Challenges in applying evidence-based practice in stroke rehabilitation: a qualitative description of health professional experience in low, middle, and high-income countries.

Purpose: Evidence-based practice (EBP) is considered central to ethical, effective service delivery in rehabilitation, and the implementation of the World Health Organisation's Rehabilitation Strategy 2030. This study aimed to explore and compare the experiences of health professionals regarding the application of EBP for stroke rehabilitation in each participant's region and country, which provided perspectives from low, middle, and high-income countries.Methods and materials: Interviews were conducted with 12 experienced rehabilitation professionals from 12 different countries (5 high-income, 2 upper-middle income, 3 lower-middle income, and 2 low-income countries) and interpreted using qualitative descriptive analysis.Results: Nine factors influencing evidence-based stroke rehabilitation were: 1) the complexity of rehabilitation research; 2) the (ir)relevance of research to local context; 3) lack of time for EBP; 4) minimal training in EBP; 5) changing health professional behaviours; 6) poor access to resources for developing EBP; 7) influence of culture, patients, and families; 8) language barriers; and 9) lack of access to research evidence. Economic constraints contributed to many challenges; but not all challenges related to the country's economic classification.Conclusion: A global approach is needed to share knowledge about EBP, especially scientific evidence and innovative thinking about its application to clinical practice. Implications for rehabilitationRehabilitation professional groups should contribute to a global network to improve informal knowledge sharing and training around evidence-based practice.Support for training in evidence-based practice and its application needs to be developed and accessible in all countries, including low and middle-income countries.It is imperative that policymakers prioritise practical, evidence-based solutions for rehabilitation research in low and middle-income countries that can be effectively implemented within local settings.There must be solutions and increased accessibility of journal articles for those working in low and middle-income countries including those whose first language is not English.

Ethical issues and dilemmas in spinal cord injury rehabilitation in the developing world: a mixed-method study.

STUDY DESIGN: Mixed-method study (small group discussions and online literature search). OBJECTIVES: Identify the ethical issues and dilemmas faced by rehabilitation professionals involved in the service delivery to the persons with spinal cord injury (SCI) in the low income and lower-middle-income countries (LIC/LMIC) located in Asia. SETTING: Small group discussions in three biomedical conferences in Dhaka, Bangladesh and Kualalampur, Malaysia. METHODS: Three small group discussions (30-45 min each) were held during three international conferences in 2019. The conferences brought together experts in the fields of neurology, rehabilitation, neurorehabilitation, and bioethics. A summary of SCI practice points and dilemmas were documented including goals of care, duties of rehabilitation professionals, health care worker-patient relationships, roles, and expectations of family members at different care settings. RESULTS: There is a paucity of literature on this topic. The application of the principles of contemporary bioethics in the pluralistic societies of LIC/LMIC can be challenging. The ethical dilemmas faced by rehabilitation professionals working in LIC/LMIC are diverse and different from those reported from the Western and developed countries. Ethical issues and dilemmas identified were understanding patient autonomy in decision making, lack of insurance for SCI rehabilitation, financial challenges, challenges of providing emerging technology in SCI rehabilitation and SCI rehabilitation during disasters. CONCLUSIONS: We have summarized the possible ethical issues and dilemmas which rehabilitation professionals in LIC/LMIC may encounter during delivery of SCI rehabilitation services. We hope it generates a discussion on an often-neglected aspect of SCI care in the LIC/LMIC and helps identify the complexities of ethical dilemmas unique to persons with SCI living in a developing country.

Cochrane Rehabilitation: 2020 annual report.

During its fourth year of existence, Cochrane Rehabilitation went on to promote evidence-informed health decision-making in rehabilitation. In 2020, the outbreak of the COVID-19 pandemic has made it necessary to alter priorities. In these challenging times, Cochrane Rehabilitation has firstly changed its internal organisation and established a new relevant project in line with pandemic needs: the REH-COVER (Rehabilitation - COVID-19 evidence-based response) action. The aim was to focus on the timely collection, review and dissemination of summarised and synthesised evidence relating to COVID-19 and rehabilitation. Cochrane Rehabilitation REH-COVER action has included in 2020 five main initiatives: 1) rapid living systematic reviews on rehabilitation and COVID-19; 2) interactive living evidence map on rehabilitation and COVID-19; 3) definition of the research topics on "rehabilitation and COVID-19" in collaboration with the World Health Organization (WHO) rehabilitation programme; 4) Cochrane Library special collection on Coronavirus (COVID-19) rehabilitation; and 5) collaboration with COVID-END for the topics "rehabilitation" and "disability." Furthermore, we are still carrying on five different special projects: Be4rehab; RCTRACK; definition of rehabilitation for research purposes; ebook project; and a prioritization exercise for Cochrane Reviews production. The Review Working Area continued to identify and "tag" the rehabilitation-relevant reviews published in the Cochrane library; the Publication Working Area went on to publish Cochrane Corners, working more closely with the Cochrane Review Groups (CRGs) and Cochrane Networks, particularly with Cochrane Musculoskeletal, Oral, Skin and Sensory Network; the Education Working Area, the most damaged in 2020, tried to continue performing educational activities such as workshops in different online meetings; the Methodology Working Area organized the third and fourth Cochrane Rehabilitation Methodological (CRM) meetings respectively in Milan and Orlando; the Communication Working Area spread rehabilitation evidences through different channels and translated the contents in different languages.

Expert opinions leave space for uncertainty when defining rehabilitation interventions: analysis of difficult decisions regarding categorization of rehabilitation reviews in the Cochrane library.

BACKGROUND: In 2017, Cochrane Rehabilitation created an online relational database to crowd-source the identification and categorization of Cochrane publications for relevance to rehabilitation. One of the challenges of this work has been the lack of an operational definition to determine what is or is not a rehabilitation intervention. As such, categorization decisions have been largely based on expert opinion, with two health professionals screening each review, and with disagreements in categorization decisions being adjudicated by the Cochrane Rehabilitation Review Committee. AIM: To analyze the rationale for resolving conflicts in the identification of rehabilitation reviews from all Cochrane reviews to contribute to future work on the scope and definition of rehabilitation interventions. METHODS: We extracted data on decisions made about all Cochrane titles (both protocols and reviews) published between 1 January, 1996, and 31 August, 2019, and identified all titles where there had been disagreement between any people categorizing the reviews. We used thematic analysis methods to classify the reasons for including or excluding reviews from a collection of reviews on rehabilitation interventions. We compared across groups to identify areas of conflict and errors in the initial categorization. RESULTS: Of the 9756 Cochrane titles screened, we identified 894 (9.2%) where some disagreement existed about whether a review was about rehabilitation interventions or not. Of these, 333 (37.2%) had met our original pragmatic criteria for being a "rehabilitation" review, while 561 (52.8%) had not. Seven hundred and nineteen of these reviews (80.4%) could be grouped by inductively created, reportable criteria to justify the initial categorization decisions. Fifty-seven reviews (6.4%) were on topics that were too idiosyncratic to easily group with others for the purposes of categorization. Conflicts in the rationale for categorization decisions were identified in 90 reviews (10.1%) and errors in the initial categorization for 28 reviews (3.1%). CONCLUSIONS: The challenges and conflicts identified in this study clearly indicate the need for better operational definition of rehabilitation interventions. This study provides a foundation for future work to check the utility of any new definition of rehabilitation interventions and to improve the trustworthiness of categorization decisions regarding the Cochrane Rehabilitation database.

Cochrane Rehabilitation: 2019 annual report.

During its third year of existence, Cochrane Rehabilitation goals included to point out the main methodological issues in rehabilitation research, and to increase the Knowledge Translation activities. This has been performed through its committees and specific projects. In 2019, Cochrane Rehabilitation worked on five different special projects at different stages of development: 1) a collaboration with the World Health Organization to extract the best evidence for Rehabilitation (Be4rehab); 2) the development of a reporting checklist for Randomised Controlled Trials in rehabilitation (RCTRACK); 3) the definition of what is the rehabilitation for research purposes; 4) the ebook project; and 5) a prioritization exercise for Cochrane Reviews production. The Review Committee finalized the screening and "tagging" of all rehabilitation reviews in the Cochrane library; the Publication Committee increased the number of international journals with which publish Cochrane Corners; the Education Committee continued performing educational activities such as workshops in different meetings; the Methodology Committee performed the second Cochrane Rehabilitation Methodological Meeting and published many papers; the Communication Committee spread the rehabilitation evidence through different channels and translated the contents in different languages. The collaboration with several National and International Rehabilitation Scientific Societies, Universities, Hospitals, Research Centers and other organizations keeps on growing.

Clinical replicability of rehabilitation interventions in randomized controlled trials reported in main journals is inadequate.

OBJECTIVE: The objective of this study was to study if randomized controlled trials (RCTs) in rehabilitation (a field where complex interventions prevail) published in main journals include all the details needed to replicate the intervention in clinical practice (clinical replicability). STUDY DESIGN AND SETTING: Forty-seven rehabilitation clinicians of 5 professions from 7 teams (Belgium, Italy, Malaysia, Pakistan, Poland, Puerto Rico, the USA) reviewed 76 RCTs published by main rehabilitation journals exploring 14 domains chosen through consensus and piloting. RESULTS: The response rate was 99%. Inter-rater agreement was moderate/good. All clinicians considered unanimously 12 (16%) RCTs clinically replicable and none not replicable. At least one "absent" information was found by all participants in 60 RCTs (79%), and by a minimum of 85% in the remaining 16 (21%). Information considered to be less well described (8-19% "perfect" information) included two providers (skills, experience) and two delivery (cautions, relationships) items. The best described (50-79% "perfect") were the classic methodological items included in CONSORT (descending order: participants, materials, procedures, setting, and intervention). CONCLUSION: Clinical replicability must be considered in RCTs reporting, particularly for complex interventions. Classical methodological checklists such as CONSORT are not enough, and also Template for Intervention Description and Clinical replication do not cover all the requirements. This study supports the need for field-specific checklists.

Cochrane Rehabilitation: 2018 annual report.

During its second year of existence, Cochrane Rehabilitation worked hard to accomplish new and old goals. The Review Committee completed the massive task of identifying and "tagging" all rehabilitation reviews in the Cochrane library. The Publication Committee signed agreements with several international journals and started the publication of Cochrane Corners. The Education Committee performed educational activities such as workshops in International Meetings. The Methodology Committee has completed a two days Cochrane Rehabilitation Methodological Meeting in Paris of which the results will soon be published. The Communication Committee reaches almost 5,000 rehabilitation professionals through social media, and is working on the translation of contents in Italian, Spanish, French, Dutch, Croatian and Japanese. Memoranda of Understanding have been signed with several National and International Rehabilitation Scientific Societies, Universities, Hospitals, Research Centres and other organizations. The be4rehab (best evidence for rehabilitation) project has been started with the World Health Organisation (WHO) to extract from Cochrane reviews and clinical guidelines the best currently available evidence to produce the WHO Minimum Package of Rehabilitation Interventions. The Cochrane Rehabilitation ebook is under development as well as a priority setting exercise with 39 countries from all continents.

One in 11 Cochrane Reviews Are on Rehabilitation Interventions, According to Pragmatic Inclusion Criteria Developed by Cochrane Rehabilitation.

OBJECTIVE: To identify all published protocols and reviews in the Cochrane Library relevant to the scope of practice of rehabilitation; to test pragmatic criteria to identify rehabilitation interventions; to begin categorizing reviews according to the professionals involved in delivering the intervention and broad areas of clinical practice. DATA SOURCES: Cochrane Database of Systematic Reviews. STUDY SELECTION: We screened all published reviews and protocols in the Cochrane library. DATA EXTRACTION: We built an online relational database into which we imported titles and abstracts of all reviews and protocols published in the Cochrane Library from 1996 to August 2018. We recruited rehabilitation professionals worldwide through Cochrane Rehabilitation's social media to find and tag rehabilitation reviews in this database. One rehabilitation physician and 1 allied health professional independently tagged each title against prespecified criteria. The Cochrane Rehabilitation Review Committee examined disagreements between contributors for any uncertainties about how to categorize a review. We revised and improved our preliminary criteria for identifying rehabilitation interventions as the work progressed. DATA SYNTHESIS: We identified that 9.4% of all Cochrane publications (894/9471 reviews and protocols) are directly relevant to the practice of rehabilitation. The professional groups whose interventions were most frequently the subject of rehabilitation reviews and protocols were rehabilitation physicians and physical therapists. We also identified a final list of inclusion and exclusion criteria for reviews on rehabilitation interventions. CONCLUSION: Many Cochrane Reviews are directly relevant to rehabilitation. Cochrane needs to consider the rehabilitation community a major stakeholder in all its work. The pragmatic criteria we tested are offered for future discussions on the identification and categorization of rehabilitation interventions by stakeholders worldwide. This work will support the spread of content from the Cochrane Library to rehabilitation professionals and guide future research.

Combating Scientific Misconduct: The Role of Focused Workshops in Changing Attitudes Towards Plagiarism.

Introduction Scientific misconduct is a global issue. There is low awareness among health professionals regarding plagiarism, particularly in developing countries, including Pakistan. There is no formal training in the ethical conduct of research or writing for under- and post-graduate students in the majority of medical schools in Pakistan. Internet access to published literature has made plagiarism easy. The aim of this study was to document the effectiveness of focused workshops on reducing scientific misconduct as measured using a modified version of the attitude towards plagiarism questionnaire (ATPQ) assessment tool. Materials and methods A cross-sectional study was conducted with participants of workshops on scientific misconduct. Demographic data were recorded. A modified ATPQ was used as a pre- and post-test for workshop participants. Data were entered in SPSS v20 (IBM< Armonk, NY, US). Frequencies and descriptive statistics were analyzed. An independent sample t-test was run to analyze differences in mean scores on pre-workshop ATPQ and differences in mean scores on post-test scores. Results There were 38 males and 42 females (mean age: 26.2 years) who participated in the workshops and completed the pre- and post-assessments. Most (59; 73.75%) were final-year medical students. One-third (33.8%) of the respondents had neither attended workshops related to ethics in medical research nor published manuscripts in medical journals (32.5%). More than half (55%) admitted witnessing unethical practices in research. There was a significant improvement in attitudes toward plagiarism after attending the workshop (mean difference = 7.18 (6.2), t = 10.32, P < .001). Conclusions Focused workshops on how to detect and avoid scientific misconduct can help increase knowledge and improve attitudes towards plagiarism, as assessed by the modified ATPQ. Students, residents, and faculty members must be trained to conduct ethical medical research and avoid all forms of scientific misconduct.

Restless Genital Syndrome: Case Report of a Rare Disorder from Pakistan.

Restless genital syndrome (RGS) is a newly recognized syndrome characterized by difficult to describe genital sensations, including itching, tingling, contractions, and even pain. It can be a source of distress for the patient and may lead to social withdrawal and delayed diagnosis. Many pharmacologic and non-pharmacologic treatment options have been documented in the literature. Dopamine agonists have been shown to be the most effective in symptomatic relief. We present a case of an Asian female with symptoms suggestive of RGS for 11 years before she was diagnosed who responded well to ropinirole. We discuss the pathophysiology and reasons for the delayed diagnosis.

Compression Stockings and Pressure Ulcers: Case Series of a Neglected Issue.

Pressure ulcers develop in patients who endure long periods of immobilization, often caused by conditions such as musculoskeletal and neurological diseases. Pressure ulcers adversely affect the patient and increase caregiver burden and healthcare costs. Typical sites for these ulcers include the sacrum, trochanters, and heels; they also occur on the nape of the neck, penis, nostrils, helix of the ear, and upper back. Compression stockings are commonly used to prevent and stop the progression of venous disorders, including deep vein thrombosis, but their role in the development of pressure ulcers is not well known. We describe three case reports of pressure ulcer development due to prolonged application of compression stockings. In each case, the nursing staff who were primarily responsible for the prevention of pressure ulcers applied the stockings continuously without any intermittent relief. Moreover, the stockings did not include manufacturer instructions, such as recommended exposure times and applications. We recommend that nursing staff be trained in pressure relief and prevention of pressure ulcers, including rare occurrences, and that manufacturers give detailed guidance regarding the safe use of compression stockings.

Prevalence and Perceptions of Musculoskeletal Disorders Among Hospital Nurses in Pakistan: A Cross-sectional Survey.

INTRODUCTION: Nursing is a professionally demanding job, and nurses are prone to develop musculoskeletal disorders. However, no data is available regarding its prevalence among Pakistani nurses. This study was conducted to document the pattern of work-related musculoskeletal disorders (WRMDs) in Pakistani nurses and their perceptions about contributing factors and management of WRMDs. METHODS: A questionnaire-based, cross-sectional survey was conducted in six hospitals in Lahore and Rawalpindi, which were selected using a convenient sampling technique. A four-part questionnaire comprised of demographic data, experience of musculoskeletal disorders, and perception of management and contributing factors of WRMDs was distributed among 150 nurses. One hundred and seventeen nurses returned completed forms. Data was analyzed using SPSS Statistics v20 (IBM, Armonk, New York, USA). Ethics review committee approval was obtained by CMH Lahore Medical College and the Institute of Dentistry, and informed consent was obtained. RESULTS: The prevalence of musculoskeletal disorders over a 12-month period was 31.6%, with the most common site being the low back (32%) followed by the shoulder (20%), upper back, and knees (10%). Among those affected, 60.6% sought professional help. Married nurses were more prone to WRMDs (p=0.0001). Regarding management, most (94%) agreed that rest is required to get better, neglecting problems of this kind can cause permanent health problems (89.7%), and physical activity should be avoided (38.7%). Working in the same positions for long periods (93.1%), attending an excessive number of patients in one day (81.2%), and working in awkward and cramped positions (78.6%) were the most commonly perceived risk factors for WRMDs. CONCLUSION: About one-third of Pakistani nurses in this cohort reported work-related musculoskeletal disorders with the low back most commonly affected. There is a need to increase awareness regarding ergonomics and posture maintenance to reduce WRMDs and improve patient care. This can be achieved by workshops and seminars on ergonomics and WRMDS.

A Questionnaire-Based Survey of Physical Medicine and Rehabilitation Residency Training in Pakistan.

Pakistan is one of the three countries in South East Asia that has an active postgraduate physical medicine and rehabilitation (PM&R) training program. College of Physicians and Surgeons Pakistan (CPSP) offers a four-year structured training program in PM&R. It consists of clinical teaching, lectures, rotations in other specialties, and writing a research dissertation. The aim of this survey was to provide an objective analysis of the current PM&R training program, including the facilities available for training, the participation of residents in academic activities, and their participation in different PM&R procedures. Hospital ethics committee approval was obtained. The questionnaire had sections on informed consent; basic demographics; the different components of residency training; and self-assessement of competence in different procedural skills. It was approved by the dean of PM&R at CPSP. There are six accredited training centers in Pakistan. Twelve residents are undergoing residency training at four different centers (Dec 2015). Key persons were nominated at each center to facilitate data collection. All residents (100% response rate) completed the survey. Almost all had read the CPSP training manual. Most had submitted the research dissertation. Training facilities varied across different centers, with the military center being the best equipped. The self-assessed competence of residents in different PM&R procedures varied among different centers, but overall it conformed to the competency levels specified in the training manual. Overall PM&R residency training in Pakistan is satisfactory, but there is a need to strengthen the weak areas and standardize the training across all centers in the country.

World Health Organisation Global Disability Action Plan 2014-2021: Challenges and perspectives for physical medicine and rehabilitation in Pakistan.

OBJECTIVE: To provide an update on disability and outline potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Pakistan. METHODS: A 6-day workshop at the Armed Forces Institute of Rehabilitation Medicine, Islamabad facilitated by rehabilitation staff from Royal Melbourne Hospital, Australia. Local healthcare professionals (n = 33) from medical rehabilitation facilities identified challenges in service provision, education and attitudes/approaches to people with disabilities, using consensus agreement for objectives listed in the GDAP. RESULTS: Respondents agreed on the following challenges in implementing the GDAP: shortage of skilled work-force, fragmented healthcare system, poor coordination between acute and subacute healthcare sectors, limited health services infrastructure and funding, lack of disability data, poor legislation, lack of guidelines and accreditation standards, limited awareness/knowledge of disability, socio-cultural perceptions and geo-topographical issues. The main facilitators included: need for governing/leadership bodies, engagement of healthcare professionals and institutions using a multi-sectoral approach, new partnerships and strategic collaboration, provision of financial and technical assistance, future policy direction, research and development. CONCLUSION: The barriers to implementing the GDAP identified here highlight the emerging priorities and challenges in the development of rehabilitation medicine and GDAP implementation in a developing country. The GDAP summary actions were useful planning tools to improve access and strengthen rehabilitation services.

Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction.

Background: Non-traumatic spinal cord dysfunction (SCDys) is caused by a large range of heterogeneous etiologies. Although most aspects of rehabilitation for traumatic spinal cord injury and SCDys are the same, people with SCDys have some unique rehabilitation issues. Purpose: This article presents an overview of important clinical rehabilitation principles unique to SCDys. Methods: Electronic literature search conducted (January 2017) using MEDLINE and Embase (1990-2016) databases for publications regarding SCDys. The focus of the literature search was on identifying publications that present suggestions regarding the clinical rehabilitation of SCDys. Results: The electronic search of MEDLINE and Embase identified no relevant publications, and the publications included were from the authors' libraries. A number of important clinical rehabilitation principles unique to people with SCDys were identified, including classification issues, general rehabilitation issues, etiology-specific issues, and a role for the rehabilitation physician as a diagnostic clinician. The classification issues were regarding the etiology of SCDys and the International Standards for Neurological Classification of Spinal Cord Injury. The general rehabilitation issues were predicting survival, improvement, and rehabilitation outcomes; admission to spinal rehabilitation units, including selection decision issues; participation in rehabilitation; and secondary health conditions. The etiology-specific issues were for SCDys due to spinal cord degeneration, tumors, and infections. Conclusions: Although there are special considerations regarding the rehabilitation of people with SCDys, such as the potential for progression of the underlying condition, functional improvement is typically significant with adequate planning of rehabilitation programs and special attention regarding the clinical condition of patients with SCDys.

Case Report of a Pressure Ulcer Occurring Over the Nasal Bridge Due to a Non-Invasive Ventilation Facial Mask.

Non-invasive ventilation (NIV) is used in patients with respiratory failure, sleep apnoea, and dyspnoea related to pulmonary oedema. NIV is provided through a facial mask. Many complications of NIV facial masks have been reported, including the breakdown of facial skin. We report a case of an elderly male admitted with multiple co-morbidities. The facial mask was applied continuously for NIV, without any relief or formal monitoring of the underlying skin. It resulted in a Grade II pressure ulcer. We discuss the possible mechanism and offer advice for prevention of such device-related pressure ulcers.

Knowledge Regarding Basic Facts of Stroke Among Final Year MBBS Students and House Officers: A Cross-Sectional Survey of 708 Respondents from Pakistan.

INTRODUCTION: Stroke is the leading cause of neurological disability in the world. In Pakistan, house officers (HOs) are usually the first contact for a stroke patient in the emergency department. Sometimes they need to make quick decisions regarding diagnosis and management without specialist supervision. Thousands of current final year MBBS (Bachelor of Medicine, Bachelor of Surgery) students will be performing the duties of HOs soon. This study documents the knowledge and confidence levels of final year students and HOs in Pakistan regarding basic facts related to initial diagnosis and management of stroke. MATERIALS AND METHODS: A questionnaire was developed using two standard textbooks of medicine and current stroke guidelines of the American Heart Association. The pre-tested self-administered questionnaire was distributed among 800 final year MBBS students and HOs in 14 medical colleges and hospitals in four different cities. The response rate was 88.5%. Data analysis was done using SPSS V.21. The CMH Lahore Medical College Ethics Review Committee approved this project. RESULTS: Respondents included medical students (n=496) and HOs (N= 212); most were female (n = 452, 63.9%). Of these, 31.4% had managed or assisted in the management of a patient with a stroke and had a higher confidence level in its diagnosis (p< 0.001) and management (p <0.001). Having a family member with stroke was associated with higher confidence in the diagnosis of stroke (p < 0.05) but not with confidence in its management (p = 0.41). Most correctly defined stroke (60.6%), identified the CT scan as the initial diagnostic modality (88.1%), knew the dosage of aspirin (64.9%), knew the time limit for thrombolysis (67.4%), and were familiar with the risk of deep vein thrombosis in immobilized stroke patients (85.4%). Less than half (44.5%) chose tissue plasminogen activator (t-PA) as the preferred initial intervention for acute ischemic stroke. CONCLUSION: This multicenter survey shows that the knowledge and confidence of medical students and HOs in Pakistan regarding initial diagnosis and management of stroke are inadequate in most domains. There is a need to improve the medical training for stroke in emergency departments for optimal outcomes. Public education campaigns about stroke should be conducted to increase the general awareness of the population about the prevention, signs, symptoms, and emergency steps to be taken when encountering a case of stroke.

Demographics of Lower Limb Amputations in the Pakistan Military: A Single Center, Three-Year Prospective Survey.

INTRODUCTION : The Pakistan military has been actively engaged in the war against terror for more than a decade. Many officers and soldiers have lost their limbs in this war. But the data on traumatic lower limb amputations in Pakistan is sparse. The aim of this study is to prospectively document the epidemiological profile of lower limb military amputees presenting at the largest rehabilitation centre of Pakistan over a three-year period. MATERIALS & METHODS : A prospective three-year survey was conducted at the Armed Forces Institute of Rehabilitation Medicine (AFIRM), Pakistan. One hundred twenty-three consecutive patients with lower limb amputations were enrolled in the survey. The demographic data, etiology, associated injuries, complications profile, and type of prosthesis provided were documented. The data analysis was done using the statistical analysis tool SPSS V 20 (IBM®,NY, USA). RESULTS : All patients were male. Most had traumatic amputation (119), were between 20-40 years (106), with unilateral amputation (115). Mine blast injury was the leading cause in 73 (59.3%) and most (58.5%) were fitted with modular prosthesis. Transtibial amputation was the commonest level (65), followed by transfemoral (30). The time of surgical amputation was not documented in 87% of the patients. Half of the patients (54%) had associated injuries. Seventy-nine patients had at least one complication with phantom pain being the commonest in 25% cases. CONCLUSIONS : This is the largest prospective demographic survey of lower limb amputees in Pakistan military to date. Scores of soldiers and civilians in Pakistan have suffered lower limb amputation. The availability of demographic data can improve the trauma and rehabilitation services for better understanding and management of such cases. There is a need to conduct large scale community-based epidemiological surveys to direct future policies and develop amputee rehabilitation services in the public sector.