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Literature Review

Narrative Review of Clinical Practice Guidelines for Rehabilitation of People With Spinal Cord Injury

2010–2020

Gerber, Lynn H. MD; Deshpande, Rati MBBS; Prabhakar, Shruthi BS; Cai, Cindy PhD; Garfinkel, Steven PhD; Morse, Leslie MD; Harrington, Amanda L. MD

Author Information
American Journal of Physical Medicine & Rehabilitation: May 2021 - Volume 100 - Issue 5 - p 501-512
doi: 10.1097/PHM.0000000000001637
  • Free

Abstract

The annual incidence of spinal cord injury (SCI) in the United States is 54 per million or approximately 17,000 new cases per year, according to the National SCI Statistical Center.1 Although this is a relatively low number, the impact on an individual is substantial in terms of life expectancy, impact on function, and cost.2,3 Population studies have indicated that there has been no appreciable change in the incidence of SCI over the past 25 yrs. The prevalence of people in the United States with SCI is approximately 282,000. What has changed significantly is that the mean age of people with SCI was 29 yrs, is now 42 yrs, and has been climbing over the past decade.1,2 This has resulted from an increase in the number of older people who sustain injury from falls. In addition, more injuries in the older people result in tetraplegia, and its incidence has been rising.4 Other interesting observations about the change in demographics are that the number of younger men (age 16–24 yrs) sustaining SCI has dropped from 144 per million to 87 per million, but the number of men older than 65 yrs sustaining SCI has risen from 84 per million to 131 per million in the interval 1993–2012.3,4 This has resulted in a significant impact on mortality, which is rising in the older people and falling in younger people with SCI, likely attributable to a lower prevalence of tetraplegia in the younger population,5 because mortality is highly correlated with the extent of neurological injury.6

The changes in demographic have an impact on the rehabilitation needs of people with SCI and the outcomes that they value. Return to participation in life activities is negatively impacted by SCI, and the higher the neurologic level of injury, the greater the impact on participation, and the greater the need for care.3 High neurological levels of injury have been shown to negatively affect social integration, employment, and/or return to school after injury.1 There are important changes in the demographics of people who sustain SCI and in new technologies. This is one rationale for reviewing clinical practice guidelines (CPGs) and assessing whether such changes have been reflected in existing CPGs.

An excellent guideline,7 written in 2008 under the auspices of the Paralyzed Veterans of America, has not since been updated (https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/early_acute_cpg_web.pdf). This CPG guideline provided guidance for rehabilitation of people with SCI in acute care settings and recommended specific treatments for impairments and complications of SCI. In addition, acute traumatic events are often life-threatening, and efforts to save lives and stabilize the acutely injured have been one of the major challenges for successful management of SCI. The use of data from acute care settings to inform practice is common in rehabilitation in general, and especially so for traumatic injuries.

Published scoping reviews of clinical rehabilitation research indicate that much of the research is conducted in acute or hospital-based settings,8–10 these are usually descriptive studies with relatively few treatment intervention studies, and many studies may be limited to a single phase of recovery, the immediate postinjury period, limiting its utility to other recovery phases. However, as the field matures, one would hope to see rehabilitation studies across the spectrum of injury and recovery, addressing function and societal integration. Without studies addressing the multiple phases of SCI, from acute through recovery and societal integration, there is a significant challenge to developing meaningful CPGs.

This narrative review has identified some gaps in the state of knowledge for SCI management and exemplified how the field has changed over the past 12 yrs. A number of investigators have identified the need for currency, and some include concerns for the need for more intervention trials and use of function as part of rehabilitation research outcomes.11,12 These have been identified as specific challenges pertaining to clinical rehabilitation research,13 which became the topic of a special supplemental issue of the Archives of Physical Medicine and Rehabilitation. In that issue, contributors addressed specific issues related to how to maximize research relevance to enhance knowledge translation.13,14

We maintain that CPGs are an important way to provide recommendations that can be trusted and should be evaluated from that perspective.

In summary, our goals for this review are to review CPGs for SCI rehabilitation. We have elected to review these from the perspective of assessing whether the guideline development has followed a prescribed and recognized vetting process and the CPG content specifically includes function, one of the hallmarks of rehabilitation. In addition, we have used this analysis to identify opportunities for future research that may expand our level of knowledge and inform rehabilitation practice and improve the lives of people with SCI.

METHODS

A key word search using the terms “Spinal Cord Injury AND Clinical Practice Guidelines AND Rehabilitation” was undertaken in the following databases: PubMed, Cochrane Data Base, Embase, CINHAL, and Web of Science. In addition, a Google search using the same key words mentioned was performed to learn whether there were any additional CPGs from other sources not identified through the literature search. Specifically, we accessed websites from well-known organizations and societies addressing issues pertaining to SCI. Once the articles and CPGs were identified, they were read in full to determine whether the CPGs followed an established, accepted vetting process such as that by Oxford,15 or United States Preventive Services Task Force,16 or Institute of Medicine.17 The CPG development process had to describe the key elements for these vetting processes and include some or all of the following: establishing transparency, managing conflicts of interest, developing guidelines for group composition, establishing a process for systematic literature review, establishing foundations of evidence for and strength of recommendations, articulating recommendations, establishing a process and committee for external review, and updating recommendations. In addition, all articles were reviewed to determine whether they actually addressed rehabilitation, because there were some that used the word, but this was not substantiated in the published material. Criteria for qualifying as rehabilitation was that the CPG aimed to improve, maintain, or restore human function and/or provide treatment(s) designed to facilitate the process of recovery from injury, illness, or disease to as normal a condition as possible. The definition of the word “function” in this context is taken from the International Classification of Functioning, Disability and Health.18 Functioning, as used in the International Classification of Functioning, Disability and Health descriptions, is “a dynamic interaction between her or his health conditions, environmental factors, and personal factors.” The article review and selection processes followed the Preferred Reporting Items for Systematic review and Meta-analysis (PRISMA) algorithmic approach.19 A schematic using this approach is presented in Figure 1. The articles were reviewed for duplicates, which were removed. The full reviews assured that all inclusion and no exclusion criteria were met, were properly vetted, and met criteria for rehabilitation.

FIGURE 1
FIGURE 1:
*One article added in final selection is included from the New South Wales Agency for Clinical Innovation (NSW ACI) agency guidelines. It met all the criteria for inclusion.

In preparing the tables for CPGs meeting all criteria, we selected the following: title of the article and its authors; the journal in which it was published; the professional affiliation of the endorsing organization (e.g., Paralyzed Veterans of America, European Society of Physical and Rehabilitation Medicine); the setting for which the guidelines apply (e.g., acute care, postacute care, community-based care); and which vetting criteria were used (e.g., Institute of Medicine, Oxford, United States Preventive Services Task Force). A brief summary of the recommendations made in each of the guidelines is also provided.

Information gathered from publications addressing SCI and rehabilitation, which did not undergo a standard CPG vetting process, is also provided in a separate table for readers’ comparison.

RESULTS

The search produced 359 articles that met inclusion criteria (Table 1). After abstract review, 262 publications were eliminated because they did not address rehabilitation/function despite the inclusion of these terms in the key words. There were 58 articles that remained, of which there were 45 that had not followed an identifiable vetting process required to produce a quality clinical guideline. Thirteen articles20–32 met criteria for inclusion and had been properly vetted (Fig. 1). An additional one was added following a review of the gray literature that met all criteria but had not been cited in the databases searched.33 This was retrieved by searching for CPGs for SCI using publicly available (e.g., Google) search engines, not literature data bases, and well-known organizations and societies addressing issues pertaining to SCI. These included the Paralyzed Veterans of America, American Spinal Injury Association, Spinal Cord Injury Network International, etc. Data from each of the reviewed articles that met all inclusion criteria are presented in Table 2.20–33 The variables of interest that pertain to these articles include the following: title of the article, reference citation, the supporting organization for the guideline, the setting in which the guideline applies, confirmation of its having been vetted, confirmation that the guideline addresses rehabilitation and/or functional outcomes, and a summary of recommendations. There were eight guidelines in Table 2 that had been performed in acute care settings23–27,31–33 and 10 in postacute and/or community settings.20–23,28–31,33 When examining the types of studies done and the kinds of outcomes measured, seven studies offered CPGs that addressed a comprehensive approach to rehabilitation and one included pharmacological and nonpharmacological interventions. Four studies addressed exercise interventions exclusively, both cardiorespiratory and resistance exercise. One study addressed treatment guidelines for pressure ulcers,25 and two provided guidelines for pain management.24,26 One study addressed wheelchair prescription and training, exclusively,29 but several of the CPGs that presented general rehabilitation recommendations and included pharmacological and nonpharmacological intervention also provided guidelines for wheelchair prescription and training.

TABLE 1 - Results of literature search
Source Key Word Search Count
PubMed SCI AND guidelines 11,215
SCI AND rehab 24,857
SCI AND guidelines AND rehab 618
Spinal cord injury AND rehab 16,153
Spinal cord injury AND guidelines 1312
Spinal cord injury AND rehab AND guidelines 472
Spinal cord injury and clinical practice guidelines AND rehabilitation 151
Spinal cord injury and clinical practice guidelines AND rehabilitation (2010–2020) 95
Embase Spinal cord injury 64,956
Guidelines or practice guidelines 452,554
Rehabilitation or rehab 78,418
Spinal cord injury AND clinical practice guidelines and rehabilitation 34
Spinal cord injury AND clinical practice guidelines and rehabilitation (2010–2020) 31
Web of Science Spinal cord injury AND practice guidelines AND rehabilitation (2010–2020) 214
CINAHL Spinal cord injury AND guidelines 966
Spinal cord injury AND rehabilitation 7092
Spinal cord injury AND guidelines AND rehabilitation 227
Spinal cord injury AND clinical practice guidelines 152
Spinal cord injury AND clinical practice guidelines AND rehabilitation 29
Spinal cord injury AND clinical practice guidelines AND rehabilitation (2010–2020) 19
Cochrane SCI AND rehabilitation 13 reviews, 583 trials
SCI AND guidelines 8 reviews, 91 trials
SCI and guidelines AND rehabilitation 1 reviews, 24 trials
SCI AND clinical practice guidelines 4 reviews, 35 trials
Spinal cord injury AND guidelines 8 reviews, 91 trials
Spinal cord injury AND rehab 5 reviews, 966 trials
Spinal cord injury AND guidelines AND rehabilitation 0 review, 35 trials
Spinal cord injury AND clinical practice guidelines 0 review, 44 trials
Spinal cord injury AND clinical practice guidelines AND rehabilitation 0 review, 21 trials
Spinal cord injury AND clinical practice guidelines AND rehabilitation (2010–2020) 0 review, 18 trials

TABLE 2 - Guidelines meeting inclusion criteria
Title, Citation, and URL/Link Treatment Guidelines Sponsor
Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Martin Ginis KA, van der Scheer JW, Latimer-Cheung AE, et al. Spinal Cord. 2018;56(4):308–321. [published correction appears in Spinal Cord. 2018].18https://doi.org/10.1038/s41393-017-0017-3 • Institutional and community postacute care setting
• This guideline emphasizes cardiorespiratory fitness and muscle strength rehabilitation to improve cardiometabolic health
• Recommended for chronic SCI patients (1-yr postinjury) under health professional supervision
• For cardiorespiratory benefit: 20 mins of moderate to vigorous intense aerobic exercise 2×/wk and 3 sets of strength exercises for each functioning major muscle 2×/wk
• For cardiometabolic health: 30 mins of moderate to vigorous intense aerobic exercise 3×/wk
ICORD
Exercise and Sports Science Australia (ESSA) position statement on exercise and spinal cord injury. Tweedy SM, Beckman EM, Geraghty TJ, et al. J Sci Med Sport. 2017;20(2):108–115.19https://doi.org/10.1016/j.jsams.2016.02.001 • Institutional and community postacute care setting
• Exercise recommendations for people with SCI: ≥30 mins of moderate aerobic exercise on ≥5 d/wk or ≥20 mins of vigorous aerobic exercise ≥3 d/wk; strength training ≥2 d/wk, including scapula stabilizers and posterior shoulder girdle; and ≥2 d/wk flexibility training, including shoulder internal and external rotators
• Exercise interventions improve cardiorespiratory fitness, improve muscle strength, decrease depression, and improve quality of life in regards to better muscular functioning, mobility, and thus functional independence
ESSA
Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Nash MS, Groah SL, Gater DR Jr, et al. Top Spinal Cord Inj Rehabil. 2018;24(4):379–423.20https://doi.org/10.1310/sci2404-379 • Postacute care community setting
• Guideline emphasis on cardiorespiratory fitness and muscular strength rehabilitation. The guideline risks for cardiometabolic disease include obesity, insulin resistance, dyslipidemia, and hypertension
• Individuals with SCI become physically deconditioned after injury. Physical deconditioning contributes to cardiometabolic disease and its risk determinants in persons with SCI
• Regular aerobic exercise is fundamental in maintaining physical capacity and good cardiovascular and metabolic health in persons with SCI
Paralyzed Veterans of America
Evidence-based position paper on physical and rehabilitation medicine (PRM) professional practice for persons with spinal cord injury. Rapidi CA, Tederko P, Moslavac S, et al. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med. 2018;54(5):797–807.21https://doi.org/10.23736/s1973-9087.18.05374-1 • Acute, subacute, and postacute care institutional and community setting
• The professional role of PM&R physicians having expertise in the rehabilitation of SCI is to lead rehabilitation programs in multiprofessional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI
• Recommendations include vocational rehabilitation, appropriate use of advanced technology (robotic exoskeleton, etc.) and physical agents (FES) in SCI rehabilitation therapeutic exercises, telehealth, and psychosocial and occupational health interventions.
• SCIM III is adequately validated and should be used to assess components of functioning during rehabilitation
• WISCI II should be used to assess ambulation of persons with SCI
• This guideline emphasis is on psychosocial and mobility rehabilitation
UEMS PMR
The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord: recommendations for treatment. Guy SD, Mehta S, Casalino A, et al. Spinal Cord. 2016;54(suppl 1):S14–S23.22https://doi.org/10.1038/sc.2016.90 • Institutional subacute care setting
• Whereas most CPGs on treatment of neuropathic pain generally focus on pharmacologic management, this guideline is the first to include both pharmacologic and nonpharmacological treatments
• Provides a sequential approach to the management of neuropathic pain that is specific to the SCI population, with recommendations that are based solely on evidence within the SCI literature
• Rehabilitation recommendations in terms of improved pain management leading to better functional outcomes such as personal well-being and mobility
CanPainSci WG
French guidelines from PERSE, SoFCPRE and SOFMER for the medical and surgical management of pressure ulcers in persons with spinal cord injury. Gelis A, Colin D, Perrouin-Verbe B, et al. Ann Phys Rehabil Med. 2018;61(5):352–354.23https://doi.org/10.1016/j.rehab.2018.05.1318 • Institutional subacute care setting
• Surgery is indicated when medical treatment for wound healing for pressure ulcers becomes impossible. A holistic approach is recommended before deciding on surgery, with a benefit and risk analysis, assessment of patient’s lifestyle, patient’s personal prevention practices, and psychological and social pressure ulcer consequences
• A multidisciplinary consultation is recommended before surgical indication: physicians (physical and rehabilitation medicine, infectious disease, general practitioner, and other specialist physicians if necessary), surgeons (plastic or orthopedic), nurses and nurse assistants, occupational and physical therapists specialized in positioning, dieticians, social workers, and psychologists
• This guidelines emphasizes a holistic approach in rehabilitation, improving personal well-being and social/community integration practices
PERSE, SOFMER, and SoFCPRE
The CanPain SCI clinical practice guideline for rehabilitation management of neuropathic pain after spinal cord: recommendations for model systems of care. Guy SD, Mehta S, Harvey D, et al. Spinal Cord. 2016;54 suppl 1:S24–S27.24https://doi.org/10.1038/sc.2016.91 • Institutional subacute care setting
• Delivery of care for neuropathic pain in people with SCI should be coordinated, interprofessional, timely, patient centered, using a biopsychosocial framework, and evidence based
• Multidisciplinary care coordinated through a SCI rehabilitation team is recommended when significant functional impacts and/or significant psychological comorbidity factors resulting from neuropathic pain need to be addressed
• A detailed plan of care shared among healthcare providers needs to be implemented across primary, secondary, and tertiary services
• This guideline recommendations self-management interventions to develop or improve self-efficacy skills in goal setting, problem solving, management of psychological consequences, medication management, symptom management, social support, and communication
SOFMER
Physical and rehabilitation medicine (PRM) care pathways: spinal cord injury. Albert T, Beuret Blanquart F, Le Chapelain L, et al. Ann Phys Rehabil Med. 2012;55(6):440–450.25https://doi.org/10.1016/j.rehab.2012.04.004 • Institutional acute, subacute, and postacute care setting
• This guidelines emphasizes psychosocial and socioprofessional rehabilitation
• Assess, prevent, and provide early treatment for common impairments by initiating early rehabilitation with appropriate therapies under guidance of PM&R
• Provide environmental control, ventilatory assistance, wheelchair mobility
• Educate the patient and the patient’s family about the patient’s therapy
SOFMER and FEDMER
Professional standards of practice for psychologists, social workers, and counselors in SCI rehabilitation. Russell HF, Richardson EJ, Bombardier CH, et al. J Spinal Cord Med. 2016;39(2):127–145.26https://doi.org/10.1080/10790268.2015.1119966 • Institutional and community postacute care setting
• The biopsychosocial rehabilitation process should involve a continuum of services from the onset of an SCI throughout the life span
• The individual and family shall have access to psychosocial and physical rehabilitation services, which must be specific to the individual’s needs, respect his or her cultural preferences, and be directed toward the goal of optimal psychological, social, and physical functioning
• The individual should be involved in community reintegration activities on a regular basis to practice and develop those skills acquired in physical rehabilitation
• Social skills training should teach the skills necessary to manage interpersonal relationships, individual attitudes, and societal barriers
• Self-advocacy training begins with participating in identifying crucial goals of the individual, related to community living and educational and vocational interests. The focus of training begins with SCI education and the person’s critical role in preventative care, health maintenance, life care planning, and community reintegration.
None identified
Development of clinical guidelines for the prescription of a seated wheelchair or mobility scooter for people with traumatic brain injury or spinal cord injury. Lukersmith S, Radbron L, Hopman K. Aust Occup Ther J. 2013;60(6):378–386.27https://doi.org/10.1111/1440-1630.12077 • Postacute care community setting
• This guideline intends to reduce the potential poor prescription for wheelchairs and inform and guide practice for better functional outcomes in terms of functional independence and mobility
• The therapist should consider the dynamic interaction of the client’s health condition, activity and participation goals, client’s context, as well as clinical context for wheelchair prescription
• The therapist should use appropriate functional outcome measures at baseline or assessment at other stages to measure change or assess user’s progress toward the goals
National Health and Medical Research Council, New South Wales, Australia
Clinical practice guideline to improve locomotor function following chronic stroke, incomplete spinal cord injury, and brain injury. Hornby TG, Reisman DS, Ward IG, et al. J Neurol Phys Ther. 2020;44(1):49–100.28https://doi.org/10.1097/npt.0000000000000303 • Postacute care institutional and community setting
• Recommendations for moderate- to high-intensity walking training after acute onset central nervous system injury
• The primary outcomes used in this CPG are gait speed and timed distance, which are strongly associated with strength, balance, peak fitness, falls, and balance confidence, as well as selected measures of quality of life, participation, and mortality
• Virtual reality walking training and circuit and combined training for better walking outcomes and upper body function
APTA and ANPT
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the type and timing of rehabilitation. Fehlings MG, Tetreault LA, Aarabi B, et al. Global Spine J. 2017;7(3 suppl):231S–238S.29https://dx.doi.org/10.1177%2F2192568217701910 • Subacute and postacute care institutional setting
• Emphasis on psychosocial and mobility rehabilitation
• Evidence-based recommendations for the optimal type and timing of rehabilitation in patients with acute SCI
• Goal to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, encouraging clinicians to make more evidence-informed decisions, and influence policy changes to ensure adequate resource allocation
• Early rehabilitation be offered to patients with acute SCI when they are medically stable and can tolerate required rehabilitation intensity
• Anticipated desirable effects are improved neurologic outcomes, activities of daily living, ambulation, and quality of life
AOSpine, ONF, and the AANS/CNS Section on Neurotrauma and Critical Care
A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Fehlings MG, Tetreault LA, Wilson JR, et al. Global Spine J. 2017;7(3 suppl):84S–94S.30https://dx.doi.org/10.1177%2F2192568217703387 • Acute institutional care setting
• Rehabilitation to be offered to patients with acute SCI when they are medically stable and can tolerate required rehabilitation intensity, offering body weight–supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise
• Individuals with acute and subacute cervical SCI to be offered functional electrical therapy as an option to improve hand and upper extremity function.
AOSpine, ONF, and the AANS/CNS Section on Neurotrauma and Critical Care
Guide for Health Professionals for Psychosocial Care of Adults With Spinal Cord Injury. Reviewed and updated in 2013. Craig A and Perry KN. Reviewed and updated in 2013.31https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155233/Guide-Psychosocial-Care.pdf • Subacute and postacute care institutional and community setting
• Emphasis on psychosocial and community integration rehabilitation
• Psychosocial factors that impact on rehabilitation outcomes should be integrated into all SCI services, and clients should have access to all psychosocial support services throughout the lifespan
• Psychosocial assessment should commence at the time of admission to the units and all SCI patients should receive a multidisciplinary rehabilitation program in which psychosocial care is a a core component based upon an individual needs assessment
Agency for Clinical Innovation, New South Wales, Australia
ANPT, Academy of Neurologic Physical Therapy; APTA, American Physical Therapy Association; CanPainSci WG, CanPainSCI Working Group; ESSA, Exercise and Sport Science Australia; FEDMER, French Federation of Physical and Rehabilitation Medicine; FES, functional electrical stimulation; ICORD, International Collaboration on Repair Discoveries; ONF, Ontario Neurotrauma Foundation; PERSE, Prevention éducation recherche soins escarre; SCIM III, Spinal Cord Independence Measure; SoFCPRE, Société française de chirurgie plastique, reconstructrice et esthétique; SOFMER, Société française de médecine physique et de réadaptation (French Physical and Rehabilitaiton Medicine Society; UEMS PMR, Union Europeens de Medecins Specialists de PRM; WISCI II, Walking Index for SCI.

Table 3 lists guidelines that met all criteria except that the guidelines had not addressed any rehabilitation/function and two were not vetted.34–41 These were included despite not having rehabilitation or functional outcomes included in their recommendations, because it was thought that they would be informative to the readership. Topics included the following: management of pain, use of anticoagulation for prevention of deep vein thrombosis, prevention of pressure sores, interventions for bladder control, and approaches to evaluation of the needs of people with SCI without treatment or intervention recommendation.

TABLE 3 - Guidelines of interest not meeting inclusion criteria
Title, Citation, URL/Link Treatment Guidelines Sponsor
Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Walters BC, Hadley MN, Hurlbert RJ, et al. Neurosurgery. 2013;60(CN_suppl_1):82–91.32https://doi.org/10.1227/01.neu.0000430319.32247.7f • Acute institutional care setting
• 2013 updated guideline for acute cervical spine and SCI including assessment for functional outcomes, neck pain after SCI, radiographic assessment, pharmacology, atlanto-occipital dislocation, cervical subaxial injury classification schemes, pediatric spinal cord injuries, vertebral artery injuries, and venous thromboembolism
• Includes 112 recommendations
Joint Section on Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons
Prevention of Venous Thromboembolism in Individuals with Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers. 3rd ed. Consortium for Spinal Cord Medicine. Top Spinal Cord Inj Rehabil. 2016;22(3):209–240.33https://dx.doi.org/10.1310%2Fsci2203-209 • Acute, subacute, and postinstitutional care setting
• Recommendations regarding general approach to thromboprophylaxis in acute SCI
• Screening recommendations for asymptomatic DTE and pediatric VTE management and prophylaxis
Paralyzed Veterans of America
Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2010;33(3):281–336.34https://doi.org/10.1080/10790268.2010.11689709 • Postinstitutional and community care setting
• Recommendations to address and provide access to education about sexuality throughout the treatment continuum
• Recommendation to utilize the neurologic examination and a medical assessment of the sexual reproductive system to aid in evaluation of sexual function after SCI
• Evaluate the individual with SCI for diagnosis of depression or other psychological disorders whether they exhibit symptoms such as loss of libido, poor concentration, fatigue, and/or changes in sleep or appetite
Consortium for Spinal Cord Medicine
A systematic review of outcome measures in initial rehabilitation of individuals with newly acquired spinal cord injury: providing evidence for clinical practice guidelines. Tomaschek R, Gemperli A, Rupp R, Geng V, Scheel-Sailer A, German-speaking Medical SCI Society (DMGP) Ergebniserhebung Guideline Development Group. Eur J Phys Rehabil Med. 2019;55(5):605–617.35https://doi.org/10.23736/s1973-9087.19.05676-4 • Subacute and postinstitutional care setting
• Not a vetted guideline
• Literature review of outcome measures and assessments used during initial rehabilitation of patients with a newly acquired SCI to systematically evaluate their scientific quality
• Twenty-nine assessments were identified from current evidence as potential outcome measures in the acute and subacute phases after SCI.
• Identified assessments were categorized according to the ICF into following categories: body functions, mental functions, sensory functions and pain, neuromusculoskeletal functions, mobility, activity, participation, and quality of life
German Speaking Medical SCI Society
Optimal bladder management following spinal cord injury: evidence, practice and a cooperative approach driving future directions in Australia. May Goodwin D, Brock J, Dunlop S, et al. Arch Phys Med Rehabil. 2018;99(10):2118–2121.36https://doi.org/10.1016/j.apmr.2018.04.030 • Acute and subacute care setting.
• Not a vetted guideline
• Reviews bladder management across the Australia in the context of varied clinical practices, challenges to implementing practice, community practice, and evidence based practice.
• Discussion on using indwelling catheter immediately after SCI, long-term pathophysiological changes, and standardization of urine microbiology testing to create an SCI bladder health picture
Australian and New Zealand Spinal Cord Society
Pressure ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. 2nd ed.37Consortium for Spinal Cord Medicine. Paralyzed Veterans of America. https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/cpg_pressure-ulcer.pdf • Acute and subacute care setting
• Recommendations for pressure ulcer risk assessment after SCI and prevention strategies across the continuum of care.
• Evaluation of support surfaces for the bed and wheelchair specific to pressure ulcer prevention and provide an individually prescribed seating system
• Implement an ongoing exercise regimen to promote maintenance of skin integrity and prevent contractures.
• Assessment and reassessment after pressure ulcer onset and surgical and nonsurgical treatment
Consortium for Spinal Cord Medicine
Spinal cord injury (acute management). This guideline is currently under review.38 The Royal Children’s Hospital Melbourne. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Spinal_Cord_Injury_Acute_Management/ • Acute institutional care setting
• Guidelines for acute care for children with SCI
• Acute management in the form of initial assessment, referrals, admission location, spinal immobilization, neurological assessment, imaging, vital signs, and autonomic control
Royal Children’s Hospital Melbourne, Nursing Effectiveness Committee
Pharmacological therapy for acute spinal cord injury. In: Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Hurlbert RJ, Hadley MN, Walters BC, et al. Neurosurgery. 2013;72(suppl 2):93–105.39https://www.guidelinecentral.com/share/summary/52d5608890b9f#section-society • Acute institutional care setting
• Guidelines regarding the recommendation to no use high-dose methylprednisolone and GM-1 for management and treatment of acute cervical SCI
Guidelines Author Group of the Joint Section of Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons
Nutritional support after spinal cord injury. In: Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Dhall SS, Hadley MN, Aarabi B, et al. Neurosurgery. 2013;72(suppl 2):255–259.40https://www.guidelinecentral.com/share/summary/52d56085b6cbb#section-society • Subacute and postinstitutional care setting
• Recommends indirect calorimetry as the best means to determine the caloric needs of persons with SCI
• Nutritional support of SCI patients is recommended as soon as feasible.
• Early enteral nutrition (initiated within 72 hrs) is safe but has not been shown to affect neurological outcome, length of stay, or the incidence of complications in patients with acute SCI.
Guidelines Author Group of the Joint Section of Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons
DTE, deep vein thromboembolism; ICF, International Classification of Functioning, Disability and Health; VTE, venous thromboembolism.

DISCUSSION

Clinical practice guidelines are important contributors to improving quality medical care, reducing practice variation, and creating quality performance measures.42–44 Health care practitioners rely on them to provide evidence-based, unbiased recommendations for patient care. Patients and their families may also rely on published CPGs to learn about what is recommended for them and help form expectations for their own care.

There are significant challenges to the field of physical medicine and rehabilitation (PM&R) in developing CPGs for people with SCI. Physical medicine and rehabilitation is a specialty that provides treatments aimed at improving function and limiting and mitigating functional decline. Its literature comprises relatively few randomized controlled trials,45 which are considered the criterion standard for generating medical evidence and form the basis of material from which CPGs are developed. Rarely do clinical rehabilitation research studies have homogeneous study populations in terms of disabilities and function, making the level of evidence for these outcomes difficult to rate highly.46,47 People are diverse, and the impact of injury/disability is dependent on the biology of the individual, comorbidities, environmental interactions, and social networking, among other possible influences. These variables impact treatment outcomes. Controlling for these multiple factors makes it difficult to properly size and design randomized controlled trials and limits the ability to translate findings into guidelines. These concerns have been discussed in the rehabilitation literature, and recommendations have been underway to develop a Cochrane Field for rehabilitation that approaches systematic reviews of clinical rehabilitation research in a fashion that can factor these challenges while preserving the integrity of the studies so that they can effectively inform practice.48,49

The specialty of PM&R has had challenges in producing quality and sufficient intervention trials for people with disability.50,51 In this review of CPGs, we have demonstrated that there are only a handful of recent CPGs that address rehabilitation for people with SCI, a total of 14. Many of these SCI guidelines rely heavily on publications for management of acute SCI and its immediate postacute care. The support for treatment recommendations, even in the acute care management literature, is deficient in a strong evidence base. Third, many guidelines address a particular impairment (hypotension, wound care, bladder management), important for improved well-being, but do not collect data related to the functional outcomes of such interventions. Functional outcomes are particularly important for the field of rehabilitation. The document cited previously is thorough, clear about recommendations, and presents a point of view acknowledging the contributions of and the need for multidisciplinary care teams. It is properly vetted and well researched. What is missing is evidence from controlled intervention trials, and there are little data from community-based and chronic phases of SCI rehabilitation. Nonetheless, the review panel strongly recommends the need for referral to a rehabilitation facility although the recommendations for specific rehabilitation interventions, such as occupational and/or physical therapy and speech language pathology, do not have substantiating data to support recommendations. The strength of the recommendation is based on the opinion of the panel, and often, there are no data upon which to determine whether there is likely to be a high level of effectiveness.7(pp47–48)

The CPGs, which we report, have all been vetted and include functional outcomes, but the level of evidence is often very low and relies on expert opinion for recommendation rather than evidence from randomized trials. Although this is also true of other specialties, it is particularly true for this specialty. Although there are some guidelines that are addressing function and functionality, they are limited in scope, out of date, and tend to focus on management of specific organ system functions. Although these are critical for good care of people with SCI, they may not specifically address the rehabilitation, specifically functional needs, of people with SCI. The CPGs reported here are addressing both inpatient and outpatient populations, and they do address the multidomain model outlined in the International Classification of Functioning, Disability and Health, including work and social integration. Nonetheless, they are few in number and have low level of evidence to support recommendations.

This review confirms many of these observations and identified a relatively low level of CPGs for people with SCI, with a high proportion of CPGs that address impairments and management in acute care settings.

The group of people who sustain SCI is undergoing change. The demographic has shifted significantly toward an older population, and the type of injury is shifting toward tetraplegia.1–3 Studies of people with tetraplegia have been underrepresented in the CPG literature reported here. Some of the frequently used CPGs are almost 2 decades old and have not been updated. As mentioned previously, eight of the current Paralyzed Veterans of America guidelines were published before 2010, with dates in publication of current editions ranging from 1998 to 2018, suggesting that many may be out of date. In addition, there are no vetted CPGs addressing the potential role of external ambulation devices, robotic assistance, or body-brain interface technology. These exciting new areas need studies to help practitioners guide patients and families through these newer technologies. Medications are available for control of neurogenic bladder and bowel. Their use is widespread clinically, based on empirical evidence, which have improved patient care but have not yet been incorporated into rehabilitation CPGs. There is a paucity of studies that link better bladder/bowel control and specific organ dysfunction to important functional outcomes and participation in social and community activities.

The reasons why these linkages are not always addressed in the research literature are protean. In the opinion of the authors, it may be because hospital-based studies are more efficient. Acute, hospital-based rehabilitation and immediate postacute care rehabilitation enable access to a larger group of patients to be studied in one setting. Research in outpatient or community settings may not see the volume of patients in a short period and is labor intensive. Biomedical research funding tends to support mechanistic research rather than research aimed at improving function and participation. Lastly, in the drive to publish the results of rehabilitation research, investigators may be likely to select data that are more readily available from hospital-based electronic records and rely on impairment-based measures, and journal editors/reviewers often favor publications that use objective measures for outcomes.

Absent is a cure, SCI is a chronic condition, and treatment throughout life is important for long-term functional and health outcomes. Because PM&R addresses the needs of people with disability and dysfunction throughout the trajectory of illness and the life span, CPGs should reflect this.

This review identified that there are relatively few published CPGs. Clinical practice guideline development is usually a multiyear process and is labor intensive requiring consensus building, especially when there are relatively few quality studies, and evidence to support recommendations is limited. Ideally, guidelines are as definitive as possible, developed through a rigorous and systematic review of the most current evidence, followed by formal consensus building among a diverse and unconflicted group of stakeholders and experts. This is needed because endorsement of CPGs helps set reimbursement for care and establishes health policies. When the Institute of Medicine (now the National Academy of Medicine) responded to increasing concern about establishing standards by which to treat and assess patient outcomes,17 they included important topics for considerations to assure the integrity of the outcomes. These included the following: managing conflicts of interest, engaging a diverse set of stakeholders, conducting systematic reviews, providing a standard for rating evidence (e.g., the GRADE [Grading of Recommendations, Assessment, Development and Evaluations] framework),52,53 and articulating recommendations. One interesting outcome of this implementation was the funding of a National Guideline Clearinghouse (no longer funded as of 2018), which curated CPGs and led to a reduction of many published guidelines that did not meet the Institute of Medicine standards.54 The research community remained focused on quality of evidence to inform practice, but additionally, they wished to assure a balanced view of the literature, a repeatable process to follow that reflected all stakeholders, including health professionals and people receiving treatment.55,56 This remains to be achieved.

Several research groups have written about the reliability of the process for establishing CPGs and how robust the data are for recommending practice. One group reported a study (CHRONIDE) that had reviewed 421 CPGs to assess quality using the AGREE-II scores.57 Only 23% were considered high quality. Interestingly enough, the domains that were most poorly represented were applicability and rigor of development. Others have found a relatively low level of evidence in CPGs58 and failure to adhere to the guideline framework.59

The CPGs do not, however, assure relevance, a term that refers to issues of external, social, and ecological validity,60 although not required as part of the vetting process. Therefore, the current status of CPGs, many believe, is in need of fixing.61 If one combines the small number of guidelines that have been published, the inconsistency of quality, the lack of uniformity for the guideline development process, the situation challenges the reliability, and utility of CPGs. Researchers suggest a more prescriptive approach with the use of centralized clearinghouses for CPG’s. Several exist (https://www.guidelinecentral.com/summaries/categories/rehabilitation/; https://g-i-n.net/) at the current time but do not have proper oversight to assure their quality.62

The approach we took in evaluating the published CPGs for SCI rehabilitation revealed substantial gaps in the literature. These include, but are not limited to, the following: (a) relatively few intervention studies from which to generate a high level of evidence for rehabilitation interventions in the management of people with SCI; (b) very few published intervention studies addressing function and participation; (c) very few community-based studies and studies addressing these needs over the life span of people with SCI-related disability; (d) outdated guidelines, and none addressing recent innovations (devices and pharmacological) in management likely to influence functional outcomes; (e) published literature is often narrowly focused on organ system function and impairments without linkage to desires functional outcomes; (f) no evidence of patient participation in the selection of which CPGs need to be developed; (g) the discontinuation of funding for the guideline clearing house has reduced access to quality and varied CPGs in the field for patients, caregivers, and health professionals.

CONCLUSIONS

There are significant gaps in the rehabilitation research literature that has resulted in the publication of only a few CPGs for people with SCI in recent years. More intervention trials need to be done and reported. Particularly, they should incorporate the newer pharmacological agents, robotics, and implantable devices. They should study the elderly spinal cord–injured patient and address important issues of tetraplegia. These trials should include patient input into design and outcomes and study all phases of the trajectory of SCI from acute injury through community integration to provide quality comprehensive care. Finally, in an effort to assure quality and transparency in developing guidelines, more should be developed using a systematic, vetting process that assures transparency and recommendations that we can trust.

REFERENCES

1. National Spinal Cord Injury Statistical Center: 2018 Annual Statistical Report for the Spinal Cord Injury Model Systems. Birmingham, AL, University of Alabama at Birmingham. Available at: https://www.nscisc.uab.edu/reports.aspx. Accessed June 23, 2020
2. Wilson JR, Cronin S, Fehlings MG, et al.: Epidemiology and impact of spinal cord injury in the elderly: results of a fifteen-year population-based cohort study. J Neurotrauma 2020;37:1740–51
3. Spinal cord injury (SCI) 2016 facts and figures at a glance. J Spinal Cord Med 2016;39:493–4
4. Jain NB, Ayers GD, Peterson EN, et al.: Traumatic spinal cord injury in the United States, 1993–2012. JAMA 2015;313:2236–43
5. Toda M, Nakatani E, Omae K, et al.: Age-specific characterization of spinal cord injuries over a 19-year period at a Japanese rehabilitation center. PLoS One 2018;13:e0195120
6. Middleton JW, Dayton A, Walsh J, et al.: Life expectancy after spinal cord injury: a 50-year study. Spinal Cord 2012;50:803–11
7. Consortium for Spinal Cord Medicine: Early Acute Management in Adults With Spinal Cord Injury. Washington, DC, Paralyzed Veterans of America, 2008
8. Gerber LH, Bush H, Holavanahalli R, et al.: A scoping review of burn rehabilitation publications incorporating functional outcomes. Burns 2019;45:1005–13
9. Gerber LH, Bush H, Cai XC, et al.: Scoping review of peer reviewed publications addressing rehabilitation for people sustaining traumatic spinal cord injury. J Spinal Cord Med 2019;43:421–7
10. Gerber LH, Bush H, Cai C, et al.: Scoping review of clinical rehabilitation research pertaining to traumatic brain injury: 1990–2016. NeuroRehabilitation 2019;44:207–15
11. Spyridonidis D, Hendy J, Barlow J: Leadership for knowledge translation: the case of CLAHRCs. Qual Health Res 2015;25:1492–505
12. Moore JL, Shikako-Thomas K, Backus D: Knowledge translation in rehabilitation: a shared vision. Pediatr Phys Ther 2017;29(suppl 3):S64–72
13. Sander AM, Van Veldhoven LM, Backus D: Maximizing usability of evidence in rehabilitation practice: tips for researchers. Arch Phys Med Rehabil 2013;94(1 Suppl):S43–8
14. Backus D, Jones ML: Maximizing research relevance to enhance knowledge translation. Arch Phys Med Rehabil 2013;94(1 suppl):S1–2
15. Oxford Centre for Evidence-based Medicine: Levels of evidence. CEBM. Available at: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/. Published March 2009. Accessed December 4, 2020
16. U.S. Preventive Services Task Force: Grade definitions. 2018. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/grade-definitions. Accessed December 4, 2020
17. Institute of Medicine (US) Committee on Standards for Developing Trustworthy Clinical Practice Guidelines: Clinical Practice Guidelines We Can Trust. Graham R, Mancher M, Miller Wolman D, et al: (eds). Washington, DC, National Academies Press (US), 2011. PMID: 24983061
18. World Health Organization: International classification of functioning, disability and health. WHO. Available at: http://www.who.int/classifications/icf/en/. Published March 2, 2018.Accessed September 20, 2019
19. Moher D, Shamseer L, Clarke M, et al.; PRISMA-P Group: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1
20. Martin Ginnis KA, van der Scheer JW, Latimer-Cheung AE, et al.: Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord 2018;56:308–21. Erratum in: Spinal Cord. 2018 Oct 4; PMID: 29070812
21. Tweedy SM, Beckman EM, Geraghty TJ, et al.: Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury. J Sci Med Sport 2017;20:108–15
22. Nash MS, Groah SL, Gater DR Jr., et al.; Consortium for Spinal Cord Medicine: Identification and management of cardiometabolic risk after spinal cord injury: clinical practice guideline for health care providers. Top Spinal Cord Inj Rehabil 2018;24:379–423
23. Rapidi CA, Tederko P, Moslavac S, et al.; Professional Practice Committee of the UEMS-PRM Section: Evidence-based position paper on physical and rehabilitation medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med 2018;54:797–807
24. Guy SD, Mehta S, Casalino A, et al.: The CanPain SCI clinical practice guidelines for rehabilitation management of neuropathic pain after spinal cord: recommendations for treatment. Spinal Cord 2016;54(suppl 1):S14–23
25. Gelis A, Colin D, Perrouin-Verbe B, et al.: French guidelines from PERSE, SoFCPRE and SOFMER for the medical and surgical management of pressure ulcers in persons with spinal cord injury. Ann Phys Rehabil Med 2018;61:352–4
26. Guy SD, Mehta S, Harvey D, et al.: The CanPain SCI clinical practice guideline for rehabilitation management of neuropathic pain after spinal cord: recommendations for model systems of care. Spinal Cord 2016;54(Suppl 1):S24–7
27. Albert T, Beuret Blanquart F, Le Chapelain L, et al.; French Physical and Rehabilitation Medicine Society; French Federation of PRM: Physical and rehabilitation medicine (PRM) care pathways: “spinal cord injury”. Ann Phys Rehabil Med 2012;55:440–50
28. Russell HF, Richardson EJ, Bombardier CH, et al.: Professional standards of practice for psychologists, social workers, and counselors in SCI rehabilitation. J Spinal Cord Med 2016;39:127–45
29. Lukersmith S, Radbron L, Hopman K: Development of clinical guidelines for the prescription of a seated wheelchair or mobility scooter for people with traumatic brain injury or spinal cord injury. Aust Occup Ther J 2013;60:378–86
30. Hornby TG, Reisman DS, Ward IG, et al.: Clinical practice guideline to improve locomotor function following chronic stroke, incomplete spinal cord injury, and brain injury. J Neurol Phys Ther 2020;44:49–100
31. Fehlings MG, Tetreault LA, Aarabi B, et al.: A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the type and timing of rehabilitation. Global Spine J 2017;7(3 suppl):231S–8S
32. Fehlings MG, Tetreault LA, Wilson JR, et al.: A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Global Spine J 2017;7(3 suppl):84S–94S
33. Craig A, Perry KN: Guide for Health Professionals on the Psychosocial Care of People with a Spinal Cord Injury. Chatswood, NSW, Agency for Clinical Innovation. February 2014. Available at: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0019/155233/Guide-Psychosocial-Care.pdf. Accessed December 4, 2020
34. Walters BC, Hadley MN, Hurlbert RJ, et al.; American Association of Neurological Surgeons; Congress of Neurological Surgeons: Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery 2013;60(CN_suppl_1):82–91
35. Consortium for Spinal Cord Medicine: Prevention of venous thromboembolism in individuals with spinal cord injury: clinical practice guidelines for health care providers, 3rd ed. Top Spinal Cord Inj Rehabil 2016;22:209–40
36. Consortium for Spinal Cord Medicine: Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med 2010;33:281–336
37. Tomaschek R, Gemperli A, Rupp R, et al.; German-speaking Medical SCI Society (DMGP) Ergebniserhebung Guideline Development Group: A systematic review of outcome measures in initial rehabilitation of individuals with newly acquired spinal cord injury: providing evidence for clinical practice guidelines. Eur J Phys Rehabil Med 2019;55:605–17
38. May Goodwin D, Brock J, Dunlop S, et al.: Optimal bladder management following spinal cord injury: evidence, practice and a cooperative approach driving future directions in Australia. Arch Phys Med Rehabil 2018;99:2118–21
39. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals, 2nd ed. Paralyzed Veterans of America. Consortium for 40. Spinal Cord Medicine. Spinal Cord Injury (Acute Management). The Royal Children’s Hospital Melbourne. Available at: https://pva-cdnendpoint.azureedge.net/prod/libraries/media/pva/library/publications/cpg_pressure-ulcer.pdf. Accessed December 4, 2020
40. Hurlbert RJ, Hadley MN, Walters BC, et al.: Pharmacological therapy for acute spinal cord injury. Neurosurgery 2013;72(suppl 2):93–105
41. Dhall SS, Hadley MN, Aarabi B, et al.: Nutritional support after spinal cord injury. Neurosurgery 2013;72(suppl 2):255–9
42. Agency for Health Care Policy and Research: Using Clinical Practice Guidelines to Evaluate Quality of Care. Vol. 1. Rockville, MD: AHCPR; 1995. (Pub. No. 95-0045)
43. Carnett WG: Clinical practice guidelines: a tool to improve care. Qual Manag Health Care 1999;8:13–21
44. Farias M, Jenkins K, Lock J, et al.: Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines. Health Aff (Millwood) 2013;32:911–20
45. Johnston MV, Dijkers MP: Toward improved evidence standards and methods for rehabilitation: recommendations and challenges. Arch Phys Med Rehabil 2012;93(8 suppl):S185–99
46. Seel RT, Dijkers MP, Johnston MV: Developing and using evidence to improve rehabilitation practice. Arch Phys Med Rehabil 2012;93(8 suppl):S97–100
47. Dijkers MP, Bushnik T, Heinemann AW, et al.: Systematic reviews for informing rehabilitation practice: an introduction. Arch Phys Med Rehabil 2012;93:912–8
48. Negrini S, Kiekens C, Meerpohl JJ, et al.: Contributing to the growth of physical and rehabilitation medicine (PRM): call for a Cochrane Field in PRM. Eur J Phys Rehabil Med 2015;51:239–43
49. Negrini S, Arienti C, Gimigliano F, et al.: Cochrane Rehabilitation: organization and functioning. Am J Phys Med Rehabil 2018;97:68–71
50. Kiekens C, Negrini S, Thomson D, et al.: Cochrane physical and rehabilitation medicine: current state of development and next steps. Am J Phys Med Rehabil 2016;95:235–8
51. Negrini S, Kiekens C, Levack W, et al.: Cochrane physical and rehabilitation medicine: a new field to bridge between best evidence and the specific needs of our field of competence. Man Ther 2016;26:vii–viii
52. Guyatt G, Oxman AD, Akl EA, et al.: GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011;64:383–94
53. Grol R, Cluzeau FA, Burgers JS: Clinical practice guidelines: towards better quality guidelines and increased international collaboration. Br J Cancer 2003;89(1 suppl):S4–8
54. Incze M, Ross JS: On the need for (only) high-quality clinical practice guidelines. JAMA Intern Med 2019;179:561
55. Shekelle PG, Woolf SH, Eccles M, et al.: Clinical guidelines: developing guidelines. BMJ 1999;318:593–6
56. Shekelle P, Woolf S, Grimshaw JM, et al.: Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines; updating guidelines; and the emerging issues of enhancing guideline implementability and accounting for comorbid conditions in guideline development. Implement Sci 2012;7:62
57. Molino CGRC, Leite-Santos NC, Gabriel FC, et al.; Chronic Diseases and Informed Decisions (CHRONIDE) Group: Factors associated with high-quality guidelines for the pharmacologic management of chronic diseases in primary care: a systematic review. JAMA Intern Med 2019;179:553–60
58. Schumacher RC, Nguyen OK, Deshpande K, et al.: Evidence-based medicine and the American Thoracic Society Clinical Practice Guidelines. JAMA Intern Med 2019;179:584–6. Erratum in: JAMA Intern Med. 2019 May 28; PMID: 30776054; PMCID: PMC6450279
59. Kung J, Miller RR, Mackowiak PA: Failure of clinical practice guidelines to meet institute of medicine standards: two more decades of little, if any, progress. Arch Intern Med 2012;172:1628–33
60. Bowen SJ, Graham ID: From knowledge translation to engaged scholarship: promoting research relevance and utilization. Arch Phys Med Rehabil 2013;94(1 suppl):S3–8
61. Seekins T, White GW: Participatory action research designs in applied disability and rehabilitation science: protecting against threats to social validity. Arch Phys Med Rehabil 2013;94(1 suppl):S20–9
62. Benavidez G, Frakt AB: Fixing clinical practice guidelines. Health Affairs Blog. August 5, 2019. doi: 10.1377/hblog20190730.874541
Keywords:

Spinal Cord Injury; Rehabilitation; Clinical Practice Guidelines; Function

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