Mastering Our Own Magic in the Evolution Toward Precision Practice.

Is Sleep Disordered Breathing Confounding Rehabilitation Outcomes in Spinal Cord Injury Research?

Telehealth Opportunities in the Digital Age

International collaboration in spinal cord injury (SCI) research is necessary to overcome the challenges often encountered by clinicians and researchers, including participant recruitment, high cost, and the need for specialized expertise. However, international collaboration poses its own obstacles. The objective of this study was to conduct an international online survey to assess barriers and facilitators to international SCI clinical research, potential initiatives to facilitate future collaborations, and the use of SCI-specific data sets and standards. Results were analyzed using descriptive statistics. Of 364 total respondents, 213 completed the survey, with the majority of these participants based in North America (38%), Asia (22%), Europe (18%), and Oceania (16%). Over half had more than 10 years of experience in SCI research or clinical practice (57%) and 60% had previous experience with international collaborations. Funding was identified as a top barrier (82%), a facilitator (93%), and a proposed future initiative (97%). Communication and technology were also identified as strong facilitators and proposed future initiatives. The International Standards for Neurological Classification of SCI were used by 69% of participants, the International Standards to document remaining Autonomic Function after SCI by 13% of participants, and the International SCI Data Sets by 45% of participants. As the need for international collaborations in SCI research increases, it is important to identify how clinicians and researchers can be supported by SCI consumer and professional organizations, funders, and networks. Furthermore, unique solutions to overcome modifiable barriers and creation of new facilitators are also needed.

Background:Conducting and/or disseminating research in partnership with potential research users is a popular approach to conducting useful and relevant research. Despite calls for guidance to support these research partnerships, evidence-based tools and resources remain limited. Aims and objectives:This study aimed to explore principles and related strategies for conducting and/or disseminating spinal cord injury (SCI) research in partnership with the SCI community, in order to gain insight into ways to support SCI research partnerships. This qualitative study included ten semi-structured interviews with SCI research partnership champions. The interviews focused on participants’ experiences with SCI research projects that are conducted or disseminated in partnership, and related principles and strategies to work in research partnerships. Participants mainly talked about principles related to: (1) the relationship between researchers and research users (for example, respect each other, avoid tokenism); (2) co-production of knowledge (for example, research user engagement early and throughout); and (3) meaningful engagement (for example, allowing flexibility). Examples of related strategies included attending collaborative conferences, research user engagement in refinement of research questions, training in research methods, and hiring people with SCI as part of the research team. Key conclusions:This qualitative study presents research partnership principles (norms) and related strategies (observable actions). This study can provide guidance for other researchers and research users who want to engage in (SCI) research partnerships. The findings of this study could be used to inform the development of evidence-based tools and resources to support future research partnerships.

mTOR pathway: A potential therapeutic target for spinal cord injury.

Background/Objective: The use of the American Spinal Injury Association (ASIA) motor score as an outcome measure requires metrological study. This paper tests the hypothesis that a more accurate representation of motor function is obtained using separate upper and lower extremity scales rather than combining all 20 key muscle ratings into a single ASIA motor score.Methods: We analyzed archived data from 6,116 ASIA motor scale records extracted from the National Spinal Cord Injury Statistical Center Database.Results: The hypothesis that separate scales more accurately represent motor function than a single motor scale was supported (X2(indifference)= 2,596; df= 1; P < 0.0001). Two scales account for 87% of the variance, whereas a single scale accounts for only 82%. Lower extremity function is well represented in both solutions; however, upper extremity function is accurately represented only with the use of 2 separate scales.Conclusions: The use of components of the ASIA standards for other than classification of spinal cord injury needs study. Several lines of study converge to provide strong support for the existence of 2 distinctive dimensions underlying the ASIA motor scale. The use of a single motor score in spinal cord injury research should be questioned and justified to the extent possible. The use of upper and lower extremity scales will lead to a reduction in measurement error when the motor score is used as an outcome measure. The confirmation of 2 separate dimensions underlying the ASIA motor score will enable more accurate representation of motor function in spinal cord injury research.

Despite considerable progress in spinal cord injury (SCI) research, there remains a pressing need for interventions that effectively restore neurological function after injury beyond that which occurs spontaneously. A major steppingstone towards the development of effective therapies for SCI is the ability to accurately predict recovery and identify individuals who are most likely to respond to intervention. Currently, the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) remains the primary tool for assessing neurological impairment after injury. However, based on the inherent limitations of the ISNCSCI exam, accurate and sensitive biomarkers are required. Understanding the role of biomarkers in SCI is crucial for improving diagnosis, prognosis, and treatment strategies. In 2024, the Spinal Cord Outcome Partnership Endeavour (SCOPE) sponsored a precourse at the American Spinal Injuries Association (ASIA) meeting. The international panel discussed the scope, utility, and application of biomarkers in SCI clinical trials and clinical practice. This article summarizes key insights from this discussion, highlighting the value of various types of biomarkers, ranging from molecular and cellular markers to those reflecting neural circuits, systems, and movement. We also summarize the context of using different types of biomarkers and their application in research versus clinical practice. While there are currently no FDAqualified SCI biomarkers, the development of reliable biomarkers holds the potential to accelerate the pace of discovery and enable more precise approaches to treatment.

Spinal immobilisaton in pre-hospital and emergency care: A systematic review of the literature.

To the Editor: We thank Dr Abulla and colleagues for their interest in our article.1,2 Novel applications of ultrasound are vast and ever increasing. We limited our review to studies that applied ultrasound to the spinal cord because of the shear breadth and depth of ultrasound research in spinal cord injury (SCI). We acknowledge that ultrasound has been studied extensively outside of the spinal cord in the setting of SCI. Abulla et al2 have mentioned ultrasound-based diagnosis and monitoring of hematoma, deep vein thrombosis, and muscle atrophy.1 In addition, studies have applied ultrasound to enhance the management of pressure ulcers, bladder dysfunction, and musculoskeletal and vascular conditions in patients with SCI.3-5 Ongoing research and development efforts are leveraging ultrasound's versatility to target multiple systems to improve both functional outcome and quality of life of patients with SCI. This trend supports our belief that ultrasound technology is well-poised to become a powerful multifaceted adjunct in the management of acute and chronic SCIs. In the context of neurorehabilitation after SCI, we agree with Abdulla et al that a robust closed-loop system based on physiologically and functionally sound and meaningful feedback signals is paramount to success. One promising avenue is neurofeedback. Neurofeedback is the ability to record neurobehavioral data and present it as sensory stimuli to the subject for self-regulation of responses.6 Neurofeedback has been used in a wide range of neurological and neurobehavioral disorders including stroke, traumatic brain injury, autism, and pain disorders.7 Neurofeedback has been studied in SCI, most commonly with electromyography (EMG) recordings delivered as audiovisual feedback for muscle training.8 Electroencephalogram has also been used to modulate neuropathic pain.9 Although no study has used ultrasound for neurofeedback in SCI motor rehabilitation, this method could have distinct advantages over EMG for accessibility, signal fidelity, cost-effectiveness, and noninvasiveness. Ultrasound has been shown to detect differences in functional muscle status with real-time video monitoring after SCI.10 Capabilities that enable ultrasound to generate multisensory input signals already exist, and future studies should investigate their utility in neurorehabilitation settings. Ultrasound-based wearable technology also holds great promise. We are excited to see how ultrasound will revolutionize the way we care for our patients with SCI in the near future.

Change is everywhere: in health care, in education, in society. Change causes many emotions—excitement, discomfort, fear, exhilaration. In all cases, change brings opportunity. What we do with this opportunity is what determines the strength of who we are—as individuals, as physical therapists, as educators, and as an organization. A new CEO, a new manager, a new colleague, a new job, a new title, a new office—we have all experienced the discomfort that accompanies saying goodbye to the old and having to create the new without any guarantees. However, in many cases, these changes allow for growth, re-direction, and opportunities that may have been difficult had those changes not occurred. The Education Section, originally known as the Schools Section, is the oldest continuous section in the American Physical Therapy Association (APTA). It was made a permanent section in 1941 and is the only section not established under the aegis of the House of Delegates.1 In fact, at the time of the section's incorporation, APTA was still known as the American Physiotherapy Association. For many years, the Education Section has consisted of 4 distinct but overlapping member groups: special-interest groups (SIGs), the Academic Administrator SIG (AASIG), the Academic Faculty SIG (AFSIG), the Clinical Educator SIG (CESIG), and the Physical Therapist Assistant Educators SIG (PTAESIG). These groups have unique interests, concerns, and needs—all related to education. Historically, the leadership of the Education Section has been overwhelmingly composed of individuals involved in academic institutions. The focus of much of the business and most of the activities of the section has been on supporting academic issues as they impacted the classroom and the clinic. With the evolution of physical therapy education progressing to a doctor of physical therapy, the AASIG members determined that a different structure and organization was needed in order to accomplish their goals of providing educational leadership. The Academic Council, functioning under the APTA Board of Directors, was formed “to advance the enterprise of academic physical therapy by promoting the highest standards of excellence in academic programs.”2 During the Business Meeting of the Education Section at the Combined Sections Meeting (CSM) in February 2011, the membership voted to dissolve the AASIG. Throughout the development of the Academic Council, and under the assumption that AASIG issues would no longer drive its activities, the Education Section focused its attention on the opportunities and future goals for the section. The Executive Board of the section conducted a strategic planning session at CSM in February 2010 in San Diego. Enthusiasm was high and debates were lively as the future identity and purpose of the section were discussed. The result was a new brand, a new mission, and new goals that will inform the future activities and decisions of the section. The new brand is “Every PT and PTA is an educator.” Many of our guiding documents within APTA address our role as educators. The APTA Strategic Plan,3 adopted June 12, 2010, identifies education as a primary target area. The Code of Ethics for the Physical Therapist,4 Standards of Practice for Physical Therapy,5 and APTA's Guide for Conduct of the Physical Therapist Assistant6 address education as an obligation and commitment for the physical therapist and physical therapist assistant. Every clinician—no matter what the area of practice, level of expertise, or years of experience—spends more of his or her time educating others than on any other skill or activity. We educate our patients/clients, our colleagues, family members, students, caregivers, other health care providers, referral sources, third-party payers, legislators, attorneys—the list is endless. However, when we make decisions on how to spend our continuing education resources, improving our knowledge and strategies regarding our education skills may not seem that important. Why is that? Do you know the most effective and most evidence-based method of educating a teenager in how to manage her diabetes? Would the same teaching strategies be equally effective in educating her father or her grandmother? Is a lecture followed by a lab always the most effective way of educating your students in the classroom? Are group wellness programs more effective than one-on-one sessions? Are your educational materials, such as brochures, DVDs, and blogs—the preferred method of learning for your patient population? When designing your home exercise programs, is 3 enough? Is 6 too many? Are self-report logs reliable for determining compliance? What does the evidence say? These questions and many others helped the leadership of the Education Section to establish its new mission statement: To inspire all PTs and PTAs in their roles as educators and to enhance the development and implementation of evidence-based education practices. In order to meet this new mission, 3 major goals were developed for the section: 1. Standards of Practice: Provide support for the PT and PTA educator role by disseminating accessible resources on evidence-based teaching and learning principles, methods, and strategies. 2. Research: Promote scholarly activities and access to new knowledge that facilitates evidenced-based educational practices. 3. Education: Increase professional development opportunities to enhance the various educator roles in physical therapy practice. The first task that is currently underway to address our new goals is a grassroots needs assessment. Input that is derived from these informational focus groups across the country will be used to determine activities that will best meet the needs of the PT and PTA in their roles as educators. In addition, collaborative efforts are being explored between the Education Section and other sections to bring their combined expertise to educational presentations at national meetings. The development of special-interest groups (SIGs) has always stemmed from the need for networking among those who share similar personal and professional experiences, goals, and concerns. The purposes of the SIGs within the Education Section are to serve as a resource and forum for individuals, to facilitate networking and mentoring, and to share resources.7-9 Are there additional groups who seek such support? Is it time to develop an SIG within the Education Section for those who provide mentorship in postprofessional residency and fellowship programs? The atmosphere has been brisk at conference programming that addresses the differences between guiding and teaching students and mentoring postprofessional students. Rich discussions both locally and regionally suggest that there is a need for a residency and fellowship SIG. We need to cast a broader net. The term “educator” encompasses all of us, not just those teaching in higher education. Every PT and PTA educates someone, somewhere, every day, in every interaction that he or she has. Are we educating others in the most effective manner possible? Should we spend at least as much time honing our education skills as we do our manual skills? Education does not just occur in the classroom and the lab. It does not just occur when there is a PT or PTA student present in the clinic. It is not separate from our other professional obligations when we consider our responsibility to “promote optimal health and functioning in individuals by pursuing excellence in practice.”5 The newly established brand, mission, and goals cast a broad net for the Education Section. But the future of the section does not lie with the Executive Board. It is the members of the section who will determine its future. The members will decide if the new guiding documents and direction of the section reflect what they need to effectively assume their roles as professional physical therapists and physical therapist assistants. You, the members, will determine how the section will serve you. Make your voice heard. Participate in the needs assessment. Serve as an SIG officer. Talk with the Executive Board members. Volunteer your time and effort to ensure that your Education Section is what you need it to be. Change brings opportunity. Let's make the most of it.

Spinal cord injuries affect nearly five to ten individuals per million every year. Spinal cord injury causes damage to the nerves, muscles, and the tissue surrounding the spinal cord. Depending on the severity, spinal injuries are linked to degeneration of axons and myelin, resulting in neuronal impairment and skeletal muscle weakness and atrophy. The protection of neurons and promotion of myelin regeneration during spinal cord injury is important for recovery of function following spinal cord injury. Current treatments have little to no effect on spinal cord injury and neurogenic muscle loss. Clemastine, an Food and Drug Administration-approved antihistamine drug, reduces inflammation, protects cells, promotes remyelination, and preserves myelin integrity. Recent clinical evidence suggests that clemastine can decrease the loss of axons after spinal cord injury, stimulating the differentiation of oligodendrocyte progenitor cells into mature oligodendrocytes that are capable of myelination. While clemastine can aid not only in the remyelination and preservation of myelin sheath integrity, it also protects neurons. However, its role in neurogenic muscle loss remains unclear. This review discusses the pathophysiology of spinal cord injury, and the role of clemastine in the protection of neurons, myelin, and axons as well as attenuation of skeletal muscle loss following spinal cord injury.

Literature review of basic scientific and clinical research in spinal cord injury (SCI). To provide physicians with an overview of the neurobiologic challenges of SCI, the current status of investigation for novel therapies that have been translated to human clinical trials, and the preclinical, scientific basis for each of these therapies. An abundance of recent scientific and clinical research activity has revealed numerous insights into the neurobiology of SCI, and has generated an abundance of potential therapies. An increasing number of such therapies are being translated into human SCI trials. Clinicians who attend to SCI patients are increasingly asked about potential treatments and clinical trials. Published data review of novel treatments that are either currently in human clinical trials for acute SCI or about to initiate clinical evaluation. A number of treatments have bridged the "translational gap" and are currently either in the midst of human SCI trials, or are about to begin such clinical evaluation. These include minocycline, Cethrin, anti-Nogo antibodies, systemic hypothermia, Riluzole, magnesium chloride in polyethylene glycol, and human embryonic stem cell derived oligodendrocyte progenitors. A systematic review of the preclinical literature on these specific therapies reveals promising results in a variety of different SCI injury models. The SCI community is encouraged by the progression of novel therapies from "bench to bedside" and the initiation of clinical trials for a number of different treatments. The task of clinical evaluation, however, is substantial, and many years will be required before the actual efficacy of the treatments currently in evaluation will be determined.

It was an honor for me to present the 2014 G. Heiner Sell Memorial Lecture at the annual American Spinal Injury Association (ASIA) meeting in San Antonio. For this purpose, I provided a comprehensive review of the scope of research targeting discovery and translational and clinical investigations into spinal cord injury (SCI) research. Indeed, these are exciting times in the area of spinal cord research and clinical initiatives. Many laboratories and clinical programs throughout the world are publishing data related to the pathophysiology of SCI and new strategies for protecting and promoting recovery in both animal models and humans. For this lecture, several topics were discussed including neuroprotective and reparative strategies, neurorehabilitation, quality of life issues, and future directions. In the area of neuroprotection, pathophysiological events that may be targeted with therapeutic strategies, including pharmacological and targeted temperature management were reviewed. For reparative approaches, the importance of both intrinsic and extrinsic mechanisms of axonal regeneration was highlighted. Various cell therapies currently being tested in preclinical and clinical arenas were reviewed as well as ongoing US Food and Drug Administration approved trials for SCI patients. Neurorehabilitation is an evolving research field with locomotive training strategies, electrical stimulation, and brain-machine interface programs targeting various types of SCI. The importance of testing combination approaches including neuroprotective, reparative, and rehabilitative strategies to maximize recovery mechanisms was therefore emphasized. Finally, quality of life issues that affect thousands of individuals living with paralysis were also presented. Future directions and specific obstacles that require attention as we continue to move the SCI field forward were discussed.

The global incidence of spinal cord injury (SCI) is between 10 and 80 new cases per million people each year. This equates to between 250,000 and 500,000 injuries worldwide per year. In the United Kingdom, approximately 4400 people per year sustain an SCI. People with tetraplegia report upper limb function as their highest priority for improvement after SCI. Using immersive virtual reality (VR) headsets, physical rehabilitation exercises can be completed in engaging digital environments. Immersive VR therefore has the potential to increase the amount of therapy undertaken, leading to improvements in arm and hand function. There is little evidence supporting immersive VR as exercise in SCI, especially while patients with SCI are undergoing acute rehabilitation. In SCI research, co-design of new interventions is not a widely adopted approach, yet people with tetraplegia want to contribute with their expert knowledge on their experiences of SCI. This study aims to explore the lived experiences of people with tetraplegia and specialist SCI therapists related to acute upper limb rehabilitation and identify design considerations for VR-based interventions targeting the upper limb. We conducted 7 online focus groups using Microsoft Teams: 4 with people with tetraplegia (n=15; age range, 36-65 years) and 3 with occupational therapists and physiotherapists specializing in SCI rehabilitation (n=11). Participants were asked to discuss their experiences and expertise about acute SCI upper limb rehabilitation and their opinions and ideas on the use of VR for upper limb rehabilitation. The transcripts were analyzed using content analysis, enabling the proposition of design characteristics of a VR-based intervention for upper limb exercise. The study identified 5 major themes describing the clinical features, treatment, and recovery of people with SCI during the acute stage of SCI, their motivations for participating in therapy, and suggestions for the design of a VR intervention in treating the upper limbs following SCI. The themes identified in this study allow the elicitation of software requirements for a bespoke immersive VR platform for upper limb rehabilitation following SCI. They can also contribute to a better understanding of the advantages of using VR as an adjunct to upper limb rehabilitation. Additionally, participants used their expertise to suggest factors that would enable the development of a usable and effective intervention, as well as identifying potential pitfalls and software features to avoid during intervention development. These findings can be used to design accessible VR applications for use by people with tetraplegia and their therapists.

Objective The purpose of this study was to explore the outcome measures used in upper extremity rehabilitation and research in spinal cord injury and to investigate their psychometry. Design Scoping review. Data sources PubMed, the Cochrane library, PEDro, Medline (Ovid). Eligibility criteria for selecting studies The search process and study selection was carried out as follows: Firstly, a systematic search was carried out for articles on upper extremity rehabilitation after SCI. Performance or observational outcome measures which were designed for a clinical setting were collected from selected studies. Secondly, eligible outcome measures were linked to the ICF. The ICF-linked outcome measures were further screened for inclusion according to how comprehensively they covered ICF categories. Finally, a search of the selected outcome measures was performed to investigate their psychometry. Results A total of four outcome measures and nine psychometric studies were selected for the scoping review; six studies addressed GRASSP, one addressed AuSpinal, one addressed SHFT and one addressed TRI-HFT. Of the 13 COSMIN measurement properties, studies of GRASSP covered seven, AuSpinal covered five and both SHFT and TRI-HFT covered three properties. Conclusions The psychometric properties of GRASSP were most extensively studied showing eligible reliability and validity. Although there are still some measurement properties to be explored, GRASSP can be recommended for use in the evaluation of upper extremity mobility in the SCI rehabilitation and research. More research is needed on the psychometrics of other outcome measures in people with spinal cord injuries before the outcome measures can be unconditionally recommended.