M Arora

Demographic profile of traumatic spinal cord injuries admitted at Indian Spinal Injuries Centre with special emphasis on mode of injury: a retrospective study

Objectives:To identify the demographic profile of persons with traumatic spinal cord injury (TSCI) admitted at the center.Setting:Indian Spinal Injuries Centre.Study design:Retrospective analysis.Methods:Information was collected in 2010 from case sheets of 1138 persons with TSCI admitted from January 2002 to May 2010. A telephonic survey was conducted to get further insight into fall from height (FFH) or road traffic accident (RTA) as a mode of injury.Results:The mean, median and mode for the age were 34.4, 32 and 30 years, respectively. Male:female ratio was 5.9:1 and 63.18% (n=719) were married. RTA was the most common (45%) and FFH the second most common (39.63%) mode of injury. Overall, 66.67% suffered from paraplegia and 71.18% had complete injuries.Conclusion:As compared to other Indian published studies, our study had a much larger number of persons with TSCI and could be considered as the most representative amongst available literature for the Indian population. The study suggests that the demographics of spinal injury in India differs significantly from that in the developed countries since there was a lower mean age, much larger number of males, married individuals, injuries due to two wheeler accidents/falls, paraplegics and complete injuries. In contrast to other published Indian pilot studies, RTA was the most common mode of injury. Our study brings out the need for a proper epidemiological study and for establishing services for pre-hospital and acute care.

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.

Neglected traumatic spinal cord injuries: causes, consequences and outcomes in an Indian setting

Study Design:Retrospective analysis.Objectives:To study the causes, consequences and outcomes of neglected traumatic spinal cord injuries (Neg-TSCIs) admitted at the center.Setting:Tertiary level spinal injury center, India.Methods:Information was collected from case sheets of 61 persons with Neg-TSCI for whom comprehensive management could not be initiated till at least 4 weeks after the injury and another 62 persons for whom treatment was initiated within 2 days of injury.Results:The range of duration of neglect was 4–676 weeks. Rehabilitation had not been initiated in 93.4% of Neg-TSCI patients. There was a statistically significant poorer functional outcome in Neg-TSCI.Conclusions:Neg-TSCIs are injuries in which comprehensive management is not initiated in a timely fashion. Lack of/inadequate awareness was the most common specific cause. Neg-TSCIs add to the complexity of vertebral lesion management, physical and psychosocial rehabilitation. They have a much higher incidence of complications, which are more severe and difficult to manage. They require a longer hospitalization, add to the costs and adversely affect functional outcomes. The findings differ from that of the few studies done in developed countries in that premature discharge in first admission with inadequate or no rehabilitation was the major general cause of neglect rather than overlooked diagnosis and that there was generally an unsupervised period at home before admission to the definitive center. The study brings out the importance of avoiding any delays in starting comprehensive management after spinal injury and taking treatment in a definitive spinal injury center.

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.

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.

Autologous bone marrow cell transplantation in acute spinal cord injury—an Indian pilot study

Study design:Phase- I/II, prospective, randomized, single-blind, controlled pilot study.Primary Objective:To determine the safety and feasibility of autologous bone marrow transplantation in patients with acute spinal cord injury (SCI) via two routes of transplantation as compared with controls.Setting:Indian Spinal Injuries Center, New Delhi.Methods:Twenty-one subjects with acute, American Spinal Injury Association Impairment Scale (AIS) A (complete), traumatic SCI with neurological level T1–T12, were recruited and randomized into three groups of seven subjects each. Two groups underwent cell transplantation through the intrathecal or intralesional route, whereas the third served as control. Participants were assessed at baseline and followed up at 6 months and 12-months post enrollment. Safety and tolerability were evaluated by monitoring for any adverse events. Efficacy was assessed through neurological, functional and psychological evaluation, as well as through electrophysiological studies and urodynamics.Results:Surgery was tolerated well by all participants. There were no significant adverse events attributable to the procedure. There was no significant improvement in the neurological, electrophysiological or urodynamic efficacy variables. A statistically significant improvement in functional scores as evaluated by the Spinal Cord Independence Measure and International Spinal Cord Injury Scale was observed in all groups.Conclusions:The procedure is safe and feasible in AIS A participants with thoracic-level injuries at 12-months follow-up. No efficacy could be demonstrated that could be attributed to the procedure.

Pharmacological prophylaxis for deep vein thrombosis in acute spinal cord injury: an Indian perspective

Study design:Prospective randomized single blind study.Objectives:To find out the incidence of deep vein thrombosis (DVT) in Indian acute spinal cord injury (ASCI) subjects with and without pharmacological prophylaxis.Setting:Indian Spinal Injuries Centre.Methods:Seventy four ASCI subjects were randomly divided into two groups with 37 subjects each: group I received no antithrombotic prophylaxis, and only physical measures like compression stockings were employed for prophylaxis, whereas group II received antithrombotic prophylaxis with low-molecular weight heparin (LMWH) along with physical measures as in group I. DVT was monitored through daily clinical assessment and doppler venous ultrasonography at 2 weeks.Results:Out of 37 subjects in each group, eight (21.6%) developed DVT in group I and two (5.4%) in group II. The difference was significant (P-value=0.041). Six out of eight subjects who developed DVT in group I were asymptomatic. There was no incidence of significant DVT-related complications including pulmonary embolism in any of the subjects.Conclusions:There is a significant incidence of DVT in Indian subjects with ASCI but definitely less than what has been reported in western literature. Pharmacological prophylaxis (LMWH in this study) significantly (P=0.041) decreases the incidence of DVT in subjects with ASCI. As there was no difference in the incidence of symptomatic DVT or related complications, a larger study would be required to conclude definitely on the role of pharmacological prophylaxis in the Indian population.

Strength training for partially paralysed muscles in people with recent spinal cord injury: a within-participant randomised controlled trial

Study design:Within-participant randomised controlled trial.Objectives:To determine whether strength training combined with usual care increases strength in partially paralysed muscles of people with recent spinal cord injury (SCI) more than usual care alone.Settings:SCI units in Australia and India.Methods:Thirty people with recent SCI undergoing inpatient rehabilitation participated in this 12-week trial. One of the following muscle groups was selected as the target muscle group for each participant: the elbow flexors, elbow extensors, knee flexors or knee extensors. The target muscle on one side of the body was randomly allocated to the experimental group and the same muscle on the other side of the body was allocated to the control group. Strength training was administered to the experimental muscle but not to the control muscle. Participants were assessed at baseline and 12 weeks later. The primary outcome was maximal isometric muscle strength, and the secondary outcomes were spasticity, fatigue and participants’ perception of function and strength.Results:There were no dropouts, and participants received 98% of the training sessions. The mean (95% confidence interval (CI)) between-group difference for isometric strength was 4.3 Nm (1.9–6.8) with a clinically meaningful treatment effect of 2.7 Nm. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (−0.25 to 0.32).Conclusion:Strength training increases strength in partially paralysed muscles of people with recent SCI, although it is not clear whether the size of the treatment effect is clinically meaningful. Strength training has no deleterious effects on spasticity.

Quality, language, subdiscipline and promotion were associated with article accesses on Physiotherapy Evidence Database (PEDro)

OBJECTIVE To quantify the relationship between the number of times articles are accessed on the Physiotherapy Evidence Database (PEDro) and the article characteristics. A secondary aim was to examine the relationship between accesses and the number of citations of articles. METHOD The study was conducted to derive prediction models for the number of accesses of articles indexed on PEDro from factors that may influence an articles accesses. All articles available on PEDro from August 2014 to January 2015 were included. We extracted variables relating to the algorithm used to present PEDro search results (research design, year of publication, PEDro score, source of systematic review (Cochrane or non-Cochrane)) plus language, subdiscipline of physiotherapy, and whether articles were promoted to PEDro users. Three predictive models were examined using multiple regression analysis. Citation and journal impact factor were downloaded. RESULTS There were 29,313 articles indexed in this period. We identified seven factors that predicted the number of accesses. More accesses were noted for factors related to the algorithm used to present PEDro search results (synthesis research (i.e., guidelines and reviews), recent articles, Cochrane reviews, and higher PEDro score) plus publication in English and being promoted to PEDro users. The musculoskeletal, neurology, orthopaedics, sports, and paediatrics subdisciplines were associated with more accesses. We also found that there was no association between number of accesses and citations. CONCLUSION The number of times an article is accessed on PEDro is partly predicted by how condensed and high quality the evidence it contains is.