SCI Care: What Really Matters
SCI Care: What Really Matters
Australia/New Zealand Guidelines for the Physiotherapy Management of Spinal Cord Injury
Key points:
- This podcast summarizes the results of a rigorous evaluation of the evidence for physiotherapy interventions in spinal cord injury using the GRADE methodology
- Muscle strengthening exercises are effective for partially paralyzed muscles with MRC Grade 3 and 4 strength
- Further evidence is required in the optimal management of severely paretic muscles
Speaker:
Dr. Joanne Glinsky is an Associate Professor of Allied Health (Sydney Local Health District/University of Sydney) and a Senior Research fellow at the John Walsh Centre for Rehabilitation (Kolling Institute/University of Sydney). She has a strong interest in physiotherapy management of people with Spinal Cord Injury and has worked for over 25 years as a clinician, educator and researcher in this field.
The opinions of our host and guests are their own; ISCoS does not endorse any individual viewpoints, given products or companies.
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Contact us directly with any questions or comments at iscos@associationsltd.co.uk
Hello, I'm Michael Phalings, Professor of Neurosurgery at the University of Toronto, and I'm editor-in-chief of Spinal Cord, which is a signature publication of the International Spinal Cord Society or ISCOS. And I'm pleased to bring to you our regular podcast series in which we uh highlight um editor's choice articles in uh spinal cord. And I'm uh very pleased to have with us on this um uh a podcast uh uh episode um uh Joe Glinski, who's an associate professor of Allied Health and a Senior Research Fellow Um at the John Walsh Center for Rehabilitation Research at the um University of Sydney. Joe, welcome.
SPEAKER_00:Thanks, Prof. Fillings, and thanks for the opportunity to come and chat with you today.
SPEAKER_01:Oh, yeah, it's uh it's a pleasure. And you're you and your group have been doing some uh amazing work. And uh today I thought we might uh uh highlight an article that came out a couple of months ago in Spinal Cord related to an Australian and New Zealand clinical practice guideline for the physiotherapy management of people with spinal cord uh uh injuries. I I felt that this was a very important article to highlight. Uh could you perhaps um briefly summarize the key points in this article?
SPEAKER_00:I'd be really happy to summarize the key points, prof Fellings. This article was the work of a collaboration of Australian and New Zealand physios, and that was led by myself and Prof. Lisa Harvey. And we got together and we felt it was really important to develop a guideline for physiotherapists that would give physiotherapists access to the evidence. So what we did was we set about set uh setting 100 pico questions related to the physio management of people with spinal cord injury. We set these 100 pico questions, then we went about using the grade process to develop recommendations and consensus statements related to these PICOs. And what we ended up with in this paper was a methodology of how we conducted these clinical practice guidelines and an overview of the guidelines across 13 clinical areas for physiotherapy.
SPEAKER_01:Great. Um, what would you say are, you know, kind of some of the key take-home messages, sort of practical practice points that you could highlight?
SPEAKER_00:Yeah, there's many take-home messages within this guideline, but probably the key messages that we'd like to let people know is there's around 75 randomized controlled trials that inform these guidelines. And these guidelines cross 13 clinical areas. Now, it's important for people reading the guidelines to understand that within the guidelines, there's recommendations, and recommendations mean we've got quite good evidence for this. There's strong recommendations and weak recommendations, and actually, we only have uh weak recommendations within the guideline, and there's also consensus statements. So, probably our key point to let people know is the guidelines followed a really rigorous process, the grade process outlined by Cochrane. They've covered 13 key areas, and for each of these key areas, we've made either recommendations or consensus statements. For example, if you look at the recommendation around strength training, it's a weak recommendation for strength training in partially paralyzed muscles of people with spinal cord injury. Or if you look at the recommendation around fitness training, it's a weak recommendation for fitness training. So it's important, the key messages would be it's important to understand the methodology by which the guidelines were developed in order to understand the recommendations and consensus statements that people are that we're making within the guidelines.
SPEAKER_01:Are there any surprises that that emerged uh from this process? So, so um recommendations or uh um uh consensus points that perhaps you hadn't anticipated?
SPEAKER_00:It was interesting, actually. The main surprise was the difficulty of the methodology. So, because there's limited numbers of randomized controlled trials with large numbers of participants to inform physiotherapy practice, we often had not a large amount of evidence to inform our recommendations. So the grade methodology works really well when there's lots of large high-quality randomized controlled trials. What we were surprised to find was the methodology works less well when there's not as many randomized controlled trials, which we found in our case, and therefore we had to use other methodologies such as consensus statements in order to make our guidelines useful for clinicians. So we were surprised that applying this grade methodology to these physiotherapy guidelines was quite difficult. The actual findings weren't as surprising because we knew the randomized controlled trials that were available already. So we knew we'd have a limited number of recommendations and we knew we'd have to make some consensus statements. It was more the process that was a surprise to us. It was quite difficult and it was quite lengthy for the many clinicians from across Australia and New Zealand that helped us to develop these guidelines.
SPEAKER_01:Well, I can relate to the rigor of the great process, having chaired a few guidelines development groups myself around the acute management of uh spinal cord injury. Um, are there any key knowledge gaps which your clinical practice guideline group identified?
SPEAKER_00:There was, there is a lot of key knowledge gaps. So we covered 13 areas of physiotherapy practice. There was trials to inform what most of these areas. However, in many areas, there wasn't sufficient trials to make strong recommendations. So in our guidelines, we have all weak recommendations. So our gaps are around not having strong recommendations in any of our clinical practice areas. Where we have weak recommendations, there's still gaps. For example, if you think again about the recommendation about strength training, which is a weak recommendation for in spinal cord injury, we have sufficient RCTs to guide strength training in grade three and four muscles, but insufficient RCTs to guide strength training in grade one and two muscles. If we think about things like interventions for pain, such as shoulder pain, we have quite a few randomized controlled trials to guide the physiotherapy treatment of shoulder pain. But what happened when we looked at these randomized controlled trials? We had some for physiotherapy interventions for shoulder pain and some that were actually on the other side of the forest plot. So what we found when we looked at these two sets of trials, we couldn't make a decision about the best interventions for shoulder pain. So there is, we've been able to make recommendations and consensus statement across all 13 areas that we've got. But there's definitely gaps in all of these areas. For example, again, another one is contraction management. We have some trials to inform contraction management, and we made a weak recommendation for long-duration stretch. However, these trials only extend out to 12 weeks after spinal cord injury. So there's a big gap there when people after spinal cord injury live lifelong needing to manage contracture. Areas like spasticity are fairly poorly investigated as well. And that's perhaps an area that might want to be considered in the future. Another surprising area of gap is different types of motor training in people with spinal cord injury. So I think we just presume motor training is effective, and it's probably reasonable to presume this. So there's very few randomized controlled trials that compare motor training with no intervention. For example, transfer training of people with paraplegia to no intervention. So there's evidence gaps there as well. So there are many areas where physiotherapists can continue to work together around the world in to put together large clinical trials for key questions across all of the domains of physiotherapy.
SPEAKER_01:Yeah, very good. It's certainly been a you know kind of rigorous process. And I also want to highlight the fact that your group has recently published in Spinal Cord a set of complementary guidelines and clinical practice recommendations around um the respiratory management of spinal cord injury. I wonder if you might just briefly uh uh comment on that article as well.
SPEAKER_00:Within our guidelines group, we had the 13 key areas, and two of those key areas were related to respiratory management. So we split that off into a different paper because the respiratory management of people with spinal cord injury is something that's reasonably poorly understood for physiotherapists. So within that paper, we covered ventilation and we covered secretion clearance and we looked at all of the different recommendations and consensus statements. Within that paper, we also provided a clinical rationale for the different types of treatments we were suggesting. The clinical rationale was more important within that paper because these interventions are less used around the world. So we were really keen to help people to put the recommendations and consensus statements into practice. So where the first paper outlined the methodology, the second paper regarding respiratory interventions gave clinical tips for how people can put those interventions into practice.
SPEAKER_01:Yeah, and I I I enjoyed uh reading both um articles, and I thought that there were a number of practice uh points of a practical nature related to both, but I I I found the uh respiratory management article also quite uh uh interesting. So, what are the what are the key next steps um for you yourself and and your colleagues uh to follow up on this very rigorous process that you've uh gone through?
SPEAKER_00:We're prof Lisa Harvey and I are really keen to follow up on this process. We put together a really fantastic committee of volunteers, over 30 people from Australia and New Zealand who sat on this panel over many, many sessions to make these recommendations. This panel, as well as Prof. We're committed to adding more PICO questions to our hundred questions, and we've received suggestions of what to do, and we're committed to making these into living guidelines. Usually, living guidelines are used when evidence is really rapidly developing. In the case of physiotherapy, it's not rapidly developing, but living guidelines are going to be useful for us because it's the best way to keep these updated. So when you run a search for clinical practice guidelines, you get all of the randomized controlled trials and you work and you put together all of the information. And at that minute, that's the minute you take the search, and that's the last trials you get to put towards your recommendations. And those trials go to your panel and your panel makes decisions. What we're currently setting up is a system whereby we run the searches and we get the trials coming in continuously. And then we're planning to make living guidelines whereby our hopefully our panel will be willing to come and work with us to continually update the recommendations as new trials come in. It's a tricky process because it's not just about the systematic reviews, it's about the evidence to decision framework as well that the panel has to use to make decisions. So we need the systematic reviews and we need our panel to keep going. So our plan from here on in is to make our guidelines living, to reform our guidelines committee. And if the international spinal cord injury community is willing, we'd also like to make these guidelines international. We've also had a wild thought that perhaps we could make them multidisciplinary and we could do this across other areas, not just physiotherapy. But our first priority will be to make these ones living and ongoing so that they're useful to drive physiotherapy management worldwide.
SPEAKER_01:Thank you. And those are I I think um approaches that are very um uh you know consistent with the the knowledge to action uh uh cycle that uh Susan uh uh uh Strauss has uh has espoused. Well, uh, you know thank you for for taking a few minutes to talk about this uh this this excellent article and this very impactful process. So I'm just gonna draw this podcast to a close. Um I'm Professor Michael Faling's editor-in-chief of spinal cord, and I've been having a conversation with associate of Professor Joe Glinski from the University of Sydney, and we've been talking about the Australian New Zealand Clinical Practice Guidelines for the Physiotherapy Management of People's Spinal Cord injuries. This is an open access editor's choice uh article in spinal cord. I would encourage uh all of you in the spinal cord injury uh community to take a few minutes and you can download the article, you can have a look at it online. I think the work is um of tremendous uh uh interest and impact. And Joe, thank you for taking a few minutes. I realize that um uh you know the timing uh right now is quite uh late um in the evening in Australia, but uh your comments have been uh very fresh and on the mark um nonetheless. So thank you very much.
SPEAKER_00:Thanks, Prof. Also, direct listeners to the guidelines website at www.sciptguide.com. Thanks, Professor Felings.