The Spinal Cord Injury - Interventions Classification System: development and evaluation of a documentation tool to record therapy to improve mobility and self-care in people with spinal cord injury

Sacha van Langeveld, PT (Researcher)
Marcel Post, PhD (Project leader)
Floris van Asbeck, MD, PhD
Karin Postma, MsC, PT
J. Leenders, OT
Cees Pons, MD
Hans Liefhebber, manager

On July 8, 2010, Sacha van Langeveld defended her dissertation entitled: The Spinal Cord Injury-Interventions Classification System (SCI-ICS)

Summary

Chapter 1, the introduction, describes the rationale and the main aims of the research project and presents an outline of this thesis. lnpatient rehabilitation in specialized spinal cord injury units is regarded worldwide as the best treatment for the complex consequences of spinal cord injury. However, little is known about the elements that make this the 'best treatment'. To date, therapy provided in rehabilitation has only been recorded for administrative purposes: the number of treatments, the hours of therapy, and by whom it is provided (e.g. physical therapists, ccupational therapists). Since there is no instrument to record therapy time, nor the contents of therapy, it is impossible to compare rehabilitation treatments between patients, centers and countries. The research described in this thesis focused on the development and evaluation of a clear, uniform, reliable and complete classification system of interventions used by physical therapists, occupational therapists and sports therapists to improve the mobility and self-care of patients with a spinal cord injury. This classification system enables the contents of treatments to be identified, information that can be used to improve the effectiveness and efficiency of inpatient rehabilitation of patients with a spinal cord injury.

Chapter 2 describes how the first version of the classification system, which was later named the Spinal Cord lnjury-lnterventions Classification System (SCl-ICS ), was tested in a modified Delphi consensus procedure. The main aim of this study was to reach consensus about definitions of the levels, the categories and interventions in the system and to refine them if necessary. A total of 30 therapists from 10 Dutch and Flemish specialized SCI rehabilitation centers completed the first and second Delphi rounds. The results showed that the SCI-ICS met with high levels of consensus among the therapists in terms of the definitions of the 3 levels (range 87%-100%), the terminology used and the completeness of the classification (range 75%-100%). The perceived relevance of the categories for therapists' everyday work differed between disciplines. We concluded that the SCI-ICS seemed a potentially useful classification system to record clinical treatment sessions in physical therapy, occupational therapy and sports therapy for persons with spinal cord injury.

Chapter 3 reports on a study into the feasibility of the SCI-ICS. A total of 36 physical therapists, occupational therapists, and sports therapists from 3 Dutch specialized spinal cord injury rehabilitation centers used the SCI-lCS to record 856 treatment sessions of 142 inpatients and outpatients during 4 consecutive weeks, and completed questionnaires on the clarity of the SCI-ICS. Ninety-eight percent of all interventions could be classified, and the categories and interventions were mutually exclusive. Ninety-three percent of the treatment sessions were classified with little or no doubt. The therapists were able to record 45% of the treatment sessions within 1 minute, and 86Yo within 3 minutes. The therapists evaluated the general chapter of the manual (describing the structure and definitions of the SCI-lCS, and case-studies) as clear to very clear (77%), and rated the specific chapter (describing all inclusion and exclusion criteria of interventions, and detailed examples) as clear to very clear for 89% of the cases for which they consulted it. The SCI-ICS was evaluated as useful and easy to use. The feasibility study yielded several suggestions for improvement, which we used to refine the SCI-lCS. The SCI-lCS appeared suitable as a tool to record the contents of spinal cord injury treatment sessions in different settings and by different therapists.

In Chapter 4 we evaluate the reliability of the Dutch-language version of the SCI-lCS. Forty-eight randomly selected and videotaped interventions were observed and classified twice by 15 participants (12-20 per discipline) from 3 Dutch specialized spinal cord injury rehabilitation centers. A 4- or 5-digit code from the SCI-lCS was used to identify the level, category and type of the intervention. High levels of agreement between the researcher and the participants were found for both measurements, with at least 92% correctly classified interventions. The intra-rater reliability (therapists with themselves, comparing the 1.1 and 2nd measurements) was also good (91%).The inter-rater reliability (therapist with other (paired) therapist for the first and second measurements combined) was high for the physical therapists and the occupational therapists (92% and 87% respectively), but lower for the sports therapists (69%). This part of our study provided the first evidence of the reliability of the SCI-ICS.

Chapter 5 describes and compares the contents of interventions to improve mobility and self-care for patients with spinal cord injury in post-acute rehabilitation in 3 Dutch specialized spinal cord injury rehabilitation centers. During 4 consecutive weeks, 53 therapists used the SCI-ICS to record 1640 treatments of 48 patients with a recently acquired spinal cord injury. Since there was no evidence at that stage that mobility and self-care are the main domains of spinal cord injury rehabilitation treatment, this part and the subsequent part of the study used a version of the SCI-ICS that also included the option to record therapy aimed at other domains of the ICF (e.g. communication, domestic life). Findings showed that in all centers, the major part (94% overall) of the total recorded therapy time was spent on mobility and self-care interventions. The mean therapy time per patient per week (4.3 hours overall) did not differ between centers, and all centers spent most of this therapy time at the levels of body functions and basic activities, and least on task- and context-specific interventions at the complex activity level. The time spent on each level did not differ between the centers. In terms of the categories, most time was spent on interventions to improve muscle power, walking, and hand rim wheelchair propulsion. The time investment per category only differed between the centers for the categories of 'Joint mobility', 'Hand rim wheelchair propulsion' and 'Toileting'. All disciplines in all centers recorded the largest percentage of the time as exercise interventions (84% overall). This study showed more similarities than differences between 3 Dutch rehabilitation centers in terms of the therapy provided to their inpatients with spinal cord injury.

In Chapter 6 we describe and compare the contents of physical therapy, occupational therapy and sports therapy for patients with a spinal cord injury in post-acute inpatient rehabilitation in Australia, Norway and the Netherlands. Seventy-three therapists used the SCI-ICS to record 2526 treatments of 79 patients with a recently acquired spinal cord injury (48 in the Netherlands, 20 in Australia and 11 in Norway) during 4 consecutive weeks. As part of the procedure, the reliability of the English-language version of the SCI-ICS used by the Australian and Norwegian staff was tested, and proved to be good. Again, we found in all countries that by far the largest proportion of time (92% overall) was spent on mobility and self-care interventions. There were differences between the countries in the mean time spent per treatment (28 minutes in the Netherlands, 43 in Australia and 39 in Norway), and the total time per patient per week (4.3 hours in the Netherlands, 5.8 in Australia and 6.2 in Norway). Key similarity was the focus on exercises at the body function and basic activity levels, and the small proportion of time spent on task- and context-specific interventions at the complex activity level. Most therapy time was spent on 'Muscle Power' (all countries), 'Muscle Length' (Norway), 'Walking' (the Netherlands), and 'Transfers' (Australia).There were 13 categories for which the mean time spent per patient per week differed between the countries, controlled for type of SCI. We concluded that the SCI-ICS makes it possible to compare the contents of therapy between countries.

Chapter 7 presents the main conclusions of this thesis and a general discussion of our findings. Firstly, we successfully developed the SCI-ICS as an instrument to document treatment sessions by physical therapists, occupational therapists and sports therapists for the main domains of spinal cord injury rehabilitation, namely mobility and self-care. The SCI-ICS is:

sufficiently complete;
quick and easy to use;
a reliable instrument which can be used by different therapists from different settings and countries.

Second, we used the SCI-ICS to study spinal cord injury therapy programmes in different rehabilitation centers in different countries:

The 3 centers in the Netherlands provided similar therapy.
In all 5 settings of the 3 countries, most of the overall time was spent on mobility and self-care interventions, and on exercises.
There were differences between the 3 countries in the time spent on treatments and in the therapy focus.
There is a degree of overlap between treatments in physical therapy, occupational therapy and sports therapy for spinal cord injury rehabilitation.

This chapter also discusses the strengths of our study and presents methodological considerations, as well as suggestions for further development of the SCI-ICS, and implications for its use in clinical practice and future research. The SCI-ICS should be implemented in clinical practice. Team conferences can use SCI-ICS data on the contents of therapy over the period since the previous meeting as a guide to optimize individual therapy programmes, helping to achieve patients' rehabilitation goals, and to facilitate interdisciplinary communication and communication with patients. Direct electronic entry of therapy data would save therapists' time and reduce specific data entry costs. The scope of the SCI-ICS could be expanded to include cognitive therapy, communication and domestic life, and therapy provided by the nursing staff. This chapter recommends the use of the SCI-ICS in longitudinal cohort studies on spinal cord injury inpatient rehabilitation to investigate the relationships between patient characteristics, the therapy provided and the functional outcomes of rehabilitation of persons with spinal cord injury.

You can read more information about this project in the Dutch or English newsletter.

List of publications

Development of a classification of physical, occupational, and sports therapy interventions to document mobility and self-care in spinal cord injury rehabilitation. Van Langeveld SA, Post MW, van Asbeck FW, Postma K, Ten Dam D, Pons K. J Neurol Phys Ther. 32(1):2-7, 2008.
Feasibility of a classification system for physical therapy, occupational therapy, and sports therapy interventions for mobility and self-care in spinal cord injury rehabilitation. van Langeveld SA, Post MW, van Asbeck FW, Postma K, Leenders J, Pons K. Arch Phys Med Rehabil. 89(8):1454-9, 2008.
Reliability of a new classification system for mobility and self-care in spinal cord injury rehabilitation: the spinal cord injury-interventions classification system. van Langeveld SA, Post MW, van Asbeck FW, Ter Horst P, Leenders J, Postma K, Lindeman E. Arch Phys Med Rehabil. 90(7): 1229-36, 2009.
Contents of physical therapy, occupational therapy, and sports therapy sessions for patients with a spinal cord injury in three Dutch rehabilitation centres. van Langeveld SA, Post MW, van Asbeck FW, Ter Horst P, Leenders J, Postma K, Rijken H, Lindeman E. Disabil Rehabil 2010.
Comparing contents of therapy for people with a spinal cord injury in postacute inpatient rehabilitation in Australia, Norway, and the Netherlands. van Langeveld SA, Post MW, van Asbeck FW, Gregory M, van der Meer Halvorsen A, Leenders J, Postma K, Rijken H, Lindeman E. Submitted 2010.