Epidemiology and Rehabilitation Outcomes of Traumatic Spinal Cord Injuryin Iraq

Despite the fact that more than four thousandspinal cord injured (SCI) patients had been rehabilitated in Iraq during the last three decades, still there is a lack of significant epidemiological information enough to assess the rehabilitation needs of this vital problem. Moreover, the rehabilitation outcomesof spinal cord injury (SCI) are expressed in descriptive terms, which are difficult to be accepted nowadays. Therefore, it was worthwhile to explore the profile ofspinal cord injury to assess its rehabilitation outcomesby standardized measure that necessitatedthe proposing of an Arabic version of theresentand mostspecific assessment measure in this field, the Spinal Cord Independence Measure (SCIM III). Objectives 1. To explore the epidemiological characteristics and the clinical profile of the traumatic spinal cord injury (TSCI) among Iraqi patients and to assess their rehabilitation outcomes using standardized measure. 2. To assessthe reliability and validity of the Arabic version of spinal cord independence measure (Ar-SCIM-III). Study Design
Part I-Epidemiology of SCI:Hospital based, records reviewing study. Part II-Development of the Ar-SCIM III: Cross-sectional repeated measure,to assess the reliability of the proposed Ar-SCIM III Part III-Rehabilitation Outcomes of SCI Patients & Validity Evaluation of Ar-SCIM III: Prospective cohort study Setting Ibn Al-Quff Hospital for Spinal Cord Injury Rehabilitation (IQH), Baghdad Methods Part I:This study included reviewing 1500 records of allpatients who sustained TSCI through the years 2003 - 2008and admitted to Ibn Al-Quff hospital. The collected data included demographics, sociocultural information, etiology, clinical features, and rehabilitation outcomesof TSCI. All data were studied, interpreted and statistically analyzed Part II:Certified Arabic translation of SCIM III was administered to 81 patients with SCIwho admitted toIbn Al-Quff hospital. Two multidisciplinary teams and one single rater evaluatedthe patients independently. Psychometric testing included reliability byinter-rater agreement (kappa coefficient), internal consistency (Cronbach's alpha),and single versus team reliability. Part III:Functional ability was measured with the Ar-SCIM III for 40 adult patients with TSCI, on admission and before discharge by two rating groups. Validity evaluation included criterion related validity, construct validity and responsiveness to change. Rehabilitation gains and functional improvement according to the Ar-SCIM III were assessed. Results PartI:Out of 1500revised records, 918 patients with recent TSCI who admitted the hospital for the first time were. Seven hundred eighty-seven (84.4%) were males and 131 (15.6%) were female patients. The mean age at time of injury was 29.5(SD11.99) years. Baghdad residents were 590 (64.3%), their admission rate was 14.1/106/year, and 328 patients were referred from all other governorates representing 17.6% of the expected SCI patients. Violence accounted for 64%of TSCI followed by road traffic accident20% and falling injuries 12%. Tetraplegics were 21% and paraplegics being 79%. Complete SCI was reported in 79.2% of the patients and secondary complication were detected in 60.6%. Only 69% of the patients had completed their rehabilitation while inpatient mortality was reported 3.9% of the admitted patients. Community ambulators were 19.8%. Safe involuntary voiding was detected in46.3% versus 39.3% as indwelling catheter user. Part II:Total agreement between rating teams was above 70% on 16 tasks of Ar-SCIM III and all kappa coefficientswere statistically significant (p<0.001), and same results were between single rater and each teams. Pearson’s correlationcoefficientsand intraclass correlation coefficients between each pairof therating groups were above 0.95. Cronbach’s- was above 0.78with the exception of the respiration and sphincterssubscale, which was about 0.60 Part III:Pearson’s correlation coefficientsbetween two scales and at two occasions (initial and final) were 0.958 for total score and ranged between 0.745 – 0,989 for subscales with high statistical significance (p< 0.001). Significant correlation was detected between the Ar-SCIM III and the neurological indicesof SCI (p< 0.001), while itscorrelations with irrelevant variables were not significant.
The rehabilitation gain was apparent in majority of the functional tasks particularly in sphincter management and outdoors mobility. Conclusions: Violence is the commonest cause of Traumatic Spinal Cord Injuries in Iraq, which affect mainly the males at their most productive age.The low proportion of tetraplegia and concurrently high proportion of complete injuries may necessitate further explorative study for SCI management during the acute phase. The well-evaluated Arabic version of spinal cord independence measure is the first validated scale in Arabic language for use in the clinical settingof the spinal cord injured patients.