Development of Reaching, Grasping & Manipulation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Abstract

Objective: To describe the development of structure, process, and outcome indicators aimed to advance the quality of Reaching, Grasping & Manipulation (RG&M) rehabilitation for Canadians living with spinal cord injury or disease (SCI/D).

Method: Upper extremity rehabilitation experts developed a framework of indicators for evaluation of RG&M rehabilitation quality. A systematic search of the literature identified potential upper extremity indicators that influence RG&M outcomes. A Driver diagram summarized factors influencing upper extremity outcomes to inform the selection of structure and process indicators. Psychometric properties, clinical utility, and feasibility of potential upper extremity measures were considered when selecting outcome indicators.

Results: The selected structure indicator is the number of occupational and physical therapists with specialized certification, education, training and/or work experience in upper extremity therapy related to RG&M at a given SCI/D rehabilitation center. The process indicator is the total hours of upper extremity therapies related to RG&M and the proportion of this time allocated to neurorestorative therapy for each individual with tetraplegia receiving therapy. The outcome indicators are the Graded Redefined Assessment of Strength, Sensation and Prehension (GRASSP) strength and Spinal Cord Independence Measure III (SCIM III) Self-Care subscores implemented at rehabilitation admission and discharge, and SCIM III Self-Care subscore only at 18 months post-admission.

Conclusion: The selected indicators align with current practice, will direct the timing of routine assessments, and enhance the volume and quality of RG&M therapy delivered, with the aim to ultimately increase the proportion of individuals with tetraplegia achieving improved upper extremity function by 18 months post-rehabilitation.

Keywords: Health care; Outcome assessment; Physical functional performance; Quality indicators; Rehabilitation; Tetraplegia; Upper extremity.

Figure 1

Driver diagram for the RG&M Domain. The Impairment Branch is common to all 11 SCI-High Domains. The red items shown in the diagram represent the aim of the indicators. *Thicker black lines on the Technology branch reflect the greater volume of evidence supporting NMES and FES. UEMS: Upper-Extremity Motor Score, LEMS: Lower-Extremity Motor Score, NLI: Neurological Level of Injury, AIS: ASIA Impairment Scale, HR: Heart Rate, BP: Blood Pressure; FES: Functional Electrical Stimulation, AMES: Assisted Movement with Enhanced Sensation, Bioness Inc., NMES: Neuromuscular Electrical Stimulation, SARA System: Smart Assistive Reacher Arm (SARA) System, SRS System: Stimulus Router System, MeCFES: Myoelectrical Controlled Functional Electrical Stimulation, and PNSS/rTMS: Peripheral Nerve Somatosensory Stimulation System/repetitive Transcranial Magnetic Stimulation.

Figure 2

RG&M structure indicator tool.

Figure 3

Alphabetical list of therapeutic activities intended to facilitate Reaching, Grasping & Manipulation outcomes. This table was modified from Ozelie et al., 2012 with feedback from Lyndhurst Centre OTs and PTs and RG&M Working Group Members.

Figure 4

Illustration of the intersection between rehabilitation discharge (red vertical line) and the slope of change in upper extremity motor scores (MS). The red dotted line represents the median rehabilitation length of stay in Canada. The recovery timeline graph was adapted from Burns and Ditunno, 2001, displaying functional motor recovery in individuals with C6 tetraplegia with an initial MS at the C5 myotome. Solid and dotted black lines depict modeled data resulting from individuals with different motor scores.