The movement towards evidence-based practice has changed physiotherapy. It is no longer acceptable to unquestioningly adopt the beliefs about physiotherapy management of people with spinal cord injury which have been passed down through the years. Instead, we are encouraged to challenge long-held beliefs and to critically appraise the evidence underpinning them.

The desire to base practice on high quality clinical research is both promising and problematic. On the one hand, evidence-based practice has the potential to improve patient outcomes. It also increases job satisfaction for clinicians knowing that what they do each day is clearly effective. On the other hand, research evidence is always limited, both in quantity and quality. This means that we are often faced with clinical scenarios for which there is little or no evidence to guide practice. Transparency about the state of current evidence leads to ambiguity and complexity which is particularly confusing for junior physiotherapists. Junior physiotherapists faced with the day-to-day management of people with spinal cord injury want clear guidance of what to do when. It is difficult to provide this type of guidance in the presence of real uncertainty.

Ideally, most decisions about management would be based on evidence-based clinical practice guidelines. Evidence-based clinical practice guidelines are recommendations for practice based on a transparent assessment of the available evidence including, where possible, randomized controlled trials and systematic reviews (see Table 14.1).^1–3

Recommendations for clinical practice should take into account patients’ priorities and perspectives. Most importantly, there needs to be careful consideration of whether the effects of interventions justify the time, cost and inconvenience associated with providing them. Interventions which are expensive, inconvenient, uncomfortable and time-consuming should only be considered if they make a substantial and clear difference to patients’ lives. A balance needs to be achieved between encouraging patients to devote time, money and effort to therapeutic interventions which may have small benefits, and encouraging patients to spend their time participating in the broader aspects of life (e.g. returning to work, participating in family life, and engaging in social, sporting and community activities).

A search of the Cochrane⁴ and physiotherapy-specific⁵ databases in 2006 retrieved 36 randomized controlled trials,^6–41 three systematic reviews^42–44 and four sets of clinical guidelines^45–48 directly relevant to physiotherapy management of people with spinal cord injury (there are additional trials,^41,49–68 systematic reviews^69–77 and clinical guidelines^78–81 but they are not directly relevant to physiotherapy). Unfortunately, most trials involving patients with spinal cord injury are inconclusive (i.e. statistically underpowered) so few provide high quality evidence about the efficacy of physiotherapy practice. This problem is reflected in clinical guidelines. The few physiotherapy-specific recommendations contained within existing guidelines are generally based on low quality evidence.

Evidence-based practice is not only about treatment effectiveness. The goal-setting process also requires high quality physiotherapy-specific research. Ideally, physiotherapy goals would be based on algorithms which predict the probability of patients with different neurological presentations and attributes mastering different motor tasks, given individual environmental and personal circumstances. Such algorithms can be derived from cohort studies which follow representative samples of patients over time.^46,82–88 The most notable cohort studies use data collected for a large USA-based registry of spinal cord injuries [the American Uniform Data System for Medical Rehabilitation (UDSMR)].^89,90 While the results of these, and similar studies, are helpful for physiotherapists trying to set realistic and attainable goals for patients, most studies rely on global measures of activity limitations^86,91–96 captured in assessments such as the Functional Independence Measure®.^87,88,97,98 These measures primarily reflect the ability to perform a few key motor tasks, but do not provide sufficient or detailed information across the wide range of motor tasks which physiotherapists are responsible for addressing, and which people with spinal cord injury need to master. The widespread use of the Functional Independence Measure® to reflect the mobility of wheelchair-dependent patients is particularly problematic. It has poor sensitivity in this domain and fails to distinguish between those with different levels of wheelchair mobility.^87,99

No doubt physiotherapy-related research will continue to grow. The increasing number of clinical trials and systematic reviews in the area of spinal cord injuries will make possible the compilation of evidence-based clinical guidelines in the future. Perhaps emerging trials will challenge some aspects of current clinical practice, as is currently happening with contracture management (see Chapter 9). However, there are and always will be difficulties completing randomized controlled trials involving people with spinal cord injury. The most obvious difficulty is the small number of potential participants.^100–103 Less obvious difficulties are the lack of research-trained physiotherapists working in the area of spinal cord injuries and the difficulties attracting financial support to investigate the effectiveness of interventions which have long since become standard practice. Clinical decisions will therefore continue to be made on the basis of lower quality evidence than perhaps hoped for. Sometimes, results of research involving other patient groups will provide the best available estimate of treatment effects. For example, randomized controlled trials indicating the effectiveness of strength training in patients with peripheral neuropathies, multiple sclerosis, stroke or traumatic brain injury may provide the best evidence about the effectiveness of strength training in patients with partial paralysis following spinal cord injury (see Chapter 8).

The challenge for the physiotherapy profession is to critically reflect on what it does and work towards providing high quality evidence to support current practice as well as new and emerging therapies. When new evidence does emerge, the challenge is to respond to the results of clinical trials in a sensible and informed way and to change practice where appropriate.¹⁰⁴