Spinal cord injuries: recent trials and their relevance to other areas of neurology

lisa-harvey

Spinal cord injuries: recent trials and their relevance to other areas of neurology

Physiotherapy is a relatively young profession. Consequently, it is yet to build a strong evidence base for the many different physiotherapy interventions commonly administered to people with spinal cord injuries (SCI). Randomised controlled trials provide the most robust estimates of treatment effectiveness because they minimize bias arising from the expectations of clinicians, patients and researchers. We recently conducted a systematic review and identified 53 randomised controlled trials investigating the effectiveness of different physiotherapy interventions for people with SCI. This is a relatively small number of clinical trials given the scope of physiotherapy practice. This is problematic because clinicians and patients need good quality evidence to guide decisions about the most effective interventions. To address this problem, my colleagues and I have devoted the last 15 years to conducting simple randomised controlled trials aimed at systematically examining the effectiveness of physiotherapy interventions. To date we have completed 20 randomised controlled trials looking at a range of interventions such as those used to manage contractures, improve motor control, reduce respiratory complications, aid gait, enhance hand function and increase strength. Most of these trials are simple in design but with a focus on methodology to reduce bias. This includes the use of blinded assessors, concealed allocation, intention-to-treat analyses and pre-defined primary outcomes. These trials have been possible because research is embedded within clinical practice thereby minimising costs. The trials are largely done within the three Sydney SCI units by the physiotherapy clinicians. The interventions to experimental participants are administered as part of routine clinical care. A professional development program runs in parallel providing opportunities for SCI physiotherapy clinicians to attain post-graduate qualifications through their participation in the trials. The findings of the trials have sometimes challenged long-held beliefs about the effectiveness of widely administered interventions. For example six of our clinical trials have contributed to a recent Cochrane Systematic Review which provided clear evidence for the first time that stretches administered through the hands of physiotherapists are not an effective form of contracture management in people with SCI. Some of our trials have pointed to the importance of functional training while others have reconfirmed long-held assumptions about the effectiveness of interventions which have been administered to date without a good evidence base. While the primary purpose of our research program has been to progress the physiotherapy care of people with SCI, a by-product of our research program has been the development of a SCI physiotherapy work-force which is highly educated in evidence based practice. This not only helps ensure that patients receive high quality evidence-based physiotherapy but it also fosters a workplace that is intellectually stimulating for therapists. This in turn increases job satisfaction, retains staff and builds clinical expertise. This model of conducting simple trials as part of clinical practice is of relevance to physiotherapists working across all areas of neurology.