We systematically review multiple databases (MEDLINE/PubMed, CINAHL®, EMBASE, PsycINFO) to identify and synthesize all relevant literature published from 1980 to present day. MeSH headings and keywords for multiple clinical areas are paired with spinal cord injury (SCI), tetraplegia, quadriplegia or paraplegia. Studies are included if they:
- are published in English
- study at least 3 human subjects, at least 50% of which had a SCI
- use a measurable outcome associated with the treatment
Over time, new areas of study and SCI rehabilitation topics and keywords (e.g., pressure ulcers) are identified by a multi-disciplinary team of expert scientists, clinicians, policy-makers, and people with SCI. After the reference sections of meta-analyses, systematic reviews and review articles are hand-searched (it is known that hand searching provides higher rates of return than electronic searching within a particular subject area (Hopewell et al. 2007). Keywords used for each specific topic are outlined in Appendix 1 below.
External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision… Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett et al. 1996)
Quality Assessment Tools and Data Extraction
Methodological quality of individual RCTs is assessed using the Physiotherapy Evidence Database (PEDro) scale. The PEDro scale was originally developed for the purpose of accessing bibliographic details and abstracts of randomized-controlled trials (RCT), quasi-randomized studies and systematic reviews in physiotherapy. The PEDro scale has been used to assess both pharmacological and non-pharmacological studies with good agreement between raters at an individual item level and in total PEDro scores (Foley et al. 2006). Maher et al. (2003) found the reliability of PEDro scale item ratings varied from “fair” to “substantial,” while the reliability of the total PEDro score was “fair” to “good”. The PEDro scale has 11-items, in which the first item relates to external validity and the other ten items assess the internal validity of a clinical trial. One point is given for each satisfied criterion (except for the first item, which is given a YES or NO), yielding a maximum score of ten. A higher score indicates better study quality. The following cut-points were used: 9-10 (excellent); 6-8 (good); 4-5 (fair); <4 (poor). A point for a particular criterion is awarded only if the article explicitly reported that the criterion was met. The scoring system is detailed in Appendix 2 below. Two independent raters review each article. Scoring discrepancies are resolved through discussion.
Methodological quality of systematic reviews of RCTs is assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews). Two agreements using AMSTAR are required during quality assessment ensuring lower risk of bias. AMSTAR is attached in Appendix 3 below.
Data are extracted to form tables. Sample subject characteristics (Population), nature of the treatment (Intervention), measurements (Outcome Measures), and key results are presented in the tables. In cases, where a single study overlaps into multiple chapters (e.g., treadmill training has effects on the cardiorespiratory, lower extremity and bone health), the results focus on the outcomes relevant to that chapter.