J V Glinsky

Does 12 weeks of regular standing prevent loss of ankle mobility and bone mineral density in people with recent spinal cord injuries

The purpose of this study was to determine the effects of a 12-week standing program on ankle mobility and femur bone mineral density in patients with lower limb paralysis following recent spinal cord injury. An assessor-blinded within-subject randomised controlled trial was undertaken. Twenty patients with lower limb paralysis following a recent spinal cord injury were recruited. Subjects stood weight-bearing through one leg on a tilt-table for 30 minutes, three times each week for 12 weeks. By standing on one leg a large dorsiflexion stretch was applied to the ankle and an axial load was applied to the bones of the weight-bearing leg. Ankle mobility and femur bone mineral density of both legs were measured at the beginning and end of the study. Ankle mobility (range of motion) was measured with the application of a 17 Nm dorsiflexion torque. Femur bone mineral density was measured using dual energy X-ray absorptiometry (DEXA). The effect of standing was estimated from the difference between legs in mean change of ankle mobility and femur bone mineral density. The results indicated a mean treatment effect on ankle mobility of 4 degrees (95% CI 2 to 6 degrees) and on femur bone mineral density of 0.005 g/cm(2) (95% CI -0.015 to 0.025 g/cm(2)). Tilt-table standing for 30 minutes, three times per week for 12 weeks has a small effect on ankle mobility, and little or no effect on femur bone mineral density. It is unclear whether clinicians and patients would consider such effects to be clinically worthwhile.

The effectiveness of physical interventions for people with spinal cord injuries: a systematic review

Study design:Systematic review.Objectives:To provide a quantitative analysis of all randomized controlled trials designed to determine the effectiveness of physical interventions for people with spinal cord injury (SCI).Setting:Sydney, Australia.Methods:A search was conducted for randomized controlled trials involving physical interventions for people with SCI. Two reviewers independently rated methodological quality using the PEDro scale and extracted key findings from the trials.Results:Four thousand five hundred and forty three abstracts were identified of which 31 trials met the inclusion criteria. Trials examined the effectiveness of fitness and strength training (n=7), gait training (n=5), hand therapy (n=3), stretch (n=4), acupuncture (n=3), hand splinting (n=2) and other related therapies (n=7). Six trials reported a between-group mean difference with a clearly important treatment effect on at least one outcome measure. These trials supported the use of fitness, strength and gait training as well as acupuncture.Conclusion:There is initial evidence supporting the effectiveness of some physical interventions for people with SCI. However, there is a pressing need for high-quality trials to determine the effectiveness of all physical interventions commonly administered in clinical practice.

Electrical stimulation plus progressive resistance training for leg strength in spinal cord injury: A randomized controlled trial

Study design:A randomized controlled trial.Objectives:To determine the effectiveness of electrical stimulation (ES)-evoked muscle contractions superimposed on progressive resistance training (PRT) for increasing voluntary strength in the quadriceps muscles of people with spinal cord injuries (SCI).Setting:Sydney, Australia.Methods:A total of 20 people with established SCI and neurologically induced weakness of the quadriceps muscles participated in the trial. Participants were randomized between experimental and control groups. Volunteers in the experimental group received ES superimposed on PRT to the quadriceps muscles of one leg thrice weekly for 8 weeks. Participants in the control group received no intervention. Assessments occurred at the beginning and at the end of the 8-week period. The four primary outcomes were voluntary strength (Nm) and endurance (fatigue ratio) as well as the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM; points).Results:The between-group mean differences (95% confidence interval (CI)) for voluntary strength and endurance were 14 Nm (1–27; P=0.034) and 0.1 (−0.1 to 0.3; P=0.221), respectively. The between-group median differences (95% CI) for the performance and satisfaction items of the COPM were 1.7 points (−0.2 to 3.2; P=0.103) and 1.4 points (−0.1 to 4.6; P=0.058), respectively.Conclusion:ES superimposed on PRT improves voluntary strength, although there is uncertainty about whether the size of the treatment effect is clinically important. The relative effectiveness of ES and PRT is yet to be determined.

Reliability of a device designed to measure ankle mobility

Study design: Repeated measures design.Objective: To assess the reliability of a device designed to measure ankle mobility in the clinical setting.Setting: Spinal Cord Injury Unit, Sydney, Australia.Methods: Consecutive sample of 15 patients with paraplegia and tetraplegia with injuries of less than 1 year duration was studied. Ankle mobility was measured on two separate occasions 2 or 3 days apart. Stretch torque was standardised and ankle range of motion measured with an inclinometer attached to the footplate. Intraclass correlation coefficients and percent close agreement scores were used to assess agreement between mean measurements obtained on days 1 and 2.Results: The intraclass correlation coefficient was 0.95 (95% CI, 0.91–0.98). Measurements obtained on day 1 were within 3° of the measurements obtained on day 2 77% of the time and within 6° 97% of the time.Conclusion: The footplate is a reliable and simple way to measure ankle mobility in people with spinal cord injuries.Sponsorship: The Motor Accident Authority of NSW

The effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injury: a systematic review

Study design:A systematic review of randomised controlled trials.Objectives:To determine the effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injuries (SCIs).Methods:The inclusion criteria contained 22 pairs of key interventions and outcomes. Each intervention and outcome was considered independently such that 22 brief reviews were conducted and summarised in this one paper. The interventions included hand, wheelchair, seated mobility, fitness, strength and gait training, as well as electrical stimulation, passive movements, stretch, cycling, exercise and transcutaneous electrical nerve stimulation (TENS). Interventions were compared with no or sham treatment, usual care or another physiotherapy intervention. The primary outcome for each review was one of the following: seated mobility, wheelchair mobility, hand function, gait, voluntary strength, joint mobility, fitness and pain. Data were extracted to determine mean between-group differences or risk ratios (95% confidence interval). Where possible, results were pooled in meta-analyses and the strength of evidence rated using Grading of Recommendations Assessment, Development and Evaluation.Results:Thirty-eight randomised controlled trials met the inclusion criteria and were relevant to 15 of the brief reviews. The following four interventions were clearly effective: fitness, hand and wheelchair training as well as TENS; however, the strength of evidence was not high for any of these interventions. None of the other interventions were clearly effective.Conclusion:There is initial evidence to support four physiotherapy interventions, but there is still a long way to go to put a strong evidence base to the range of physiotherapy interventions commonly used to manage people with SCI.

www.elearnSCI.org: a global educational initiative of ISCoS

Objective:To develop a web-based educational resource for health professionals responsible for the management of spinal cord injury (SCI).The resource:www.elearnSCI.org is comprised of seven learning modules, each subdivided into various submodules. Six of the seven modules address the educational needs of all disciplines involved in comprehensive SCI management. The seventh module addresses prevention of SCI. Each submodule includes an overview, activities, self-assessment questions and references.Development of the resource:Three hundred and thirty-two experts from The International Spinal Cord Society (ISCoS) and various affiliated societies from 36 countries were involved in developing the resource through 28 subcommittees. The content of each submodule was reviewed and approved by the Education and Scientific Committees of ISCoS and finally by an Editorial Committee of 23 experts.Key features:The content of the learning modules is relevant to students and to new as well as experienced SCI healthcare professionals. The content is applicable globally, has received consumer input and is available at no cost. The material is presented on a website underpinned by a sophisticated content-management system, which allows easy maintenance and ready update of all the content. The resource conforms to key principles of e-learning, including appropriateness of curriculum, engagement of learners, innovative approaches, effective learning, ease of use, inclusion, assessment, coherence, consistency, transparency, cost effectiveness and feedback.Conclusion:www.elearnSCI.org provides a cost effective way of training healthcare professionals that goes beyond the textbook and traditional face-to-face teaching.

Effectiveness and cost-effectiveness of telephone-based support versus usual care for treatment of pressure ulcers in people with spinal cord injury in low-income and middle-income countries: study protocol for a 12-week randomised controlled trial

Introduction Pressure ulcers are a common and severe complication of spinal cord injury, particularly in low-income and middle-income countries where people often need to manage pressure ulcers alone and at home. Telephone-based support may help people in these situations to manage their pressure ulcers. The aim of this study is to determine the effectiveness and cost-effectiveness of telephone-based support to help people with spinal cord injury manage pressure ulcers at home in India and Bangladesh. Methods and analysis A multicentre (3 sites), prospective, assessor-blinded, parallel, randomised controlled trial will be undertaken. 120 participants with pressure ulcers on the sacrum, ischial tuberosity or greater trochanter of the femur secondary to spinal cord injury will be randomly assigned to a Control or Intervention group. Participants in the Control group will receive usual community care. That is, they will manage their pressure ulcers on their own at home but will be free to access whatever healthcare support they can. Participants in the Intervention group will also manage their pressure ulcers at home and will also be free to access whatever healthcare support they can, but in addition they will receive weekly telephone-based support and advice for 12 weeks (15–25 min/week). The primary outcome is the size of the pressure ulcer at 12 weeks. 13 secondary outcomes will be measured reflecting other aspects of pressure ulcer resolution, depression, quality of life, participation and satisfaction with healthcare provision. An economic evaluation will be run in parallel and will include a cost-effectiveness and a cost-utility analysis. Ethics and dissemination Ethical approval was obtained from the Institutional Ethics Committee at each site. The results of this study will be disseminated through publications and presented at national and international conferences. Trial registration number ACTRN12613001225707.

How well do randomised controlled trials of physical interventions for people with spinal cord injury adhere to the CONSORT guidelines? An analysis of trials published over a 10-year period

Study design:Cross-sectional descriptive study of randomised controlled trials involving physical interventions for people with spinal cord injury (SCI) published between 2003 and 2013.Objectives:To determine how well randomised controlled trials of physical interventions for people with SCI adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines.Setting:University of Sydney, Sydney, NSW, Australia.Methods:A search was conducted for randomised controlled trials designed to determine the effectiveness of physical interventions for people with SCI published between 2003 and 2013. The CONSORT checklist for the reporting of randomised controlled trials was used to determine how well each trial adhered to the guidelines. Two independent reviewers rated each trial on each of the 37 items on the CONSORT checklist using the following criteria: ‘fully reported’, ‘partially reported’, ‘not reported’, ‘not relevant’ or ‘not reported but unable to determine if relevant/done’.Results:Fifty-three trials were retrieved. None of the trials ‘fully reported’ all items of the CONSORT guidelines. The median (IQR) number of items that was ‘fully reported’ was 11/37 (7–20). The median (IQR) number of items that was either ‘fully reported’ or ‘not relevant’ or ‘not reported but unable to determine if relevant’ was 20/37 items (17–27).Conclusion:The reporting of randomised controlled trials in SCI is only partially adhering to the CONSORT guidelines. Journals can help lift standards by encouraging authors of randomised controlled trials to adhere to the CONSORT guidelines.

A Massive Open Online Course for teaching physiotherapy students and physiotherapists about spinal cord injuries

Study design:A descriptive audit.Objectives:To audit the participation and satisfaction in a Massive Open Online Course (MOOC) for teaching physiotherapy students and physiotherapists about spinal cord injuries.Setting:Global and online.Methods:A 5-week MOOC about the physiotherapy management of spinal cord injuries was hosted by Physiopedia and run in partnership with the International Spinal Cord Society. The MOOC was based on the physiotherapy-specific module of www.elearnSCI.org, and also involved extra readings, activities and online discussion through a closed Facebook group. Participation and satisfaction was quantified through a pre- and post-MOOC knowledge assessment and an online course evaluation. Participation was also gauged through Facebook activity and internet-based usage statistics.Results:Three thousand five hundred and twenty-three people from 108 countries registered for the MOOC and 2527 joined the Facebook group. One thousand one hundred and twenty-one completed the pre- and post-MOOC knowledge assessments, with more completing one or the other. The median (interquartile range) results for those who completed the pre and post-MOOC knowledge assessments were 70% (60–80%) and 90% (80–95%), respectively. One thousand and twenty-nine completed the online course evaluation, with more than 80% agreeing or strongly agreeing with 12 of the 13 positive statements posed to them about the course.Conclusion:Most participants who completed the MOOC performed well on the post-MOOC knowledge assessment and enjoyed the learning experience. However, these results may be biased if those who did not complete the MOOC were dissatisfied and/or did not sit the post-MOOC knowledge assessment.

Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial.

Study design:A multicentre, prospective, assessor-blinded, parallel randomised controlled trial.Objectives:The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries.Methods:One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI >3 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes.Results:The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval −0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant.Conclusion:The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.