The Experience of Limited Access to Care for Community-Based Patients With Spinal Cord Injury and Stroke in Nepal and the Potential of Telerehabilitation: A Qualitative Study.

This study explores the experiences of care received and management of disability for individuals with spinal cord injury and stroke following discharge from a specialty rehabilitation center, alongside perspectives on the potential role of telerehabilitation. We employed qualitative in-depth face-to-face interviews with patients who had accessed and been discharged from a specialist rehabilitation center in Nepal were used. Interviews sought perspectives of adjusting to, living with, and managing disability alongside the potential role of telerehabilitation in the community setting. Inductive thematic analysis was used to derive themes. A total of 17 participants with spinal cord injuries or stroke were interviewed. Four generated themes included: (i) Difficulties accessing support and perceived mismanagement following initial neurological injury; (ii) Realizing the magnitude and impact of an injury in the absence of clear routes to support; (iii) A multi-faceted symptom burden and its impact; and (iv) The nature and types of interaction with health professionals post-discharge and the potential role of telerehabilitation. We detail accounts of suspended periods with minimal or no support provided from healthcare providers for people with spinal cord injury and stroke following initial acute management. Telerehabilitation could be a worthwhile approach to enhance access to rehabilitation in the community setting but must accompany national efforts to enhance the provision of specialist rehabilitation.

Cognition and Quality of Life of People with Spinal Cord Injury.

Objectives: The aim of this study was to assess the cognitive abilities of people with spinal cord injury (SCI) using the Edinburgh Cognitive and Behavior Amyotrophic Lateral Sclerosis Screen (ECAS), a tool designed for testing cognition in individuals with limited hand motor function. The impact of cognitive dysfunction on quality of life was also assessed. Methods: Forty-one patients with SCI were assessed using ECAS, the brief version of the World Health Organisation Quality of Life questionnaire (WHOQOL-BREF), and the Spinal Cord Independence Measure. Results: Overall, 28 of the 41 participants scored below the cut-off threshold for normal population in ECAS. The domains affected were language, 63%; memory, 51%; executive function, 44%; verbal fluency, 44%; and visuospatial skills, 24%. On multiple regression analysis, the ECAS total score moderately strongly explained the variance in the WHOQOL-BREF psychological (ß = 0.428, t = 2.958, P = 0.005) and environmental (ß = 0.411, t = 2.819, P = 0.008) domains. ECAS memory scores independently influenced WHOQOL-BREF physical (ß = 0.398, t = 2.67, P = 0.011) and environmental (ß = 0.37, t = 2.697, P = 0.010) domains. WHOQOL-BREF psychological scores were significantly influenced by ECAS executive scores (ß = 0.415, t = 2.85, P = 0.007), whereas the social domain was not significantly influenced by ECAS scores. Conclusions: It was feasible to use ECAS in individuals with SCI. Cognitive ability influenced the quality of life of people with SCI.

TEleRehabilitation Nepal (TERN) for People With Spinal Cord Injury and Acquired Brain Injury: A Feasibility Study.

BACKGROUND: Spinal Cord Injury (SCI) or Acquired Brain Injury (ABI) leads to disability, unemployment, loss of income, decreased quality of life and increased mortality. The impact is worse in Low-and Middle-Income Countries (LMICs) due to a lack of efficient long-term rehabilitative care. This study aims to explore the feasibility and acceptability of a telerehabilitation programme in Nepal. METHODS: Prospective cohort feasibility study in a community setting following discharge from a specialist rehabilitation centre in Nepal. Patients with SCI or ABI who had previously accessed specialist rehabilitation were connected to a specialist Multidisciplinary Team (MDT) in the centre through a video conference system for comprehensive remote assessments and virtual individualised interventions. Data were captured on recruitment, non-participation rates, retention, acceptability (via end-of-study in-depth interviews with a subset of participants) and outcome measures including the Modified Barthel Index (MBI), Depression Anxiety Stress Scale (DASS) and EuroQol-5D (EQ-5D), completed pre- and post-programme. RESULTS: 97 participants with SCI (n = 82) or ABI (n = 15) discharged from the centre during an 18-month period were approached and enrolled on the study. The telerehabilitation programme facilitated the delivery of support around multiple aspects of rehabilitation care, such as spasticity treatments and pain management. Outcome measures indicated a significant improvement in functional independence (P < .001), depression, anxiety and stress (P < .001) and quality of life (P < .001). Qualitative interviews (n = 18) revealed participants found the programme acceptable, valuing regular contact and input from MDT professionals and avoiding expensive and lengthy travel. CONCLUSION: This is the first study in Nepal to identify telerehabilitation as a feasible and acceptable approach to augment the provision of specialist rehabilitation. Future research is needed to assess the suitability of the programme for other conditions requiring specialist rehabilitation and determine the mechanisms underpinning improved outcomes for people with SCI or ABI. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04914650.

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs). SETTING: Not applicable. METHODS: MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946-2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants' sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality. CONCLUSION: There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Intermittent theta-burst stimulation for upper-limb dysfunction and spasticity in spinal cord injury: a single-blind randomized feasibility study.

STUDY DESIGN: Single-blind, sham-controlled, crossover randomized feasibility study OBJECTIVES: (1) Assess the feasibility of a full-scale trial of intermittent theta-burst stimulation (iTBS) for upper-limb sensorimotor dysfunction following spinal cord injury (SCI). (2) Determine the safety and tolerability of iTBS over primary motor cortex on upper-limb function in people with spinal cord injury (SCI). SETTING: Large Tertiary Spinal Injuries Centre METHODS: Participants with incomplete SCI, suffering with upper-limb spasticity were recruited and randomized to receive active/sham iTBS over the hand representation of the primary motor cortex. The intervention was delivered in 10 sessions over a 2-week period, followed by a 2-week washout, before being crossed over to receive the alternative intervention for the same number of sessions. Feasibility was assessed by pre-specified criteria which included recruitment rate of 3 participants per month, 10 completed interventions and 10 complete data sets for 15 recruited participants with no serious adverse events. Secondary outcomes included preliminary data collection for spasticity, pain and sensorimotor function. RESULTS: Twelve participants were recruited over 10 weeks (i.e., 4.8 per month), with 11 randomized and 10 completing the intervention protocol with no serious adverse events. Eight complete data sets were obtained as two participants failed to attend follow-up. Data from 10 participants were analyzed, with one early dropout due to an unrelated adverse event. CONCLUSIONS: It is safe and feasible to conduct a full-scale trial. Whilst iTBS has shown promising results, further research optimizing the intervention is required to improve anticipated clinical efficacy.

A rehabilitation training partnership in Madagascar.

We describe here the development of a mid-level training programme for doctors in Madagascar to direct regional and national rehabilitation services. Eight doctors enrolled and all gained their diplomas and have gone on to form the Association of Physical and Rehabilitation Medicine of Madagascar, which is leading further training and service developments. The course was specific to Madagascar's needs, and was devised according to the vision of the senior rehabilitation specialist in the Ministry of Health in Madagascar with support from the University of Antananarivo. The syllabus was developed with a senior Rehabilitation Medicine consultant responsible for setting up a comprehensive range of services and teaching in a University teaching hospital in the UK. Major barriers to success include the economic and political situation in Madagascar, which worsened steadily over the period of the training, the lack of resources for health, rehabilitation and rehabilitation workshops, and the withdrawal of aid. The sustainability of the training and the improved services that have been initiated will be evaluated, but these will be influenced by the situation of the country. It is hoped that this description of a highly practical training using modern teaching methods will be of use in other low-resource countries. Much of the teaching input was given by clinicians from a UK teaching hospital, and this resource will continue to be needed.