Cross-cultural differences in preference for recovery of mobility among spinal cord injury rehabilitation professionals.

Abstract

Direct observation of a constrained consensus-building process in three culturally independent five-person panels of rehabilitation professionals from the US, Italy and Canada.
To illustrate cultural differences in belief among rehabilitation professionals about the relative importance of alternative functional goals during spinal cord injury (SCI) rehabilitation.
Spinal Cord Injury Units in Philadelphia-USA, Rome-Italy and Vancouver-Canada.
Each of the three panels came to independent consensus about recovery priorities in SCI utilizing the features resource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) assuming different stages of recovery.
Sphincter management was of primary importance to all three groups. The Italian and Canadian rehabilitation professionals, however, showed preference for walking over wheelchair mobility at lower stages of assumed recovery, whereas the US professionals set wheelchair independence at a higher priority than walking.
These preliminary results suggest cross-cultural recovery priority differences among SCI rehabilitation professionals. These dissimilarities in preference may reflect disparities in values, cultural expectations and health care policies.

Full text

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Original Article
Cross-cultural differences in preference for recovery of mobility among
spinal cord injury rehabilitation professionals
PL Ditunno*,1, M Patrick1, M Stineman2, B Morganti3, AF Townson4and JF Ditunno1
1Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA;2Department
of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Philadelphia, PA, USA;
3Spinal Unit, IRCCS Fondazione S Lucia, Rome, Italy;4Spinal Cord Injury Rehab Program, GF Strong Rehab Centre,
Vancouver, Canada
Study design:
culturally independent five-person panels of rehabilitation professionals from the US, Italy
and Canada.
Objectives:To illustrate cultural differences in belief among rehabilitation professionals about
the relative importance of alternative functional goals during spinal cord injury (SCI)
rehabilitation.
Setting:Spinal Cord Injury Units in Philadelphia-USA, Rome-Italy and Vancouver-Canada.
Methods:Each of the three panels came to independent consensus about recovery priorities in
SCI utilizing the features resource trade-off game. The procedure involves trading imagined
levels of independence (resources) across different functional items (features) assuming different
stages of recovery.
Results:Sphincter management was of primary importance to all three groups. The Italian
and Canadian rehabilitation professionals, however, showed preference for walking over
wheelchair mobility at lower stages of assumed recovery, whereas the US professionals set
wheelchair independence at a higher priority than walking.
Conclusions:These preliminary results suggest cross-cultural recovery priority differences
among SCI rehabilitation professionals. These dissimilarities in preference may reflect
disparities in values, cultural expectations and health care policies.
Spinal Cord (2006) 44, 567–575. doi:10.1038/sj.sc.3101876; published online 29 November 2005
Direct observation of a constrained consensus-building process in three
Keywords: cross-cultural; spinal cord injury; preferences; walking; consensus building;
rehabilitation
Introduction
The annual incidence of spinal cord injury (SCI)
worldwide has been reported to be between 11.5 and
57.8 cases per million population.1Those patients
fortunate enough to survive their injury and be admitted
for rehabilitation often learn to regain function and
adapt to their disability. In order to ensure the quality of
the rehabilitation stay, patients, family and professional
staff plan, implement and continuously revise an
individually tailored course of treatment with the goal
of returning the SCI individual to the highest level of
independence possible. In the US, the Commission on
Accreditation of Rehabilitation Facilities (CARF)2
requires rehabilitation facilities to document consumer
satisfaction with services provided. A major emphasis is
that service plans are designed by teams that include the
consumer to meet their unique needs and preferences,
and that service plans are individualized to meet
consumer needs as a distinctive person, etc. In the
UK, a new clinical Needs Assessment Checklist (NAC)3
has been applied as an outcomes measure to address the
issue of quality of service and to ensure that rehabilita-
tion services are geared towards each patient’s indivi-
dualneeds.4
Thischecklist
Programme has been found to be effective in planning
SCI rehabilitation and effective as a system that reflects
individual need. Each patient is involved in goal
planning meetings interacting with multidisciplinary
rehabilitation professional staff from time of mobiliza-
tion out of bed to time of discharge. Duff et al4reports
andGoalPlanning
*Correspondence: PL Ditunno, Department of Rehabilitation Medi-
cine, Regional Spinal Cord Injury Center of the Delaware Valley,
Thomas Jefferson University, 132 South 10th Street, Suite 375 Main
Building, Philadelphia, PA 19107, USA
Spinal Cord (2006) 44, 567–575
& 2006 International Spinal Cord Society All rights reserved 1362-4393/06 $30.00
www.nature.com/sc

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that across the 65 patients she studied, positive
correlations were found between the number of goals
set and achievement, as measured by the NAC (the
highest correlations were within the activities of daily
living and skin management, the lowest correlations in
the discharge and community issues domains). Other
research has reported that active client involvement
in the rehabilitation process is a good predictor of a
positive outcome5and that addressing client wishes
increases compliance.6Thus, involvement of consumers
in design and implementation of the course of rehabi-
litation appears to enhance the quality of care and
outcome.4
Consumer preferences for functional outcomes, how-
ever, often differ from family, and staff. Steinman et al7
report similarities and differences in preferences for
functional goals between consumers with disabilities and
clinicians. In general, both clinicians and consumers
value early improvements in cognitive skills over
physical skills. Sphincter management was also deemed
most important for both groups. However, there were
differences between clinicians and consumers in prefer-
ences for recovery when assessing other physical
activities of daily living such as dressing, eating,
mobility, etc. Lack of patient–staff agreement has also
been reported within differing diagnostic groups, in-
cluding SCI. SCI rehabilitation professions tend to over-
rate patients’ emotional distress compared to patient
self-report, and SCI staff often prejudges how a patient
should react or adjust to SCI.8–10Patient–staff discor-
dance can negatively impact the rehabilitation process.11
Therefore, continuous assessment of these differences is
necessary for effective problem solving and rehabilita-
tion planning.4
Preferences for functional outcomes can also reflect
cultural differences. Governmental policies from differ-
ent nations/cultures which modify the direction of
health care could be viewed as environmental barriers12
and can influence life satisfaction outcomes. For
example, in some countries, the guidelines of third party
payers need to be followed rigorously and often these
financial constraints influence the rehabilitation length
of stay and rehabilitation plan.13If international clinical
trial designs are to be standardized for functional goals,
cross-cultural differences in preference for recovery must
be addressed. The International Campaign for Cures of
spinal cord injury Paralysis (ICCP) is a group of affiliate
not for profit organizations that has stated that one
of its objectives is to ‘encourage the development of
strategies and priorities for the international field
of spinal cord injury research’. ICCP has begun the
development of the SCI Clinical Trials Guidelines
Initiative14to foster international standardization with-
in clinical trials design; reviewing current literature and
assessing outcomes measures that are reliable and valid
for use cross-culturally.
While numerous studies15–17have addressed the life
satisfaction among persons with SCI, only a few
studies18–20have directly asked consumers with SCI to
indicate what specific improvements in physical function
are most meaningful to their quality of life. Anderson18
utilized a survey which requires clients to rank seven
physical functions in order of priority. She reports that
regaining arm/hand function is of most importance to
persons with quadriplegia, and regaining sexual function
is most important to persons with paraplegia, but bowel
and bladder and walking movement were of shared
importance to both groups. Donnelly et al,19utilizing
retrospective review, report that self-care goals were
identified most frequently and functional mobility was
among the top three goals identified on the Canadian
Occupational Performance Measure. Estores,20in a
review of six studies, identifies bowel and bladder
function, sexual function, pain and mobility as issues
of most importance to persons with SCI. These studies
were based on traditional methodologies: inventories,
questionnaires, telephone and postal surveys, focus
groups and interviews. Estores20recommends that new
research needs to address the concerns and needs of
persons with SCI utilizing newer methods – such as
trade-off models.
Stineman et al7has introduced such a model to assess
preferences for rehabilitation outcomes among different
groups of patients and staff. Utilizing items from the
Functional Independence Measure (FIM),21she devel-
oped the Feature-Resource Trade-off Game (FG) and
recently reported a discrepancy between American
consumers with disabilities’ ratings and American
clinicians’ ratings of imagined preferences for recovery
of general dimensions of disability. Using a modified
version of the Features-Resource Trade-off Game
(MFG), Patrick et al22has shown differences for
mobility between American consumers and American
SCI rehabilitation professional staff preferences for
recovery.
The purpose of this study was to apply this model to
determine if there is evidence for cross-cultural differ-
ences in preferences for recovery among SCI profes-
sional staff. Based on our investigative interest in
walking assessment of subjects for clinical trials, we
became interested in staff preferences for recovery of
mobility. In the development of the Walking Index for
Spinal Cord (WISCI),23,24
rehabilitation staff, clinicians and clinical investigators
at eight international spinal cord centers. The WISCI is
currently used in several countries to document walking
progress during rehabilitation, to assess walking func-
tion in research protocols, and has currently been
proposed as a measure of walking function by the
European Clinical Network.25During the course of this
research, questions of cross-cultural differences in
consumer and staff perceptions of importance to
mobility issues have surfaced and need to be addressed.
The present study aims to apply a new methodology
to investigate and document disparity in the relative
importance of preferences for recovery among SCI
professional from three populations. The following
specific questions will be addressed:
Is there a difference across cultures in staff preference
for recovery of walking/wheelchair mobility?
we utilized input from
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PL Ditunno et al
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Is there a difference across cultures in staff preference
for recovery of other physical functions within the
domains of self-care and sphincter control?
Methods
In order to quantify cross-cultural differences, panels
of SCI rehabilitation professionals from the US, Italy
and Canada were directly observed engaging in a
constrained consensus building process (for more detail,
see Stineman et al7) using the MFG. The objective of
the MFG is to establish the relative value of alternative
functional status states. Resource trade-off is the
imagined level of independence achieved among the
features. The features being traded for this study were 14
modified FIM items (MFIM) – including six activities
of self-care (eating, grooming, bathing, dressing upper
body, dressing lower body, toileting), two items of
sphincter control (bladder management, bowel manage-
ment) and six items of mobility (bed/chair transfers, tub
transfers,toilettransfers,
walking, stairs). Although walking and wheelchair
mobility in the FIM are combined as a single item of
locomotion, we split these functions into two variables
because we see them as separate skills with distinct
implications. Walking with a device (cane) and using
a wheelchair both allow one to get around in space
without assistance. On the FIM both are given the same
numeric score (modified independence-6) with the
implication of equality of value. In actuality, they are
not equal and have vastly differing sociological and
practical implications. Wheeled mobility is more likely
hindered by environmental barriers and often more
stigmatizing.
The levels of independence through which panelists
imagined recovery were the seven performance levels
of the FIM: (1) total assistance, (2) maximal assistance,
(3) moderate assistance, (4) minimal assistance, (5)
supervision, (6) modified independence and (7) complete
independence.
wheelchairlocomotion,
Clinical panels
Five United
(USRP) constituted the first panel (two Physical
Therapists, one Social Worker, one Psychologist, one
Rehabilitation Administrative Assistant); five Italian
Rehabilitation professionals (IRP) constituted the sec-
ond panel (two Physical Therapists, one Psychologist
and two Physiatrists) and five Canadian Rehabilitation
Professionals (CRP) constituted the third panel (one
Physical Therapist, one Occupational Therapist, one
Nurse, one Social Worker and one Recreational
Therapist).
States RehabilitationProfessionals
The feature resource trade-off game
The game involves a continuous two-step process of
building imagined recovery patterns until seven stages
are completed. A large game board (Figure 1) with the
14 MFIM items listed down the left side of the board
and the seven performance levels listed across the top
is placed at the front of the room with two trained
examiners present (one directs the game, the other
records the responses).
The stage one board is presented with all items
denoted as dependent (Figure 1). One examiner gives the
following instructions to the panel.
‘Imagine you are lying on a floor unable to eat,
groom, dress, bathe, control your bladder and bowel,
transfer to a bed, chair, toilet or tub, use a wheelchair,
walk or climb stairs.’ What single MFIM task (or self-
care task) would you want to recover first.’
a. The panel then performs step 1: each person is
allowed to move any one marker forward going
around the room until 14 moves are made. This will
define the first preliminary stage across the 14 MFIM
items. There is no discussion allowed.
b.The panel then performs step 2: each person is now
allowed the option of moving one item forward at
the expense of moving a different item back. After
that the examiner states, ‘This time each of you
are encouraged to briefly provide support for your
proposed change’. Panel members not proposing the
specific change will then each have the opportunity to
comment. After each member has had this opportu-
nity, the individual who make the proposal will
summarize and the group will then vote. The change
is accepted if the majority accepts it.
c. Steps 1 and 2 are repeated until five interim stages
(stages 2–6) are defined.
d.As each interim stage is completed, the data are
recorded and participants are told that they cannot
move a marker back to a previous stage.
e. At stage 7, all items are denoted as independent.
Graphics
Raw data for each stage is illustrated in concentric pie
charts; the innermost circle signifies total dependence
and the outer circle signifies complete independence.
Discrepancy scores
Pair wise discrepancy scores between the panels were
calculated as follows (for more detail, see Stineman
et al7).
1. The arithmetic differences in performance scores at
each stage were determined for each MFIM item
between each set of two panels being compared.
2. These differences for each item were squared to
produce item-level discrepancy scores.
3. The item-level discrepancy scores were summed
across domains and all 14 items to produce total
discrepancy scores for each stage.
4. Cumulative discrepancy scores were computed by
summing the total discrepancy scores across all
stages.
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Results
Pie charts
The following graphic representation of the panels’
response to the features game is shown in pie charts.
Figures 2–4 show the concentric pie charts depicting
preference stages 2–6 for the US, Italian and Canadian
clinician panels. Each MFIM item appears around the
periphery. The concentric circles indicate the seven
imagined performance levels beginning with total
Total
Assistance
1
Maximum
Assistance
2
Moderate
Assistance
3
Minimal
Assistance
4
Supervision
Eating
Grooming
Bathing
Dressing
Upper Body
Dressing
Lower Body
Toileting
Bladder
Management
Bowel
Management
Bed, Chair,
Wheelchair
Tranfer
Toilet Transfer
Tub Transfer
Walking
Stairs
Complete Dependence
Modified Dependence
No Helper
Helper
Modified
Independence
(Device)
6
Complete
Independence
Wheelchair
5
7
Figure 1Modified features game board
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Figure 2Concentric pie chart depicting interim stages 2–6 for the USRP
Figure 3Concentric pie chart depicting interim stages 2–6 for the IRP
Cross-cultural differences
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