Functional independence analysis in persons with spinal cord injury

Introduction: Spinal cord injury (SCI) radically changes a person’s life because of alterations in body dynamics, leading to disabilities and reduced functionality. Objective: To analyze the functional independence of individuals with spinal cord injury and compare the groups. Methods: Individuals with SCI were interviewed about their functional independence using the Brazilian version of the Spinal Cord Independence Measure - Self-Reported Version (brSCIM-SR) and later their respective domains and subdomains were compared between diagnostic groups, time since injury and sex. Results: The sample consisted of fifty individuals aged 40.92 ± 13.93 years, predominantly men and diagnosed with paraplegia. In most brSCIM-SR domains, all respondents achieved good independence in self-care, respiration and sphincter management, and in the total brSCIM-SR, except for mobility. In paraplegia, chronic SCIs and both sexes achieved excellent independence in most subdomains and in the total. Significantly low values were found for tetraplegia and recent SCI in the self-care subdomain. In most subdomains, tetraplegia reached significantly lower values. In the subdomains of respiration and sphincter management, the participants were independent in the breathing function, but in tetraplegia, they showed significant dependence on transfer to the toilet. In terms of mobility, there was great dependence on the items going up and down stairs and transfer from the floor to the wheelchair. Conclusion: The brSCIM-SR measures the degree of functionality, allowing health professionals and the patient to quantify and locate the items that indicate their deficits or gains during the rehabilitation process. Here, individuals with SCI showed good functional independence, with worse performance in the tetraplegia and recent injury groups: however, mobility showed partial dependence in the participants.


Introduction
Spinal cord injury (SCI) brings radical changes to the individual, his family and the social environment, because of changes in body dynamics and abrupt transformations, leading to disabilities, reduced functionality and readjustment to a new lifestyle. [1][2][3] During the rehabilitation process, specific assessments are necessary to determine a physiotherapeutic program and interventions, ensuring a better quality of life and functional independence in activities of daily living (ADLs). [2][3][4][5][6][7] ADLs are inherent qualities of the human being that involve self-care, mobility and feeding; functionality is the interaction or complex relationship between the health condition and contextual factors. 4 There are questionnaires that can be used in the assessment of functional independence in SCI, such as the functional independence measure (FIM), 2,7-10 which assigns scores or classifications to people with disabilities, according to the care required according to such limitations, and identifies the level of independence. 5,8 The FIM is an instrument that has reliability and validity for SCI; however, it has been little used for this population. 4,10 Other instruments can be

Methods
The sample size calculation was performed using the online version of the PSS Health tool. 16 To estimate this calculation, the confidence interval for the mean was chosen, with an absolute error margin of 5% and 95% confidence level. Considering the expected standard deviation of 15 Subsequently, the brSCIM-SR 7,9,[11][12][13]15 questionnaire was administered by the person responsible for the research, who was trained in the questioning and familiarized with its content. For a better understanding of the functional independence of individuals with SCI, participants were analyzed in subgroups, according to diagnosis (paraplegia and tetraplegia), time since injury (< or >2 years) and sex (male and female).

The brSCIM-SR questionnaire
The SCIM-SR is a specific and validated questionnaire for people with SCI that quantifies functionality in their ADLs. Its first version was published in 1997. 5 The Brazilian version (brSCIM-SR) originated from the brSCIM III version, in the self-report format, 5 In each subdomain there are several items such as: [2] I am independent using adaptation devices; [3] I am independent without adaptation devices.
The domain respiration and sphincter management (from 0 to 40 points) has eight subdomains: 5. Respiration

Results
The mean age of the 50 participants was 40.92 ± 13.93 years. In Table 1 is the information about medical diagnosis, time since SCI, sex and etiology. were observed in paraplegia and in individuals more than two years of SCI. Those with tetraplegia and those with less than two years of SCI achieved significantly lower scores. In respiration and sphincter management, all achieved a good score, except for tetraplegia, which was significantly lower compared to paraplegia. In terms of mobility, surprisingly, all had a low score, with a better performance for paraplegia, for those with more than two years since SCI and for men. In the brSCIM-SR total score, most participants achieved a good score, except for tetraplegia, which was significantly lower. Table 3   In 4. Personal hygiene, the paraplegia and chronic injuries groups and both sexes marked "I am independent without adaptation devices", and the recent injuries group marked "I need a little help". It can be seen that tetraplegia was significantly lower, except in subdomains 1 and 4 of self-care. As for time since SCI, individuals with chronic injury also reached maximum scores in the same subdomains as paraplegia; however, those with recent injury had significantly lower scores in subdomain 2A (Table 3).       help". In 12. Moving around indoors using a wheelchair, all marked "I am independent with a manual wheelchair but cannot walk". In 13. Going moderate distances (10 to 100 meters) and 14. Going outdoors more than 100 meters using a wheelchair, the majority indicated "I am independent with a manual wheelchair, but not able to walk", and the women marked "I need some help". In 15.
Going up or down stairs, everyone marked "I cannot". In 16. Transfer from wheelchair to car, the majority reached the maximum score, as they marked "I do not need any help or adaptation device", except for tetraplegics and women who marked "I need a little help, supervision or adaptation devices". In 17. Transfer from floor to wheelchair, all marked "I need help". Table 5   For Neto et al., 3 the ability in a wheelchair is defined as the ability to move around and overcome obstacles in daily activities or social commitments, which translates into independent locomotion for this population.
In the total score of brSCIM-SR, a median of 72 points corroborates previous studies, 3,9,11,13 but some studies have reported lower values. 1,12,14,15 The domains selfcare and respiration and sphincter management were

Discussion
In the present study, the brSCIM-SR was used to assess functional independence in the ADLs of individuals with SCI, who commonly face difficulties in actively returning to society, 7,15 mainly due to their physical disability and the psycho-emotional barriers they face in the process of adapting to the new condition. 9 According to Tannús  Such findings were also confirmed in the analyses of the present study, as the participants needed a little help in self-care. As for the sexes, no differences were observed between men and women, owing to the guidelines and indications of adaptations for carrying out such activities.
In subdomains 5, 6A, 6B and 7A, all reached total independence, as no one needed breathing devices, urinary catheter, catheterization and bowel aid, in agreement with another study. 13 As for respiration, despite In subdomain 12, individuals in this study who used a wheelchair were independent indoors, but could not walk, as found in a previous study. 13 It is believed that the absence of an adapted home and the presence of architectural barriers are responsible for the low score, because in no subdomain was there mention of such obstacles as those evaluated by the ICF. 8 In subdomains 13 and 14, all respondents were independent using a wheelchair outdoors and for moderate distances, but were unable to walk, as found in a previous survey. 13 It can be interpreted that individuals prefer to achieve their independence through a wheelchair and not through orthotic devices for ambulation, which translates into independent ambulation. In subdomain 15, all answered being dependent on going up or down stairs, similarly to what is seen in the literature. 13 Probably the lack of detail of the dimensions of the steps of the stairs provided an interpretation of momentary incapacity for such execution. In subdomain 16, those with tetraplegia and women reported needing a little help or adaptive devices to transfer to the car, and in 17, all needed full help, as found in an earlier study. 13 Regarding the limitations of the present study, one can comment on the scarce literature on the specificity of each item of the brSCIM-SR subdomains, which were covered in our work. Accordingly, the reflections in the discussion came more from clinical reasoning than from comparison with other investigations. Another limitation of the study was the discrepancy between the number of individuals with paraplegia and tetraplegia; therefore, further studies are needed to strengthen these findings.
As for the potential of the work, we found that the brSCIM-SR instrument is practical and easy to apply and includes the domains of the injury during the acute and chronic phases, and that it also makes it possible to quantify functionality, allowing the multidisciplinary team and the patient themself to follow their evolution.
Thus, understanding the specificity of the brSCIM-SR subdomains better directs the care and therapeutic planning of individuals with SCI.

Conclusion
The results of the present study suggest a good functional independence for paraplegic individuals and a worse performance of individuals with tetraplegia and recent SCI. The subdomain mobility showed partial