The following provides a summary of the recommendations presented in the guideline document. The reader is directed to the original guideline for a detailed discussion of each of the following topics.
The levels of evidence (I-V), grades of recommendations (A-C), and strength of panel opinion (low, moderate and strong) are repeated at the end of the Major Recommendations.
Expected outcomes and their measurement are divided into four domains: motor recovery, functional independence, social integration, and quality of life. Within each domain, recommendations are offered regarding appropriate assessment, goal setting, and documentation. An overarching principle for all outcome assessment and documentation is that the measurement instruments should be standardized, well-validated, and reliable.
Expected Motor Recovery Outcomes
- Perform a neurological examination to establish the diagnosis as soon as possible after a suspected spinal cord injury, ideally within 6 hours.
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Perform a comprehensive neurological examination according to International Standards for Neurological and Functional Classification between 3 and 7 days after injury.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
- Monitor neurological status periodically until recovery has reached a plateau (overall recovery, zone-of-injury recovery, and ambulation potential).
Scientific evidence: monitoring frequency: None; overall recovery: V; zone-of-injury recovery: V; ambulation potential: V; Grade of recommendation: monitoring frequency: Expert consensus; overall recovery: C; zone-of-injury recovery: C; ambulation potential: C; Strength of panel opinion: Strong
- After neurological plateau has been reached, conduct periodic evaluations of neurological status throughout the individual's lifetime.
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
Expected Functional Independence Outcomes
- Establish short- and long-term functional goals with the participation of the person served based upon a comprehensive, individualized assessment by a team of health-care professionals experienced in the care and treatment of people with spinal cord injury (See Table 6 in the guideline document for expected functional outcomes of individuals with motor complete spinal cord injury).
Scientific evidence: V; Grade of recommendation: C; Strength of panel opinion: Strong
- Monitor functional ability throughout the rehabilitation process, modifying treatment strategies to maximize functional outcome.
Scientific evidence: None; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
- After achievement of functional goals, conduct periodic evaluations of functional status throughout the individual's lifetime.
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Document deviations in the achievement of functional outcomes (with reference to the normative data in Table 6 of the original guideline document) by groups of individuals receiving rehabilitation. Address such deviations in terms of improvement of clinical processes of care or unique population characteristics requiring risk adjustment.
Scientific evidence: Unpublished data from the National Spinal Cord Injury Statistical Center system; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
Expected Social Integration Outcomes
- After the initial acute care and rehabilitation phase, discharge individuals with spinal cord injury back into the community.
Scientific evidence: III, V; Grade of recommendation: C; Strength of panel opinion: Strong
- Focus on providing opportunities for societal participation in meaningful roles.
Scientific evidence: Meta-analyses and unpublished data from the National Spinal Cord Injury Statistical Center; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
- Document deviation in social participation and integration (with reference to Figures 5–8 of the original guideline document, which display normative data for the Craig Handicap Assessment and Reporting Technique) by groups who have completed rehabilitation. Address such deviations in terms of improvement of clinical processes of care or unique population characteristics requiring risk adjustment.
Scientific evidence: Meta-analyses and unpublished data from the National Spinal Cord Injury Statistical Center; Grade of recommendation: Expert consensus; Strength of panel opinion: Strong
Expected Quality-of-Life Outcomes
- Assess quality of life for individuals with spinal cord injury using direct perceptions of the individual involved.
Scientific evidence: III, V and meta-analyses; Grade of recommendation: C; Strength of panel opinion: Strong
- Facilitate opportunities for optimal quality of life within the full continuum of health-care and rehabilitation programs.
Scientific evidence: III, V and meta-analyses; Grade of recommendation: C; Strength of panel opinion: Strong
Definitions:
Hierarchy of the Levels of Scientific Evidence:
- Large randomized trials with clear-cut results (and low risk of error)
- Small randomized trials with uncertain results (and moderate to high risk of error)
- Nonrandomized trials with concurrent or contemporaneous controls
- Nonrandomized trials with historical controls
- Case series with no controls
Categories of the Strength of Evidence Associated With the Recommendations
- The guideline recommendation is supported by one or more level I studies
- The guideline recommendation is supported by one or more level II studies
- The guideline recommendation is supported only by level III, IV, or V studies
Levels of Panel Agreement with the Recommendation
Based on a 5-point scale (1 corresponding to neutrality; 5 representing maximum agreement)
Low
Mean agreement score of 1.00 to less than 2.33
Moderate
Mean agreement score of 2.33 to less than 3.67
Strong
Mean agreement score of 3.67 to 5.00
Note: If the literature supporting a guideline recommendation came from two or more levels, the number and the level of evidence supporting the studies are reported (e.g., a guideline recommendation that is supported by two studies, one a level III and the other a level V, the scientific evidence would be indicated as III, V). Likewise, if a guideline recommendation is supported by literature that crossed two categories, both categories are reported (e.g., a recommendation that includes both level II and III studies would be classified as category B, C).
