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Are Clinical Prediction Rules Used in Spinal Cord Injury Care?

Prediction Rules in Spinal Injury Care

In February this year, we published the results of a survey in “Topics in Spinal Cord Injury Rehabilitation“. The survey explored the awareness and use of clinical prediction rules amongst clinicians working in spinal cord injury care (Boyles et al, 2024).

What are clinical prediction rules?

Clinical prediction rules (CPR) are a way of combining clinical features to enable clinicians to determine the likelihood of a particular clinical outcome. They can be diagnostic, prognostic, or predictive and are intended to help condense clinical information in a way that assists with subsequent decisions about clinical management (Beattie & Nelson, 2006).

Recent work in stroke has established the value of TMS for prognosis of recovery. The PREP2 algorithm (Stinear et al, 2017) combines a measure of upper limb power with TMS measures (presence or absence of motor evoked potentials) to determine the likelihood of motor recovery in patients’ upper limbs. I am intrigued by the possibility of a similar use in spinal cord injury (SCI).

Exploring the literature on clinical prediction in SCI, I found a range of studies that have developed prediction rules for recovery of function. However, I realised I hadn’t come across these in my clinical practice. I wanted to know whether clinicians working in this area were aware of these rules and whether they used them.

Survey of practice

To explore this, I carried out a survey of practice of SCI clinicians. I also asked about people’s reasons for choosing to use these rules (or not); as well as what factors they believed were important in making clinical predictions about recovery.

I distributed the survey via mailing lists in the NHS and various special interest groups (ACPIN, RCOT, MASCIP) and received 100 responses. The majority of respondents were physiotherapists.

Results

Our main finding was that the majority of respondents (71%) were unaware of CPR for SCI. Of those who were aware, less than a third reported actually using SCI-specific CPR in their practise (8% of the total respondents). Those who chose not to use them cited concerns about their accuracy. In general, lack of familiarity with these tools appeared to be the main barrier to their adoption.

Despite this, clinicians were positive about CPR in general. They reported that they can be useful tools, and that they would use them if they were accurate. However, some noted that CPR may be more useful for more junior clinicians. Interestingly, there was a negative correlation between years of experience and awareness of CPR, indicating that more junior clinicians were less likely to be aware, despite potentially being more likely to benefit from them.

Conclusions

CPR, and prognostic tools in general, are a hot topic in neurological recovery. Clinicians know from experience that one of the key questions that people have after a neurological event is ‘am I going to get better?’. This is often a difficult question to answer. In SCI particularly, we have a heterogeneous patient group, and making predictions about recovery can be a challenge, even for expert clinicians. Certain clinical indicators, such as the completeness of the injury, can indicate recovery potential, however this often just reduces the certainty with which we can predict a poor outcome. For example, a complete injury is less likely to recover; an incomplete injury may recover more function, but the extent of this recovery is hard to gauge.

Despite there being a body of work attempting to develop CPR for SCI, we show that these have not found their way into clinical practice, in part because of concerns about their usefulness.

More accurate prognostic tools, that draw on a wider range of clinical, neurophysiological and radiological predictors may help to make fine-grained distinctions between patient presentations that can guide prognosis and selection of more personalised treatments.

References

Beattie P, Nelson R. Clinical prediction rules: what are they and what do they tell us? Aust J Physiother. 2006;52(3):157-63. doi: 10.1016/s0004-9514(06)70024-1. PMID: 16942450.

Boyles RH, Alexander CM, Belsi A, Strutton PH. Are Clinical Prediction Rules Used in Spinal Cord Injury Care? A Survey of Practice. Top Spinal Cord Inj Rehabil. 2024 Winter;30(1):45-58. doi: 10.46292/sci23-00069. Epub 2024 Feb 29. PMID: 38433737; PMCID: PMC10906376.

Stinear CM, Byblow WD, Ackerley SJ, Smith MC, Borges VM, Barber PA. PREP2: A biomarker-based algorithm for predicting upper limb function after stroke. Ann Clin Transl Neurol. 2017 Oct 24;4(11):811-820. doi: 10.1002/acn3.488. PMID: 29159193; PMCID: PMC5682112.

Long Overdue Update

Hello all Neuromap Blog followers!

Apologies for the long silence. I have been overtaken by PhD busy-ness for the last few (8!) months and haven’t found time to update the blog. I hope to make up for this with some forthcoming posts about my progress.

As you will be aware from my last post, I was successful in securing an NIHR Imperial BRC PhD fellowship and enrolled as a PhD student at Imperial College officially in November last year. The focus of the last few months has been getting the various parts of my PhD project off the ground, and has been an exciting time! Now the dust has settled slightly, I can report back on the work I have been doing and some of the key events.

The main focus over the past few months has been twofold: firstly getting the mixed methods part of my study off the ground. This aims to investigate management of upper limb impairments in UK spinal injury centres (and other settings) and we have just received ethics approval to proceed with this from the HRA. Secondly, extending the scope of the previous experimental project, to allow for repeated measures of our participants. We have also recently received ethical approval for this amendment so we are now good to go!

Earlier this year, a survey I carried out during the pre-doctoral fellowship was published in ‘Topics in Spinal Cord Injury Rehabilitation”; which you can read here: https://doi.org/10.46292/sci23-00069 .

Upcoming Posts

Over the coming weeks I will provide more information about the two strands of the project and the work done so far. This will include:

  • A post about the published article mentioned above
  • An introductions to the mixed methods study.
  • More detail about my experience of running the experimental study with TMS and our next steps.
  • The use of AI in research; I’ve recently been experimenting with AI transcription of interviews and have had some interesting results!

Watch this space.

Fellowship Success

It’s been a while since I posted, and I have a few things I want to update on, but firstly I want to share some good news. Part of the reason for the lull in posting was because alongside working on Neuromap, I was writing an application to the NIHR Imperial BRC PhD Fellowship to enable me to continue this work. As there was only one available I was realistic about my chances of success, but with a lot of hard work on the application and support from my team, I was successful and have transitioned from the predoctoral fellowship into PhD studies!

This is a really exciting development for me as it means I can really do justice to the project, and will have a lot more time to learn and grow as a researcher and clinician. I’m really grateful for the support from my supervisory team, Paul Strutton, Caroline Alexander, Maurizio Belci and Athina Belsi, as well as the Imperial Healthy Charity who awarded me the predoctoral fellowship which was essential in enabling me to develop my PhD application, and the RDS (now the RSS) who helped me write it. I’m also grateful to my colleagues at Imperial College Healthcare NHS Trust who have been so supportive of my journey, and our collaborators at Buckinghamshire Healthcare NHS Trust and the National Spinal Injuries Centre at Stoke Mandeville; I’m really looking forward to continuing to work with them on this project. Finally, thanks to the NIHR Imperial BRC, who have given me this amazing opportunity; I’m looking forward to the next 3 years!

 

First Steps in PPI

As mentioned in my previous post, we undertook Participant and Public Involvement (PPI) work to support our project. I wanted to share a brief account of this here, including some of the key learning points from the experience.

What is PPI?

Participant and Public Involvement (PPI) is an important concept in contemporary healthcare research. For research to be relevant and to best serve the people and communities it aims to study; it must be informed by people from these groups. Where possible, researchers should incorporate PPI into all stages of the research process. This leads to better quality, more ethical research, since the aims and objectives of studies are informed by the lived experience of affected people. Projects are designed to successfully recruit from target populations, and better serve their needs.

As part of this project, I completed PPI training offered by the Patient Experience Research Centre (PERC) and sought their guidance on how to set up and run our first PPI session for the project. I also received help and guidance from Lillie Shahabi, who has extensive experience running PPI projects as Neuro-oncology Network Relationship Manager at Imperial College Healthcare NHS Trust (ICHT).

Reaching our Target Population

Our first challenge was recruitment: how could we reach the people that we need to reach? Through contacts at the National Spinal Injuries Centre, we were put in touch with one of their patient representatives, Christa Dyson, who linked us in with Hannah Aubrey, Impact Manager at the Spinal Injuries Association (SIA). The SIA subsequently published information about our research in their magazine ‘Forward’, inviting people to contact us to support with our PPI work. With support from Halle Johnson at PERC we advertised on their ‘VOICE’ platform as well as on the National Institutes of Health and Care Research (NIHR) ‘People in Research’ website. This enabled us to reach a large audience and we started to receive inquiries from people with experience of SCI who wanted to participate.

One challenge here was to ensure that we were targeting a diverse population. By promoting via various channels, and because we collected demographic data from people who showed interest, we were able to do this to a certain extent, but improving this aspect of our PPI work is a goal for the project going forwards.

Our First Session

Once we had sufficient volunteers, we started to get a group together. It was decided to have a single focus-group type session, run online, as this was the most inclusive for our participant group who have significant physical disabilities. It also allowed us to include people from diverse locations within the UK as people would not have to travel. The format of the session was a presentation by me on the proposed research, followed by a Q&A to get people’s views and opinions on what they had heard. Along with myself and Dr Strutton, the meeting was attended by 6 people with lived experience of SCI, including 2 carers. The presentation stimulated a lot of debate, so much so that we almost didn’t get to our planned questions!

Perspectives of People with Lived Experience

Valuable Research

Overall, the group felt that the research was important with valuable potential to produce something of benefit to people with spinal cord injury. For example:

“If there was some connectivity, I mean would that give people longer in rehab to wait for that connectivity to have effect so that the therapist could work with them? … the potential is huge…there could be cases for extending people’s therapy time or rehabilitation time if there was felt to be a benefit with waiting a bit longer and working with that patient.”(Christa, SCI survivor)

People also felt that the research was acceptable and would be well-tolerated by people with SCI. However, they highlighted some potential issues to be aware of. One of our participants noted that travelling can be difficult for patients, some of whom live far from the NSIC. It would be helpful if separate sessions could be carried out on the same, or at least consecutive days, or alternatively combined with planned clinic visits.

Managing Expectations

Several participants highlighted the importance of managing expectations regarding how to interpret any findings from the stimulation. Patients will likely be looking for reasons to be hopeful about their recovery, but we won’t know what the TMS measures mean until the project is complete.

“I think you’ve got an issue about managing patient expectations for those participating. And I think probably it needs to be made clear that there will be no immediate benefit to the participants in terms of therapy or management of their immediate rehabilitative needs, but that this is a research study to establish a framework…or groundwork.” (Rupert, SCI survivor)

This was emphasised again, that patients are likely to be looking hard for hopeful signs from the TMS assessment:

“They’re not grasping at straws, but they want some sort of response that says, oh that was interesting. It shows that you have got a … potential connection and part of what we’re trying to do is to see if in the future we can actually sort of enhance that connection.” (Phil, SCI survivor)

So What?

This linked to another point made by several people about the potential impact of the research. People felt that it would be more meaningful if we were able to relate the TMS measures to measures of function, especially if there was longitudinal follow up.

“Because you can do all the mapping you like, but unless it’s with real benefit to understand what their potential care needs might be, if there is no recovery or the functionality that is restored. So what?” (Christa, SCI survivor)

Currently the scope of the project allows us to compare TMS and clinical measures at one time point only, but we hope to extend the research to look at how TMS and clinical measures evolve over time and what TMS measures can tell us about recovery potential. When we have a clearer plan for this, we will run a follow up PPI group session for further discussion.

Other Topics

Some other topics and questions included: Making sure that our information sheets are understandable for lay audiences and to avoid jargon. Can people with different hair types, e.g. afro hair, can participate in TMS? Do we plan to test both upper limbs? How long after injury we will test people?

The Value of PPI

As you can see from this summary, our initial PPI group session provided valuable feedback for us and made us consider aspects of our research plan in much more detail. It also gave us insight into the perspectives and priorities of people living with SCI and ideas for the design and management of our project. We are reassured that people with SCI think that the work we are doing is important and we really value all the helpful suggestions and comments that were shared. We are grateful to all those who took part, and those who assisted us in setting up this work. We look forward to doing further PPI work as our project evolves.

 

Further reading:

Staley, K., Exploring Impact: Public involvement in NHS, public health and social care research. 2009.

Welcome to the Neuromap Blog!

Welcome to my blog. This page will provide a window into a research project being run as a collaboration between Imperial College, Imperial College Healthcare NHS Trust (ICHT) and the National Spinal Injuries Centre at Stoke Mandeville Hospital.

Our Project: Using TMS for Spinal Cord Injury

My name is Rowan, I am a physiotherapist at Imperial College Healthcare NHS Trust. I was successful in obtaining an Imperial Health Charity fellowship to undertake a research secondment at Imperial College in the Nick Davey Lab, part of the Imperial MSk lab, with Dr Paul Strutton. We are investigating the potential for transcranial magnetic stimulation (TMS), to be used as an assessment to help us understand the extent of spinal cord damage that has occurred after spinal cord injury. To use TMS, we place a coil next to a person’s scalp; an electric current is passed through the coil, generating a magnetic field. This magnetic field can activate the nervous tissue in the brain, creating different effects depending on the area of the brain being stimulated. TMS is safe, painless and has been used in research and clinical applications for over 30 years.

What can TMS Tell us? Assessing motor pathways

Picture of woman with TMS coil next to her scalp
TMS session

For the purposes of our research, we want to know if there is a connection between the muscles and the area of the brain that controls movement. To find this out, we will stimulate a brain area called the motor cortex and see if this leads to any activity in the muscles. We can measure this with stick-on electrodes. If we detect activity, this shows that there are connections from the brain to the muscles; that some of the spinal pathways are still intact. Knowing this could help patients and clinicians work out how much potential a person has to recover function. This could help with planning rehabilitation or targeting specific treatments.

Neuronavigated TMS and Protocol Development

BrainSight neuronavigation system
Neuronavigation system

We will use a special kind of TMS technique called neuronavigation, which uses infrared cameras to track the location of the coil and the person being stimulated. This means we can be very precise when we target the brain areas we are stimulating.

Our first task is to define the protocol that we will use with patients. To help us do that, we are recruiting healthy participants at our lab in White City in London and using TMS to map the responses from their arm and hand muscles when we stimulate the motor cortex. We want to know which parameters are most important, and how to carry out the protocol efficiently in a way that is comfortable for people with spinal cord injury. I will share more details about the experiment soon with pictures of the equipment so you can understand more what we are doing!

Patient and Public Involvement

We have also been talking to patients with spinal cord injury and their carers about our research. Through our contacts at the Spinal Injuries Association and with help from the NIHR Imperial Patient Experience Research Centre (PERC) we recently ran a Patient and Public Involvement (PPI) group session where we presented details about our project and received valuable feedback. I plan to write about this in a future blog post.

Stay Tuned!

I hope you have found this interesting. Stay tuned for more updates about the project. Please contact me via email if you have any questions or would like to take part in any of our experiments.

 

Further reading:

Klomjai, W., R. Katz, and A. Lackmy-Vallée, Basic principles of transcranial magnetic stimulation (TMS) and repetitive TMS (rTMS). Annals of Physical and Rehabilitation Medicine, 2015. 58(4): p. 208-213.

Arora, T., et al., Utility of transcranial magnetic stimulation in the assessment of spinal cord injury: Current status and future directions. Front Rehabil Sci, 2022. 3: p. 1005111.

Rossi, S., et al., Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clinical Neurophysiology, 2009. 120(12): p. 2008-2039.