcers, urinary tract infection, and deep-vein thrombosis and mean functional scores at the time of admission. In a study, it was observed that longer r-LOS was observed in patients with surgery, urinary infection, and poor functional status, compared to the r-LOS of patients without these factors (P < 0.01). Similarly, those with pressure ulcers and associated injuries had longer r-LOS, when compared to the r-LOS of patients without these factors (P < 0.05).[10]

Our study has depicted a significant association of employment and pressure ulcers with r-LOS. This was in concordance with the study by Bwanjugu and Rhode, who had also reported similar findings. The high occurrence of pressure sores in participants could have been as a result of a lack of implementation of preventative measures or the patients not complying with the education given about pressure care.[11] The development of pressure sores at any stage in the rehabilitation process affects the rate of progress during rehabilitation, thereby prolonging their LOS. The present study did not observe any significant association between gender and neurological category, which was in agreement with the study by Jang et al.[12] Moreover, in a study by Scivoletto et al. and Moshi et al. among spinal cord paraplegics, it was observed that the length of rehabilitation stay varies according to the level of SCI, secondary complications, and associated lesions, which was in concordance with the findings in our study.[13],[14]

In a prospective cohort study, 65 (21.6%) patients developed at least one PI during acute care hospitalization. The most common localization was the sacrum (n = 53; 81.5%), followed by "other" (chin, big toe, back, ankle, elbows, proximal fibula, and trochanter) (n = 9; 13.8%) and heels (n = 3; 4.6%). The overall distribution of the severity of PI was Stage I (n = 19; 29.2%), Stage II (n = 41; 63.1%), Stage III (n = 2; 3.1%), and Stage IV (n = 2; 3.1%).[3] In our study, in patients with a longer r-LOS, 94.2% had pressure ulcers in the sacral region, followed by 85.7% ischial, 60% in the heel region and none in the occipital area and calculated on severity, longer r-LOS 18.2% had grade 1 pressure ulcer, followed by 30% had grade 2, 82.8% had grade 3, and all had grade 4 ulcers (100%).

Overall, the mean and median LOS in our study was 98.4 ± 37.2 and 98.3 (31.3) days which was much longer than other studies by Tooth et al., Gour-Provencal et al., and Gedde et al. which was 83 days (median), 29.3 ± 21.2 days (mean), and 58 ± 41 days (mean), respectively.[1],[3],[15] The reason for our long stay could be as the study was being conducted at a government-aided tertiary health-care center where the major expenditure of patients on rehabilitation is borne by the government and the out-of-pocket expenditure is also lowered.[15]

Our study has limitations like being a retrospective study, it was based on previous medical records which were not designed to collect data for research, so some information was bound to be missing as well as lost to follow-up can often not be ascertained, which may lead to bias. Still, the retrospective design is very helpful in understanding rare conditions and outcomes, which are helpful in the planning and execution of prospective studies and that's the strength of our study.


  Conclusion Top


The mean r-LOS (r-LOS) was 98.4 ± 37.2 days. Majority (40.7%) of traumatic paraplegic patients were of the age group 1530 years. The most common cause of injury was a fall from height (74.1%). More than half (55.6%) of the Traumatic paraplegic patients were of neurological category A. Pressure ulcer (48.1%) was the most common complication of paraplegics. Age, employment status, and location of residence were the epidemiological factors, while the history of operation and pressure ulcers were the clinical factors affecting the length of hospital stay.

Recommendations

Efforts should collaborate for a spinal cord registry in India. There should be provision for inclusion of traumatic paraplegics in the national insurance schemes. Proper planning of follow-up, medical care for the comorbidities, and physical assistance should be done. Strong need for all members of the rehabilitation team to ensure the implementation of effective measures to prevent the development of pressure sores, in TSCI patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tooth L, McKenna K, Geraghty T. Rehabilitation outcomes in traumatic spinal cord injury in Australia: Functional status, length of stay and discharge setting. Spinal Cord 2003;41:220-30.  Back to cited text no. 1
    
2.
NHP India. India: National Health Portal; 2020. Available form: https://www.nhp.gov.in/disease/neurological/spinal-cord-injury #:~:text=Majority%20of%20these%20 cases%20are, without%20a%20 spinal%20cord%20injury. [Last accessed on 2022 Sep 23].  Back to cited text no. 2
    
3.
Gour-Provencal G, Mac-Thiong JM, Feldman DE, Bégin J, Richard-Denis A. Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury. J Spinal Cord Med 2021;44:949-57.  Back to cited text no. 3
    
4.
Richard-Denis A, Beauséjour M, Thompson C, Nguyen BH, Mac-Thiong JM. Early predictors of global functional outcome after traumatic spinal cord injury: A systematic review. J Neurotrauma 2018;35:1705-25.  Back to cited text no. 4
    
5.
Denis AR, Feldman D, Thompson C, Mac-Thiong JM. Prediction of functional recovery six months following traumatic spinal cord injury during acute care hospitalization. J Spinal Cord Med 2018;41:309-17.  Back to cited text no. 5
    
6.
Brienza D, Krishnan S, Karg P, Sowa G, Allegretti AL. Predictors of pressure ulcer incidence following traumatic spinal cord injury: A secondary analysis of a prospective longitudinal study. Spinal Cord 2018;56:28-34.  Back to cited text no. 6
    
7.
Alito B, Filardi V, Famà F, Bruschetta D, Ruggeri C, Basile G, et al. Traumatic and non-traumatic spinal cord injury: Demographic characteristics, neurological and functional outcomes. A 7-year single centre experience. J Orthop 2021;28:62-6.  Back to cited text no. 7
    
8.
Gedde MH, Lilleberg HS, Aßmus J, Gilhus NE, Rekand T. Traumatic versus non-traumatic spinal cord injury: A comparison of primary rehabilitation outcomes and complications during hospitalization. J Spinal Cord Med 2019;42:695-701.  Back to cited text no. 8
    
9.
Chen Y, Tang Y, Vogel LC, Devivo MJ. Causes of spinal cord injury. Top Spinal Cord Inj Rehabil 2013;19:1-8.  Back to cited text no. 9
    
10.
Wu Q, Ning GZ, Li YL, Feng HY, Feng SQ. Factors affecting the length of stay of patients with traumatic spinal cord injury in Tianjin, China. J Spinal Cord Med 2013;36:237-42.  Back to cited text no. 10
    
11.
Bwanjugu PB, Rhoda A. Factors affecting length of hospital stay for people with spinal cord injuries at Kanombe military hospital, Rwanda. SA J Physiother 2012;68:33-7.  Back to cited text no. 11
    
12.
Jang HJ, Park J, Shin HI. Length of hospital stay in patients with spinal cord injury. Ann Rehabil Med 2011;35:798-806.  Back to cited text no. 12
    
13.
Scivoletto G, Morganti B, Ditunno P, Ditunno JF, Molinari M. Effects on age on spinal cord lesion patients' rehabilitation. Spinal Cord 2003;41:457-64.  Back to cited text no. 13
    
14.
Moshi H, Sundelin G, Sahlen KG, Sörlin A. Traumatic spinal cord injury in the North-East Tanzania – Describing incidence, etiology and clinical outcomes retrospectively. Glob Health Action 2017;10:1-8.  Back to cited text no. 14
    
15.
Ambade M, Sarwal R, Mor N, Kim R, Subramanian SV. Components of out-of-pocket expenditure and their relative contribution to economic burden of diseases in India. JAMA Netw Open 2022;5:e2210040.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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