This observational cross-sectional study aims to investigate the relationship between patient and therapist perceptions of safe ambulation and objective clinical outcomes in individuals with incomplete spinal cord injury (iSCI). Adults with iSCI at T3 or lower levels (ASIA C or D) admitted to an inpatient rehabilitation program are assessed for walking status using the Walking Index for Spinal Cord Injury II (WISCI II), including patient-rated and therapist-rated levels. Secondary outcomes include lower extremity muscle strength, gait speed, timed up and go, balance, functional independence, quality of life, fall risk, and assistive device preferences. The study seeks to identify the extent to which patient and therapist perceptions align with objective measures and to explore their associations with fall history and functional outcomes, aiming to improve discharge planning and fall prevention strategies.
This observational, cross-sectional study was conducted to examine the relationship between perceived and actual safe ambulation levels in individuals with incomplete spinal cord injury (iSCI) and their association with key clinical outcomes. Adult participants (≥18 years) with traumatic or non-traumatic iSCI at T3 or lower levels (ASIA C or D) admitted to an inpatient rehabilitation program were included. Exclusion criteria were inability to provide informed consent or severe cognitive impairment (Mini-Mental State Examination score \< 25). The primary outcome was walking status, assessed using the Walking Index for Spinal Cord Injury II (WISCI II). Both patient-rated (P13) and therapist-rated (T5) WISCI II levels were recorded to capture perceived safe ambulation limits. Secondary outcomes included lower extremity muscle strength (LEMS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Spinal Cord Independence Measure III (SCIM III), and WHOQOL-BREF-TR for health-related quality of life. Additional questionnaires assessed fall risk perception, assistive device preferences, readiness for discharge, coping strategies, acceptance and action levels, and assistive technology satisfaction. Gait parameters were measured on a C-Mill® treadmill platform, including step time, stance phase percentage, stride length, step width, cadence, gait speed, and double support time. Falls and near-fall incidents in the past year were self-reported. Data were analyzed to determine correlations between perception-based and performance-based measures and to explore the relationship between discrepancies in patient and therapist ratings with fall frequency and functional independence. The study aims to provide evidence to guide clinical decision-making in rehabilitation, optimize discharge planning, reduce fall risk, and improve the integration of patient perspectives into therapy planning for individuals with iSCI.
Study Type
OBSERVATIONAL
Enrollment
43
Ankara City Hospital
Çankaya, Ankara, Turkey (Türkiye)
Walking Index in Spinal Cord Injury II
Walking Index for Spinal Cord Injury II (WISCI II), which assessed walking independence and the need for assistive devices. Scores ranged from 0 to 20 based on the amount of physical assistance, use of braces, and walking aids required to walk 10 meters. In addition to the measured WISCI II score, patient-rated WISCI II (P13) and therapist-rated WISCI II (T5) levels were recorded to reflect the levels at which the individual and the clinician perceived safe ambulation.
Time frame: Baseline (single time point, within 24-month recruitment period)
ASIA Lower Extremity Muscle Score
Assessment of lower extremity muscle strength using the American Spinal Injury Association (ASIA) Lower Extremity Motor Score (LEMS)
Time frame: Baseline (single time point, within 24-month recruitment period)
Ten-Meter Walking Test
Ten-Meter Walking Test for overground walking speed assessment
Time frame: Baseline (single time point, within 24-month recruitment period)
Timed Up and Go Test
Timed Up and Go Test overground walking assessment
Time frame: Baseline (single time point, within 24-month recruitment period)
Berg Balance Scale
Berg Balance Scale for balance assessment
Time frame: Baseline (single time point, within 24-month recruitment period)
Spinal Cord Independence Measure (SCIM III)
Spinal Cord Independence Measure (SCIM III) for activity of daily living assessment
Time frame: Baseline (single time point, within 24-month recruitment period)
World Health Organization Quality of Life Scale-Short Form (WHOQOL - BREF)
World Health Organization Quality of Life Scale-Short Form (WHOQOL - BREF) for quality of life assessment
Time frame: Baseline (single time point, within 24-month recruitment period)
Quebec User Evaluation of Satisfaction with Assistive Technology 2.0 (QUEST 2.0)
A questionnaire evaluating user satisfaction with assistive devices in terms of performance and service quality.
Time frame: Baseline (single time point, within 24-month recruitment period)
RHDS/SF
The RHDS/SF assessed patients' self-perceived readiness for hospital discharge and ability to manage care needs at home, with scores from 0 to 10 where higher scores indicated greater readiness.
Time frame: Baseline (single time point, within 24-month recruitment period)
Acceptance and Action Questionnaire - II (AAQ-II)
The AAQ-II measured psychological flexibility and experiential avoidance using nine items rated from 1 (never true) to 7 (always true), with lower scores indicating greater flexibility.
Time frame: Baseline (single time point, within 24-month recruitment period)
Spinal Cord Lesion-Related Coping Strategies Questionnaire (SCLCSQ)
The SCLCSQ assessed coping strategies in individuals with spinal cord injury across three domains-acceptance, social confidence, and fighting spirit-using 12 items rated on a 4-point scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P1 - Fear of falling during daily ambulation with preferred assistive device/orthosis (Visual Analog Scale)
P1 assessed the patient's fear of falling during daily ambulation with their preferred assistive device or orthosis on a 0-100 mm visual analog scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P2 - Perceived risk of falling during daily ambulation with preferred assistive device/orthosis (Visual Analog Scale)
P2 assessed the patient's perceived risk of falling during daily ambulation with their preferred assistive device or orthosis on a 0-100 mm visual analog scale. Time Frame: Baseline (single time point, within 24-month recruitment period)
Time frame: Baseline (single time point, within 24-month recruitment period)
P3 - Perceived overall mobility compared to self-perceived maximum potential (Visual Analog Scale)
P3 assessed perceived overall mobility compared to the patient's self-perceived maximum potential on a 0-100 mm visual analog scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P4 - Degree of use of the most appropriate assistive device/orthosis during upright daily activities (Visual Analog Scale)
P4 assessed the degree to which the most appropriate assistive device or orthosis was used during upright daily activities on a 0-100 mm visual analog scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P5 - Comfort when using assistive devices/orthoses for walking or standing (Visual Analog Scale)
P5 assessed comfort when using assistive devices or orthoses for walking or standing on a 0-100 mm visual analog scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P6 - Perceived difficulty when using assistive devices/orthoses for walking or standing (Visual Analog Scale)
P6 assessed perceived difficulty when using assistive devices or orthoses for walking or standing on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P7 - Fatigue after using assistive devices/orthoses for 30-40 minutes in a single session (Visual Analog Scale)
P7 assessed fatigue experienced after using assistive devices or orthoses for 30-40 minutes in a single session on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P8 - Proportion of upright daily activities performed with walking aids (Visual Analog Scale)
P8 assessed the proportion of upright daily activities performed with walking aids on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P9 - Proportion of upright daily activities performed with seating aids (Visual Analog Scale)
P9 assessed the proportion of upright daily activities performed with seating aids such as wheelchairs on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
P10 - Average daily hours spent standing (self-reported)
P10 recorded the average daily hours spent standing as reported by the patient.
Time frame: Baseline (single time point, within 24-month recruitment period)
P11 - Average daily hours spent sitting (self-reported)
P11 recorded the average daily hours spent sitting as reported by the patient.
Time frame: Baseline (single time point, within 24-month recruitment period)
P12 - Average daily hours spent lying down (self-reported)
P12 recorded the average daily hours spent lying down as reported by the patient.
Time frame: Baseline (single time point, within 24-month recruitment period)
P14 - Assistive device/orthosis planned for use in indoor ambulation after hospital discharge (Walking Index for Spinal Cord Injury II adapted categorical item)
P14 recorded the assistive device or orthosis planned for indoor ambulation after discharge, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
P15 - Assistive device/orthosis planned for use in outdoor ambulation after hospital discharge (Walking Index for Spinal Cord Injury II adapted categorical item)
P15 recorded the assistive device or orthosis planned for outdoor ambulation after discharge, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
P16 - Type of assistive device/orthosis used for outdoor ambulation over short distances during therapy (Walking Index for Spinal Cord Injury II adapted categorical item)
P16 recorded the type of assistive device or orthosis used for outdoor ambulation over short distances during therapy, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
P17 - Number of falls within the past year in therapy and non-therapy settings (self-reported count)
P17 recorded the number of falls within the past year in therapy and non-therapy settings as self-reported by the patient.
Time frame: Baseline (single time point, within 24-month recruitment period)
P18 - Number of near-fall incidents within the past year in therapy and non-therapy settings (self-reported count)
P18 recorded the number of near-fall incidents within the past year in therapy and non-therapy settings as self-reported by the patient.
Time frame: Baseline (single time point, within 24-month recruitment period)
P19 - Assistive device/orthosis expected to be used in daily life after discharge (Walking Index for Spinal Cord Injury II adapted categorical item)
P19 recorded the assistive device or orthosis expected to be used in daily life after discharge, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
T1 - Perceived patient's fall risk during daily ambulation with preferred assistive device/orthosis (Visual Analog Scale)
T1 assessed the therapist's perception of the patient's fall risk during daily ambulation with their preferred assistive device or orthosis on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
T2 - Overall mobility compared to the patient's maximum potential (Visual Analog Scale)
T2 assessed the therapist's perception of the patient's overall mobility compared to their maximum potential on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
T3 - Mobility level compared to a similar person without the injury (Visual Analog Scale)
T3 assessed the therapist's perception of the patient's mobility level compared to a similar person without injury on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
T4 - Degree of use of the most appropriate assistive device/orthosis during upright daily activities without therapist guidance (Visual Analog Scale)
T4 assessed the degree to which the patient used the most appropriate assistive device or orthosis during upright daily activities without therapist guidance, on a 0-100 mm Visual Analog Scale.
Time frame: Baseline (single time point, within 24-month recruitment period)
T6 - Type of assistive device/orthosis used for outdoor ambulation over short distances during therapy (Walking Index for Spinal Cord Injury II adapted categorical item)
T6 recorded the type of assistive device or orthosis used for outdoor ambulation over short distances during therapy, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
T7 - Assistive device/orthosis recommended for daily life after discharge (Walking Index for Spinal Cord Injury II adapted categorical item)
T7 recorded the assistive device or orthosis recommended for daily life after discharge, adapted from Walking Index for Spinal Cord Injury II categories.
Time frame: Baseline (single time point, within 24-month recruitment period)
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