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.
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.
Rehabilitation for people with spinal cord injury in many low- and middle-income countries is not avail-able or is in the early stages of development. However, rehabilitation is recognized as crucial in order to optimize functional recovery and outcomes for patients with spinal cord injury. With an increasing incidence of spinal cord injury, the unmet need for rehabilitation is huge. This report describes the early development of a specialist rehabilitation service for spinal cord injury in Madagascar, one of the poorest countries in the world. The sustained input to an expanding rehabilitation team has led to reductions in avoidable complications. The input of the rehabilitation team has been welcomed by the neurosurgery department, which has recognized fewer delays in patients undergoing surgical treatments. Cost, lack of resources and trained staff, and poor understanding of disability continue to provide challenges. However, the development of the rehabilitation service using low technology, but with a high level of knowledge and systematic management, is a source of considerable pride. This development in Madagascar can be regarded as a model for spinal cord injury rehabilitation in other low-resource settings.
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.
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