|Year : 2018 | Volume
| Issue : 2 | Page : 135-143
Effect of pre-discharge instructions on patients’ activities and functional ability post spinal cord injury
Soheir M Weheida1, Entisar Gaad-Elmoula Shabaan2, Amal Fehr3
1 Medical Surgical Nursing, Faculty of Nursing, Alexandria University, Egypt
2 Lecturer of Medical Surgical Nursing, Faculty of nursing Aswan University, Egypt
3 Lecturer of Rheumatology and Physical Medicine, Faculty of Medicine Hlwan University, Cairo, Egypt
|Date of Submission||28-Nov-2017|
|Date of Acceptance||09-May-2018|
|Date of Web Publication||12-Nov-2018|
Entisar Gaad-Elmoula Shabaan
Lecturer in Medical Surgical Nursing, Faculty of Nursing, Aswan University, Aswan
Source of Support: None, Conflict of Interest: None
Background Spinal cord injury (SCI) disrupts spinal cord function, and patients after SCI require long-term physical and occupational therapy, as the injuries interfere with activities of daily (ADL) living and function ability. This study may bring into light the amount of care and dependency that individuals with SCI will face as they are discharged from hospital and re-integrate back into their usual life.
Aim This study aimed to evaluate the effect of predischarge instructions on ADL and functional ability of patients with SCI.
Patients and methods The study was conducted in Neurosurgery and Physical Medicine Department at Aswan University Hospital.
Sample This study included 120 adult patients of both sexes. These patients were divided equally into two groups: study and control. Data were collected from them within 1 year from January 2015 to January 2016. Inclusion criteria were recent admission because of SCI with no previous spinal surgery, no other medical problems and muscle-skeleton deformity that may interfere with educational instructions outcome, and had no hindering factors to communicate verbally. A control patient group with the same inclusion criteria was matched with the study group but was not given predischarge instructions. Four tools were used: 1. Structured interview questions and Medical Data Sheet; 2. Knowledge Questionnaire and Lifestyle Assessment Questionnaire: 3. ADL Questionnaire. 4. Compliance Discharge Instructions.
Results Findings revealed that only 8.3% of pre instruction patients were oriented about range of motion exercises, and 6.6% about healthy lifestyle as compared with the satisfactory post instructions knowledge (96.6%, 95.0% respectively), at P values=.000*).
Conclusion Statistical significant difference between pre & post instruction of discharge knowledge regarding range of motion exercises, lifestyle, ADL and overall discharge compliance.
Recommendations Encourage a simple illustrated booklet to patients’ post SCI includes all therapeutic instructions could help increasing patient’s awareness, understanding, and perform activities.
Keywords: activity of daily living, functional ability, spinal cord injury
|How to cite this article:|
Weheida SM, Shabaan EG, Fehr A. Effect of pre-discharge instructions on patients’ activities and functional ability post spinal cord injury. Egypt Nurs J 2018;15:135-43
|How to cite this URL:|
Weheida SM, Shabaan EG, Fehr A. Effect of pre-discharge instructions on patients’ activities and functional ability post spinal cord injury. Egypt Nurs J [serial online] 2018 [cited 2018 Dec 14];15:135-43. Available from: http://www.enj.eg.net/text.asp?2018/15/2/135/245119
| Introduction|| |
A spinal cord injury (SCI) is an injury to the spinal cord resulting in a change, either temporary or permanent, in the spinal cord related to motor, sensory, or autonomic function (Sabapathy et al., 2015Sabapathy et al., 2015). Common causes of damage are trauma such as car accident, gunshot, falls, and sports injuries (Blakey, 2011). Loss of function depends on the spinal cord and nerve roots damaged; the symptoms can vary rapidly, from pain to paralysis to incontinence. SCI cause loss of motors functions, which effect on the patient activates and function ability, sometime total loss of motors function (Van den Berg et al., 2011).
SCI may result in impairment of an individual’s physical and psychosocial function; it may result in disability and dependence. The extent and location of damage influences the severity of the impairments and functional limitations present. There are basic skills involved in self-care activities and mobility that are needed for higher levels of functioning in individuals with SCI (Itzkovich et al., 2007Itzkovich et al., 2007). Therefore, an improvement of these skills will have a considerable effect on the patients’ level of disability, independent functioning, and consequently their lifestyle (Van der Putten et al., 2001).
The factors that influence the functional ability of individuals with SCI resulting in temporary or permanent damage. Some of these factors are; age at onset of SCI, delayed admission, length of hospital stay including complications such as pressure sores, urinary tract infections, deterioration in neurological level, and respiratory problems (Osterthun et al., 2009).
Improvement of locomotor function is one of the primary goals for patient with a SCI. SCI treatments may focus on specific goals such as restoring walking or locomotion to an optimal level for the individual (Danner et al., 2015Danner et al., 2015).
Activities of daily living (ADL) include eating, drinking, functional bathing, grooming, dressing and toileting. Also included are functional transfers, and home activity. ADL will be encouraged to perform and personal lifestyle change will be enhanced. Patients need to learn new techniques, such as the use of assistive devices to compensate for decreased muscle strength and range of motion or to compensate for decreased endurance (Thomas, 2009).
Predischarge instructions are largely a process of education dissemination to the patient and their family; thus, instructions must provide educational knowledge and access to educational resources to the patient and family to provide competent help and support for patients with SCI (Lyn et al., 2012).
SCI can often be life-threatening for patients, and high risk for post-operative complications as, pressure sores, urinary tract infections, and deterioration in neurological level. Over a 12-month period (from 1 January 2015 to 1 January 2016), ∼360 cases were admitted to the Neurosurgery and Physical Medicine Department at Aswan University Hospital. Approximately more than half of these were caused by motor car accidents or falls from height. Therefore, Aswan is one of the governorates in Egypt with the highest incidences of spinal injuries (Hospital Statistical Record, 2015). Post-SCI status severely limits movement and takes patients longer time to return to a normal active lifestyle. This study may help such group of patients to deal with ADL and enhance their functional ability.
| Aim|| |
This study aimed to evaluate the effect of predischarge instructions on ADL and functional ability for patients with SCI.
The designed predischarge instructions have a role to maintain ADL and functional ability for patients after SCI operation.
| Patients and methods|| |
A quasi-experimental design was utilized in this study. The current research adopted this design, because it is difficult to randomize sample representing the patients.
The study was carried out at the Neurosurgery and Physical Medicine Departments at Aswan University Hospital.
This study included 120 adult patients of both sexes. These patients were divided equally into two groups: study and control. Data were collected within 1 year from January 2015 to January 2016. Inclusion criteria were recent admission because of SCI with no previous spinal surgery, no other medical problems and muscle-skeletal deformity that may interfere with educational instructions outcomes, and having no hindering factors to communicate verbally. A control group including patients with the same inclusion criteria were matched to the study group, but were not given predischarge instructions.
Tools of the study
Four tools were used to collect the necessary data. The content validity of these tools was checked by expert professors in fields of medicine and nursing, and corrections were carried out accordingly. The reliability was 0.9, as calculated by the Kuder–Richardson-20 formula. Kuder–Richardson-20 is used with dichotomous items.
- Structured interview questions for personal and medical data sheet: the first part covers variables related to age, sex, occupation, marital status, and level of education. The second part covers data related to patient’s degree of SCI, indication for surgery, number of vertebrae affected, type of surgery, effect of SCI on body function, and degree of patient dependence.
- Knowledge Questionnaire and Lifestyle Assessment Questionnaire: ADL are pertinent to knowledge related to discharge care and lifestyle modification such as exercises and device used after hospitalization, sensory changes how to touch and feel, positioning and transferring, concerns about catheters and bladder care, skin care, smoking habits, and nutrition instructions. Hamilton Health Sciences (2015). The total score was based on 15 grades, and each answer takes one grade.
- ADL checklist was used to assess patient ability to perform ADL independently. The checklist is used to detect problems in performing ADL and to plan care accordingly. The patient performance is assessed in the main seven functions of bathing, dressing, toileting use, transferring, walking, continence, and eating (Hartigan, 2007). Total score was divided as follows: 6 indicates full function, 4 indicates no assistance, 2 for needed some assistance, and 0 for complete assistance.
- Compliance discharge instructions: It includes physical activity and lifestyle compliance instructions. The first part is pertinent to exercises (range of motion exercises). The total compliance score was (48) grades, (i.e. 16 items, patient perform one item takes three greed, don’t perform takes=0). The second part was lifestyle modification compliance, which includes instructions about physical activity, sensory changes, catheters and bowel care, skin care, and proper bone and wand nutrition. The total lifestyle compliance score was 30 item-90 score. Score for each level of compliance ranged from 1 to 3 score.
The general objective of the instruction was to help patients after SCI to regain normal life. The educational instruction was developed by the researchers based on the knowledge and practice needs in a form of printed Arabic booklet. It was also supplemented with information based on review of relevant literature (nursing textbook, journals, magazine, internet resources, etc.) about lifestyle compliance instructions. The booklet was adopted from Hamilton Health Sciences (2015)Hamilton Health Sciences (2015) and Thomas (2009). Then the instruction was reviewed by a panel of experts before its implementation. The educational instructions included the following: the first part was pertinent to exercises (range-of-motion exercises), the second part to ADL, and third part to practical activity of catheters and bowel care, skin care, and proper nutrition and lifestyle.
Evaluation of the success of instructions was based on the patients’ compliance. This evaluation was done two times for knowledge and three for compliance. Discharge compliance instruction was completed from the participant by utilizing telephone call during the first month after discharge because of the difficulties for patients in moving and transferring. There was an open channel of communication between the researchers and the patients or family for consultation, feedback, and follow-up visit at outpatient of physical medicine clinic during second and third months.
Official approval letters were obtained from the Neurosurgery and Physical Medicine Departments at Aswan University Hospital to conduct the research. Oral consent was taken from the patients for participating in the study after full explanation of the program and benefits of the instructions.
Field of the work
This study was carried out through a period of data collection within 1 year from January 2015 to January 2016. The designed teaching instruction materials including educational booklet, construction, and testing of different study tools. Moreover, it was concerned with managerial arrangements to carry out the study.
The implementation of instructions among the patients who met the criteria for inclusion was identified daily from admission records. Additionally, the data were collected from the patients through structured interview and patients’ files to assess patients’ needs and problems. Sociodemographic, medical data sheet, and lifestyle sheet were filled out by the researchers.
The researchers assessed the patients’ knowledge by a written pretest. The developed health education about lifestyle modifications was implemented individually for the study group in the Physical Medicine Department at Aswan University Hospital. The performance of the educational instructions about lifestyle modification and ADL was estimated for the patients after SCI in the form of five scheduled sessions: before discharge and at 1, 2, and 3 months after discharge.
The patients were divided into four groups, with each group including 15 patients. The instructions was applied through four sessions, and each session lasted 30–45 min. Each participant took a copy of the instructions booklet that included all the required instructions and training. Patients perform exercise and Passive Range-of-Motion Exercises post SCI: Start exercises should be held for 20–30 s and repeated 2–5 times as: Shoulder and elbow, flexion, extension, and abduction. Wrist & hand flexion, extension. Hip and knee flexion, abduction. Ankle rotation, Toe flexion and extension. Active Range-of-Motion Exercises: done by patient.
On the day of discharge, discharge plan was taught to the patients. It included information about exercise, physical activity, bowel and bladder care, skin care, etc. Written booklet was given to the patients. Before patients were discharged, immediate postdischarge knowledge test was given. A control patient group matched with the study group was never given predischarge instructions during the study period, but the instructions were given at the end of the study period.
A pilot study was conducted on 10% of sample to estimate the needed time for data collection, and to test the feasibility, objectivity, and applicability of the study tool. The patients who participated in the pilot study were all included in the study sample.
A written consent was taken from each patient after explaining the reason and benefits of this research. The researchers emphasized that participation in the study was completely voluntary, and each patient had the right to withdraw from the study at any time without giving any reason. Moreover, anonymity and confidentiality were ensured through coding and tabulating the data.
The collected data were coded and entered to Statistical Package for Social Sciences windows software, version 21.0 (SPSS Inc., Chicago, Illinois, USA). The following tests were used: arithmetic mean as an average, describing the central tendency of observations, and SD, as a measure of dispersion of results around the mean. The frequency and percentage of observations were recorded, and repeated measures analysis of variance was used to measure the change over time for the studied variables.
| Results|| |
[Table 1] shows the sociodemographic characteristics of the patients and reveals that the age of the study and control groups ranged from 20 to 60 years old, with a mean of 35.67±4.89 and 35.44±5.73 years, respectively. Most study and control group patients (73.33 and 85.0%, respectively) were male. Overall, 64.0 and 76.7% of the study and control group patients were married. Moreover, 58.33% of the study and control group patients were manual workers, and 60 and 58%, respectively, were illiterate; no statistically significant difference was found between study and control groups.
|Table 1 Frequency and percentage distribution of sociodemographic characteristics among the studied participants (N=120)|
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[Table 2] depicts that ∼41.7% of SCI events were caused by motor car accidents. Overall, 68.3% of the studied sample showed indication for surgery of vertebral fractures in back or neck, and 80.00% indicated the type of surgery was metal plate insertion. Moreover, 16.7% of patients with SCI in the studied group had bed sores, and 38.33% had bowel and bladder control problems. In addition, 73.33% were having pain, and most SCI (93.39%) affected sexuality. Furthermore, 93.3% of the studied sample was completely independent postoperatively.
|Table 2 Frequency and percentage distribution related to causes, indications, vertebra affected, type of surgery, and degree of dependence among the studied patients (n=60)|
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[Table 3] shows that among those who have inaccurate knowledge, most were illiterate followed by those who could read and write, had secondary level, and had university level (70.0, 71.42, 62.5, and 60.0%, respectively). Moreover, 10.0, 14.28, 25, and 20% who good knowledge were illiterate, read and write, secondary level, and university level. However, this difference was not statistically significant (P>0.05). There was also no significant correlation between educational level of studied sample and their knowledge level.
|Table 3 Preinstruction knowledge level according to the education level of respondents (N=60)|
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[Figure 1] reveals that 38.3% performed physical activity regularly, whereas 16.6% never performed it. Overall, 53.3% of the studied sample had performed bowel and bladder care, whereas 8.3% had never performed it. Moreover, 81.6% had performed full skin care, and 56.6% had complete smoking cession. In addition, 80.0% had adopted correct nutritional habits, whereas 6.6% had not at all.
|Figure 1 Frequency and percentage distribution of the physical activity, bowel and bladder care, skin care, smoking habits, and nutritional habits after instructions (n=60).|
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[Table 4] depicts that 25.00% of the studied sample need no assistance during toileting before instructions, whereas 58.33% needed some assistance during dressing. Overall, 88.33% were dependent on someone for cleaning before instructions. After instructions, the majority of the studied sample (91.66%) needed no assistance with walking, and 63.3% were dependent on someone else for cleaning.
|Table 4 Comparison between the total score of activities of daily living before and after instruction (n=60)|
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[Table 5] illustrates that only 8.3% of patients were oriented about range-of-motion exercises and 6.6% about healthy lifestyle before instructions as compared with 96.6 and 95.0%, respectively, having sufficient knowledge after postdischarge instructions. Moreover, there was a statistically significant difference in knowledge between after and before discharge instructions regarding range of motion exercises, lifestyle, and overall discharge compliance (P=0.000).
|Table 5 Frequency and percentage distribution, and test of significance of predischarge and postdischarge knowledge among the studied patients (N=60)|
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[Table 6] illustrates that there is a statistically significant difference among the studied sample during 3 months in relation to range of motion exercise, lifestyle, and overall compliance (P=0.000).
|Table 6 Comparison of the total score of postdischarge compliance at the first, second, and third month of the studied sample (N=60)|
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[Table 7] illustrates that there is a statistically significant difference between study and control groups during 3 months in relation to range of motion exercise, lifestyle, and overall compliance (P=0.000).
|Table 7 Relation between study group and control group regarding range-of-motion exercise compliance, lifestyle compliance, and overall compliance (N=120)|
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| Discussion|| |
SCIs result in a disability that can produce severe functional impairments (Kruger et al., 2013). Patients after SCI become dependent because of either loss of motor function or loss of bladder and bowel functions, which can have a severe effect on an individual’s ADL and overall level of functioning (Bluvshtein et al., 2011).
Regarding patient characteristics, the study showed that most cases (80.0%) were in the age group of 20–50 years, and most were men (77%). This agrees with Nas et al. (2015)Nas et al. (2015) who reported SCIs cause serious disability among patients. Every year, ∼40 million people worldwide experience SCI. Most of them are young men, typically aged from 20 to 35 years. In present study, 73.33% of cases were male, whereas 26.67% were female. This agrees with Cantu et al. (2013)Cantu et al. (2013) who reported males are more likely to experience spinal trauma than females.
Concerning the causes of injury for studied patients, results revealed that approximately half of the studied sample was involved in motor car accidents. This agrees with Yip and Malaspina (2012) who found motor vehicle accidents were the most common mechanism of injury. The most common causes of SCI worldwide are traffic accidents, gunshot injuries, knife injuries, falls, and sports injuries.
In relation to patients’ preinstruction and postinstruction scores, there was a highly statistical significance (P<0.000) in the results for range of motion exercises, health lifestyle, and overall compliance, in favor of postinstructions result. This agrees with Jia et al. (2013) who reported that, present expertise staff working with this patients post operatively as well as instructions, highly significantly affect the patients’ functional ability and outcomes post SCI. Similar results by Aidinoff et al. (2011)Aidinoff et al. (2011) showed that most patients also did not reach functional independence by the time they were discharged instructions.
From this, it is seen that most participants in this study were discharged from rehabilitation without reaching functional independence. Similar results were found in a study by Aidinoff et al. (2011)Aidinoff et al. (2011) where the average discharge SCI score in paraplegic individuals was 67.8, which is not much higher than the average SCIM score in this study, and it shows that the majority of those individuals also did not reach functional independence by the time they were discharged from rehabilitation.
Concerning preinstruction and postinstruction measures, the results revealed that there were highly statistical significant differences between preinstruction and postinstruction measures in ADL (P<0.000), in favor of postinstruction measures. This agrees with Del-Ama et al. (2012)Del-Ama et al. (2012) who suggested that people with SCI may need to be directed to specialized devices and to make modifications to their environment to handle ADL and to function independently. Moreover, another opinion from Frood (2011) is that patients who are instructed to increase activity will help to increase their chances of recovery.
The study showed that there were highly significance differences in comparison of the total scores after discharge compliance at first, second, and third months of the studied sample in items range of motion exercises, lifestyle compliance and overall compliance. This agrees with Gorgey et al. (2013)Gorgey et al. (2013) who reported early predischarge instructions are important to prevent joint contractures, loss of muscle strength, conservation of bone density, and to ensure normal functioning of the respiratory and digestive system. An interdisciplinary approach is essential in rehabilitation in SCI, as in other types of rehabilitation Savaş and Ustunel (2013)Savaş and Ustunel (2013).
Yelnik et al. (2010) suggested that independent levels of functioning have frequently not been achieved in individuals with SCI at the time of discharge instructions. This finding induct emphasizing the importance of outpatient follow-up after discharge in order to reach full levels of functional independence.
Nursing team must be trained on predischarge instructions and on the importance and necessity of the instructions that must be shared with patients and their relatives (American Speech-Language-Hearing Association, ASHA, 2012). In another study performed by Wirth et al. (2008)Wirth et al. (2008) 64 patients with SCI had their functional ability assessed on admission to discharge, as well as needed follow-up instructions 1 year after injury along with their relatives.
Based on the study results, there was highly significance difference in comparison of the total score of study group and control group at first, second, and third month of the studied sample in items range of motion exercises, lifestyle compliance and overall compliance. According to Rice et al. (2013) who studied that, Intervention group with implemented dependent activities, showed significant improvements in a number of areas including exercise, transfer, ability to the car seat, toilet, bath, wheelchair movement, and eating habit. Also, recorded improvements in respiratory function, sphincter control, and no bed sores. All of these changes contributed to an improvement in functional independence.
Various outcomes of SCI instructions, at discharge and 1 year after injury, were explained by patient characteristics, whether preinjury or injury related. The amount of treatment received during inpatient instructions from various disciplines appears to explain limited or even little additional variance (American Dietetic Association, 2014).
Finally, based on the study results, significant differences were observed in patients and controls regarding overall compliance at 1, 2, 3 months. This result relates to strongly applications of predischarged instructions and follow-up.
| Conclusion|| |
Based on the results of the current study, it can be concluded that, patients who were exposed to the educational instructions after-SCI recorded improvement in knowledge mean score and overall compliance level. Moreover, a statistically significant difference was present between control and study groups.
The following recommendations could be inferred from the aforementioned conclusion:
- Encourage a simple illustrated booklet to patients after SCI, which includes all therapeutic instructions, could help increase patient’s awareness, understanding, and performing activities.
- Replication of the study on a larger probability sample from different geographical areas in Egypt.
- Further future studies should include period of follow-up longer than 3 months after-SCI, suggested to be 1 years, and this period is enough to monitor outcome to maximize the effect of instructions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Aidinoff E, Front L, Itzkovich M, Bluvshtein V, Gelernter I, Hart J et al.
(2011). Expected spinal cord independence measure, third version, scores for various neurological levels after complete spinal cord lesions. Spinal Cord 49:893–896.
American Dietetic Association (ADA) (2014). Spinal cord injury (SCI). Evidence-Based Nutrition Practice Guideline. Chicago, IL.
American Speech-Language-Hearing Association, ASHA (2012). Knowledge and skills needed by speech-language pathologist providing services to individuals with swallowing and or feeding disorders. 22:81–88.
Blakey L (2011). Falls Audit (May 2009–May 2010) at the National Spinal Injuries Centre. Unpublished work, Department of Clinical Psychology, NSIC, Stoke Mandeville Hospital, UK. Available at: http://www.buckshealthcare.nhs.uk
Bluvshtein V, Front L, Itzkovich M, Aidinoff E, Gelernter I, Hart J et al.
(2011). SCIM III is reliable and valid in a separate analysis for traumatic spinal cord lesions. Spinal Cord 49:292–296.
Cantu RC, Li YM, Abdulhamid M, Chin LS (2013). Return to play after cervical spine injury in sports. Curr Sports Med Rep 12:14–17.
Danner SM, Hofstoetter US, Freundl B, Binder H, Mayr W, Rattay F, Minassian K (2015). Human spinal locomotor function control is based on flexibly organized burst generators. Brain 138 (Pt 3):577–588.
Del-Ama AJ, Koutsou AD, Moreno JC, de-los-Reyes A, Gil-Agudo A, Pons JL (2012). Review of hybrid exoskeletons to restore gait following spinal cord injury. J Rehabil Res Dev 49:497–514.
Diong J, Harvey LA, Kwah LK, Eyles J, Ling MJ, Ben M, Herbert RD (2012). Incidence and predictors of contracture after spinal cord injury − a prospective cohort study population. Spinal Cord 50:579–584.
Douiri A, Rudd A, Wolfe C (2012). Prevalence of poststroke cognitive impairment: South London stroke register 1995-2010. Stroke 44:138–145; Originally Published Online November 13, 2012; doi: 10.1161/STROKEAHA.112.670844.
Emerich L, Parsons KC, Stein A (2012). Competent care for persons with spinal cord injury and dysfunction in acute inpatient rehabilitation. Top Spinal Cord Inj Rehabil 18:149–166.
Frood RT (2011). The use of treadmill training to recover locomotor ability in patients with spinal cord injury. Biosci Horiz 4:108–117.
Gorgey AS, Mather KJ, Gater DR (2011). Central adiposity associations to carbohydrate and lipid metabolism in individuals with complete motor spinal cord injury. Metabolism 60:843–851.
Gorgey AS, Dolbow DR, Cifu DX, Gater DR (2013). Neuromuscular electrical impulses to stimulation attenuates thigh skeletal muscles atrophy but not trunk muscles and bone after spinal cord injury. J Electromyogr Kinesiol 23:977–984.
Hartigan I (2007). A comparative review of the Katz ADL and the Barthel Index in assessing the activities of daily living of older people. Int J Older People Nurs 2:204–212.
Hamilton Health Sciences (2015). Spinal Cord Injury Rehabilitation Program. Available at: http://www.sciontario.org/
(Spinal Cord Ontario website). PD 4836 -07/2015 dt/July 19, 2015 WPCPtedScibkletSCI-Introguide-Th.Doc.
Itzkovich M, Gelernter I, Biering-Sorensen F, Weks C, Laramee M, Craven B et al.
(2007). The Spinal Cord Independence Measure (SCIM) version III: reliability and validity in a multi-centre international study. Disabil Rehabil 29:1926–1933.
Jia X, Kowalski RG, Sciubba DM, Geocadin RG (2013). Critical care of traumatic spinal cord injury. J Intensive Care Med 28:12–23.
Kruger EA, Pires M, Ngann Y, Sterling M, Rubayi S (2013). Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. J Spinal Cord Med 36:572–585.
Lyn E, Parsons KC, Adam S (2012). Competent care for persons with spinal cord injury and dysfunction in acute inpatient rehabilitation, Top Spinal Cord Int Rehabil Spring; 18:149–166.
Nas K, Yazmalar L, Şah V, Aydın A, Öneş K (2015). Rehabilitation of spinal cord injuries, around World J Orthop 6:8–16.
Osterthun R, Post MW, van Asbeck FW (2009). Characteristics, length of stay and functional outcome of patients with spinal cord injury in Dutch and Flemish rehabilitation centres. Spinal Cord 47:339–344.
Rice LA, Smith I, Kelleher AR, Greenwald K, Hoelmer C, Boninger ML (2013). Impact of the clinical practice guideline for preservation of upper limb function on transfer skills of persons with acute spinal cord injury. Arch Phys Med Rehabil 94:1230–1246.
Sabapathy V, Tharion G, Kumar S (2015). Cell therapy augments functional recovery subsequent to spinal cord injury under experimental conditions. Stem Cells Int 2015:132172.
Savaş F, Ustunel S, Omurilik yaralanması sonras (2013). Rehabilitasyon prensipleri (Principles of rehabilitation after spinal cord injury). In: Hancı M, Erhan B, editors. omurga ve omurilik yaralanmaları (Spine and spinal cord injuries). İntertıp. pp. 585–588. Available online at http://www.ftrdergisi.com
. Cite this article as: Erhan B. Updates in ASIA Evaluation: Lower Extremity Moto Evaluation. Turk J Phys Med Rehab 2015; 61. (Supp. 1):S19-S24.
Van den Berg ME, Castellote JM, Mahillo-Fernandez I, Pedro-Cuesta J (2011). Incidence of traumatic spinal cord injury in Aragon, Spain (1972–2008). J Neurotrauma 28:469–477.
Van der Putten JJ, Stevenson VL, Playford ED, Thompson AJ (2001). Factors affecting functional outcome in patients with nontraumatic spinal cord lesions after inpatient rehabilitation. Neurorehabil Neural Repair 15:99.
Wirth B, van Hedel H, Kometer B, Dietz V, Curt A (2008). Changes in physical activity after complete spinal cord injury as measured by the spinal cord independence measure II. Neurorehabil Neural Repair 22:145.
Yelnik AP, Simon O, Parratte B (2010). How to clinically assess and treat muscle overactivity in spastic paresis. J Rehabil Med 42:801–807.
Yip PK, Malaspina A (2012). Spinal cord trauma and the molecular point of no return. Mol Neurodegener 7:6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]