Early Versus Delayed Inpatient Spinal Cord Injury Rehabilitation: An Italian Study Giorgio Scivoletto, MD, Barbara Morganti, PT, Marco Molinari, MD, PhD ABSTRACT. Scivoletto G, Morganti B, Molinari M. Early versus delayed inpatient spinal cord injury rehabilitation: an Italian study. Arch Phys Med Rehabil 2005;86:512-6. Objective: To examine what effect the injury-to-rehabilita- tion interval has on the outcome of spinal cord injury (SCI) rehabilitation. Design: Retrospective study. Setting: Spinal unit of a large rehabilitation hospital. Participants: Consecutive admissions were divided into groups according to age, sex, and American Spinal Injury Association impairment grade and neurologic level of injury. The patients were matched for these variables and divided into groups according to the interval from injury to admission into acute rehabilitation. This approach resulted in 150 patients with SCI grouped into 50 comparison subgroupings. Interventions: Three comparison groups—short (30d), medium (31– 60d), and long (60d) time to admission (TTA)—were evaluated for rehabilitation outcomes. Main Outcome Measures: Barthel Index, Rivermead Mo- bility Index, Walking Index for Spinal Cord Injury, and motor scores at admission and discharge were examined. The changes and efficiencies were evaluated. Results: The 3 groups were comparable for all medical and demographic characteristics as well as neurologic recovery. The 3 subgroups differed significantly in activity of daily living outcomes, with the short TTA group exhibiting higher Barthel Index raw discharge scores, score increases, and score efficiencies. Conclusions: Early rehabilitation seems to be a relevant prognostic factor of functional outcome. Rehabilitation inter- vention in patients with SCI should begin as soon as possible, in a specialized setting, because delay may adversely affect functional recovery. Key Words: Rehabilitation; Spinal cord injuries; Treatment outcome. © 2005 by American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation S EVERAL STUDIES ON spinal cord injury (SCI) recovery have been conducted to evaluate the role of medical, per- sonal, and demographic variables in functional outcome. Age and degree of disability at admission have been identified as strong prognostic factors influencing rehabilitation programs and amount of recovery. Although the relation between age and outcomes (with increasing age being associated with worse outcomes) is very well known in SCI patients, 1 only few data are reported about the effect of either precocious or delayed rehabilitation. 2,3 It is crucial to determine when to begin rehabilitation: a considerable amount of neurologic recovery usually occurs within the first few months after SCI, although some amelio- ration may occur later. Despite this knowledge, only 1 study 2 has examined the importance of time-to-admission interval (TTA): a short interval, with rehabilitation beginning quickly after the lesion, has been recognized as a relevant favorable prognostic factor. However, TTA varies greatly in different countries. Because TTA depends on the clinical course of the acute phase and the number of beds available in rehabilitation wards, outcome studies should be adapted to each situation. In some cases, admission to a rehabilitation ward is delayed because of the patient’s comorbidities, and rehabilitation can be started only after the patient’s medical condition has stabi- lized. The aim of the present study was to evaluate the specific influence of TTA on rehabilitation outcomes in consecutive SCI inpatients after age, lesion characteristics, and disability matching was completed, to rule out the influence of factors recognized as strongly prognostic. In particular, we compared rehabilitation results across homogeneous subgroups of pa- tients who were admitted for rehabilitation of SCI sequelae and separated according to the period when they started specific rehabilitation. METHODS We retrospectively evaluated the charts of spinal cord lesion inpatient survivors admitted to our Spinal Unit between Janu- ary 1997 and December 2001. Admission of SCI patients to our free-standing rehabilitation facility is based on their ability to participate actively in rehabilitation activities and to tolerate intense therapeutic interventions. Within our system of care, we have a paucity of beds in relation to the demand for services and thus have a waiting list for admission. Admissions are controlled by administration, according to a prioritizing scheme. Thus, we find that some of our patients are discharged from the acute care setting to home before they receive for- malized acute rehabilitation services. Most of these patients received conventional home care physical therapy (PT) ser- vices while awaiting hospital admission. No patient included in this study had been admitted to acute inpatient rehabilitation in the past. Whenever a patient was discharged or transferred for more than 3 weeks, the readmission was considered a second admission and the patient was excluded. The rehabilitation plan was based on practical skills charac- teristic of activities of daily living (ADLs). Individual PT was performed for 60 minutes twice a day, 5 days a week, and a single 60-minute treatment on Saturday. All patients also un- derwent water therapy (45min twice weekly) and occupational therapy (45min 3d/wk). All rehabilitation treatment began within 24 hours of admission. If necessary, patients had access to individual training for breathing, bowel, and bladder dys- function. PT continued throughout the hospital stay. From the Spinal Cord Unit, IRCCS Foundation S. Lucia, Rome (Scivoletto, Morganti, Molinari); and Institute of Neurology, Catholic University, Rome (Molinari), Italy. Supported in part by the Italian Ministry of Health. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Giorgio Scivoletto, MD, Spinal Cord Unit, IRCCS Fondazione S. Lucia, Via Ardeatina 306, 00179 Rome, Italy, e-mail: g.scivoletto@hsantalucia.it. 0003-9993/05/8603-9049$30.00/0 doi:10.1016/j.apmr.2004.05.021 512 Arch Phys Med Rehabil Vol 86, March 2005