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Study design Double blind, non-inferiority crossover randomised controlled trial. Objectives To determine if micro enemas administered with a squeeze-tube and a 5 cm-long nozzle (squeeze-tube method) are as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe (catheter method) in people with a recent spinal cord injury. Setting Two inpatient spinal cord injury units located in Sydney, Australia. Methods Twenty people admitted to hospital with recent spinal cord injury were randomly assigned to two treatment sequences; 4 weeks of micro enemas delivered by the squeeze-tube method followed by 4 weeks of micro enemas delivered by the catheter method, or vice versa. Each treatment sequence was 8 weeks with a crossover at the end of week 4. The primary outcome was time to complete bowel care. Secondary outcomes reflected faecal incontinence, quality of life, perception of treatment effectiveness and participant reported time to complete bowel care. The primary and secondary outcomes were measured by blinded assessors in week 4 and week 8. A non-inferiority margin of 10 min for time to complete bowel care was set a priori. Results The mean between group difference (95% confidence interval) for the time to complete bowel care was −0.5 min (−2.8 to 1.8), where a negative value favours the catheter method. Results were similar for all secondary outcomes. Conclusions Micro enemas delivered by the squeeze-tube method are as good or better than micro enemas delivered by the catheter method in people with a recent spinal cord injury.

Systematic review. To determine whether any physiotherapy interventions increase Spinal Cord Independence Measure or Functional Independence Measure scores (SCIM/FIM) in people with spinal cord injury (SCI), with the overall aim of determining whether any physiotherapy interventions need to be controlled for in studies examining the effects of novel experimental interventions on SCIM/FIM. A systematic review was conducted to identify all randomised controlled trials examining the effect of any physiotherapy intervention on SCIM/FIM in people with SCI. PEDro scores were used to rate risk of bias. The results of similar trials and comparisons were pooled using meta-analyses. Thirty-three trials met the inclusion criteria but only 27 provided useable data. The median (IQR) PEDro score was 6.0 (4.0–7.0). A meta-analysis of four trials comparing robotic gait training with overground gait training that used a combination of FIM/SCIM indicated a pooled mean (95% CI) between-group difference of 0.38 standardised mean difference (SMD; 95% CI, 0.08–0.67). A second meta-analysis of two trials comparing upper limb training with and without functional electrical stimulation using FIM indicated a pooled (95% CI) between-group difference of 1.31 SMD (0.62–1.99). Another six trials examining a range of different physiotherapy interventions reported a statistically significant mean between-group difference on SCIM/FIM. There is low-quality evidence to indicate that a small number of physiotherapy interventions increase SCIM/FIM. The importance of controlling for all physiotherapy interventions in studies examining the effects of novel experimental interventions on SCIM/FIM is as yet unclear.

Study design Systematic review. Objective To determine the effectiveness of physiotherapy interventions for the treatment of spasticity in people with spinal cord injuries. Setting Not applicable. Methods A comprehensive search was undertaken to identify all randomised controlled trials of physiotherapy interventions that included an assessor-reported (objective) or participant-reported (subjective) measure of spasticity. Only trials that provided a physiotherapy intervention on more than one occasion were included. The susceptibility to bias of each trial was rated on the PEDro scale. Data were extracted to derive mean between-group differences (95% CI) for each trial. Results Twenty-eight trials were identified but only 17 provided useable data. Seven trials compared a physiotherapy intervention to no intervention (or a sham intervention) and 10 trials compared one physiotherapy intervention to another physiotherapy intervention. The median (IQR) PEDro score of the 17 trials was 6/10 (6-8). The most commonly used assessor- and participant-reported measures of spasticity were the Ashworth scale and Spinal Cord Injury Spasticity Evaluation Tool, respectively. Only one trial demonstrated a treatment effect. This trial compared continuous passive motion of the ankle to no treatment on the Ashworth scale. The remaining 16 trials were either inconclusive or indicated that the treatment was ineffective for reducing spasticity. Conclusions There is no high-quality evidence to indicate that physiotherapy interventions decrease spasticity but this may reflect a lack of research on the topic. Future trials should focus on participant-reported measures of spasticity that distinguish between the immediate, short-term and long-term effects of any physiotherapy intervention.

Double blind, non-inferiority crossover randomised controlled trial.To determine if micro enemas administered with a squeeze-tube and a 5 cm-long nozzle (squeeze-tube method) are as good or better than micro enemas administered with a 10 cm-long catheter attached to a syringe (catheter method) in people with a recent spinal cord injury.Two inpatient spinal cord injury units located in Sydney, Australia.Twenty people admitted to hospital with recent spinal cord injury were randomly assigned to two treatment sequences; 4 weeks of micro enemas delivered by the squeeze-tube method followed by 4 weeks of micro enemas delivered by the catheter method, or vice versa. Each treatment sequence was 8 weeks with a crossover at the end of week 4. The primary outcome was time to complete bowel care. Secondary outcomes reflected faecal incontinence, quality of life, perception of treatment effectiveness and participant reported time to complete bowel care. The primary and secondary outcomes were measured by blinded assessors in week 4 and week 8. A non-inferiority margin of 10 min for time to complete bowel care was set a priori.The mean between group difference (95% confidence interval) for the time to complete bowel care was -0.5 min (-2.8 to 1.8), where a negative value favours the catheter method. Results were similar for all secondary outcomes.Micro enemas delivered by the squeeze-tube method are as good or better than micro enemas delivered by the catheter method in people with a recent spinal cord injury.

Study design A multi-centred, single-blinded randomised controlled trial. Objectives To determine the effect of 10,000 voluntary contractions over 8 weeks on the strength of very weak muscles in people with spinal cord injury (SCI). Settings Seven hospitals in Australia and Asia. Methods One hundred and twenty people with recent SCI undergoing inpatient rehabilitation were randomised to either a Treatment or Control Group. One major muscle group from an upper or lower limb was selected if the muscle had grade 1 or grade 2 strength on a standard six-point manual muscle test. Participants allocated to the Treatment Group performed 10,000 isolated contractions of the selected muscle group, as well as usual care in 48 sessions over 8 weeks. Participants allocated to the Control Group received usual care alone. Participants were assessed at baseline and 8 weeks by a blinded assessor. The primary outcome was voluntary muscle strength on a 13-point manual muscle test. There were three secondary outcomes capturing therapists’ and participants’ perceptions of strength and function. Results The mean between-group difference of voluntary strength at 8 weeks was 0.4/13 points (95% confidence interval −0.5 to 1.4) in favour of the Treatment Group. There were no notable between-group differences on any secondary outcome. Conclusion Ten thousand isolated contractions of very weak muscles in people with SCI over 8 weeks has either no or a very small effect on voluntary strength.

Generic qualitative design.Australian and New Zealand SCI physiotherapists are developing clinical practice guidelines for the physiotherapy management of people living with spinal cord injury. To guide the development of the guidelines it was important to understand how physiotherapists and people living with spinal cord injury use evidence to choose interventions and the potential barriers and facilitators to the uptake of the clinical practice guidelines.Spinal Cord Injury Centres in Sydney, Australia and New Zealand.Focus groups and interviews with physiotherapists and people living with spinal cord injury were recorded, transcribed, and subjected to thematic analysis.A total of 75 participants took part in the study, 45 physiotherapists and 30 people living with spinal cord injury. Three main themes were identified from the data: (1) Types and sources of evidence that influence treatment choices, (2) the many factors determining treatment choices, and (3) ways in which clinical practice guidelines could influence treatment.Clinical practice guidelines have the potential to reduce the barriers identified by physiotherapists in accessing and interpreting research evidence on interventions for people living with spinal cord injury. Supported implementation of guidelines is required to demonstrate their benefit and encourage physiotherapists to factor in evidence when balancing the multiple factors influencing choice of physiotherapy intervention.

Cohort study embedded in a clinical trial.Community, Bangladesh.To determine the incidence, severity and time course of pressure injuries over the first two years following discharge from hospital in people with spinal cord injuries (SCI) in Bangladesh.Participants (n = 186) were contacted by telephone 39 times and assessed face-to-face 4 to 6 times over the two years following discharge. At each point of contact the presence and severity of pressure injuries were determined using the Pressure Ulcer Scale for Healing (PUSH). Survival analyses were conducted to determine the time course of development of pressure injuries and recovery from pressure injuries. Lasso regression was used to construct multivariable prediction models.Seventy-seven participants (41%; 95% CI 34% to 49%) developed at least one pressure injury in the first two years after discharge (incidence rate 0.27 per person-year, 95% CI 0.22 to 0.34). Most pressure injuries were on the sacrum (23%). Pressure injuries took a median (IQR) of 40 (29 to 57) days to heal. The median (IQR) peak PUSH score was 11.0/17 (8.0 to 13.5). The multivariable prediction models had poor predictive properties (maximum c-statistic 0.75).Pressure injuries impose a large health burden on people with SCI in Bangladesh. However, they are difficult to predict, treat and prevent. Further research is needed to identify who is at most risk and to find solutions for the treatment and prevention of pressure injuries in Bangladesh and other low-middle income countries.

IntroductionExercise, support and advice are considered core components of management for most musculoskeletal conditions and are typically provided by physiotherapists through regular face-to-face treatments. However, exercise can be provided remotely as part of a home exercise programme, while support and advice can be provided over the telephone. There is initial evidence from trials and systematic reviews to suggest that remotely provided physiotherapy can be used to manage a variety of musculoskeletal conditions safely and effectively.Methods and analysisThe aim of this single-blind randomised controlled non-inferiority trial is to determine whether a supported home exercise programme is as good as or better than face-to-face physiotherapy for the treatment of musculoskeletal conditions. Two hundred and ten participants will be recruited from five public hospitals in Sydney, Australia. Participants will be randomised to either the supported home exercise group or the face-to-face physiotherapy group. Participants allocated to the supported home exercise group will initially receive one face-to-face session with the trial physiotherapist and will then be managed remotely for the next 6 weeks. Participants allocated to the face-to-face physiotherapy group will receive a course of physiotherapy as typically provided in Sydney government hospitals. The primary outcome is function measured by the Patient Specific Functional Scale at 6 weeks. There will be nine secondary outcomes measured at 6 and 26 weeks. Separate analyses will be conducted on each outcome, and all analyses will be conducted on an intention-to-treat basis. A health economic evaluation will be conducted from a health funder plus patient perspective.Ethics and disseminationEthical approval was obtained on the 17 March 2017 from the Northern Sydney Local Health District HREC, trial number HREC/16HAWKE/431-RESP/16/287. The results of this study will be submitted for publication to peer-reviewed journals and be presented at national and international conferences. Recruitment commenced in March 2019, and it is anticipated that the trial will be completed by December 2021. This trial will investigate two different models of physiotherapy care for people with musculoskeletal conditions.Trial registration numberCPMP/ICH-135/95.Protocol versionThe most recent version of the protocol is V.1.2 dated November 2019.

Systematic review.To determine whether any physiotherapy interventions increase Spinal Cord Independence Measure or Functional Independence Measure scores (SCIM/FIM) in people with spinal cord injury (SCI), with the overall aim of determining whether any physiotherapy interventions need to be controlled for in studies examining the effects of novel experimental interventions on SCIM/FIM.A systematic review was conducted to identify all randomised controlled trials examining the effect of any physiotherapy intervention on SCIM/FIM in people with SCI. PEDro scores were used to rate risk of bias. The results of similar trials and comparisons were pooled using meta-analyses.Thirty-three trials met the inclusion criteria but only 27 provided useable data. The median (IQR) PEDro score was 6.0 (4.0-7.0). A meta-analysis of four trials comparing robotic gait training with overground gait training that used a combination of FIM/SCIM indicated a pooled mean (95% CI) between-group difference of 0.38 standardised mean difference (SMD; 95% CI, 0.08-0.67). A second meta-analysis of two trials comparing upper limb training with and without functional electrical stimulation using FIM indicated a pooled (95% CI) between-group difference of 1.31 SMD (0.62-1.99). Another six trials examining a range of different physiotherapy interventions reported a statistically significant mean between-group difference on SCIM/FIM.There is low-quality evidence to indicate that a small number of physiotherapy interventions increase SCIM/FIM. The importance of controlling for all physiotherapy interventions in studies examining the effects of novel experimental interventions on SCIM/FIM is as yet unclear.

Systematic review.To determine the effectiveness of physiotherapy interventions for the treatment of spasticity in people with spinal cord injuries.Not applicable.A comprehensive search was undertaken to identify all randomised controlled trials of physiotherapy interventions that included an assessor-reported (objective) or participant-reported (subjective) measure of spasticity. Only trials that provided a physiotherapy intervention on more than one occasion were included. The susceptibility to bias of each trial was rated on the PEDro scale. Data were extracted to derive mean between-group differences (95% CI) for each trial.Twenty-eight trials were identified but only 17 provided useable data. Seven trials compared a physiotherapy intervention to no intervention (or a sham intervention) and 10 trials compared one physiotherapy intervention to another physiotherapy intervention. The median (IQR) PEDro score of the 17 trials was 6/10 (6-8). The most commonly used assessor- and participant-reported measures of spasticity were the Ashworth scale and Spinal Cord Injury Spasticity Evaluation Tool, respectively. Only one trial demonstrated a treatment effect. This trial compared continuous passive motion of the ankle to no treatment on the Ashworth scale. The remaining 16 trials were either inconclusive or indicated that the treatment was ineffective for reducing spasticity.There is no high-quality evidence to indicate that physiotherapy interventions decrease spasticity but this may reflect a lack of research on the topic. Future trials should focus on participant-reported measures of spasticity that distinguish between the immediate, short-term and long-term effects of any physiotherapy intervention.

A systematic review. The aim of this review was to determine the effectiveness of physiotherapy (PT) interventions for increasing voluntary muscle strength in people with spinal cord injuries (SCI). We included randomised controlled trials of PT interventions for people with SCI. We were interested in two comparisons: PT interventions compared with sham or no intervention, and PT interventions compared to each other. The outcome of interest was voluntary strength of muscles directly affected by SCI. All included studies were rated according to the Cochrane Risk of Bias Tool and results of similar trials were pooled using meta-analyses where possible. Twenty-six trials met the inclusion criteria and provided useable data. A statistically significant between-group difference was found in four comparisons, namely, resistance training versus no intervention (standardised mean difference (SMD) = 0.64; 95% CI, 0.22–1.07; p = 0.003); resistance training combined with electrical stimulation versus no intervention (mean difference (MD) = 14 Nm; 95% CI, 1–27; p = 0.03); a package of PT interventions versus no intervention (MD = 4.8/50 points on the Lower Extremity Motor Score (LEMS); 95% CI 1.9–7.7; p = 0.01); and robotic gait training versus overground gait training (MD = 3.1/50 points on the LEMS; 95% CI, 1.3–5.0; p = 0.0008). There is evidence that a small number of PT interventions increase voluntary strength in muscles directly affected by SCI.

Questions: Do interventions involving repetitive practice improve strength after stroke? Are any improvements in strength accompanied by improvements in activity? Design: Systematic review of randomised trials with meta-analysis. Participants: Adults who have had a stroke. Intervention: Any intervention involving repetitive practice compared with no intervention or a sham intervention. Outcome measures: The primary outcome was voluntary strength in muscles trained as part of the intervention. The secondary outcomes were measures of lower limb and upper limb activity. Results: Fifty-two studies were included. The overall SMD of repetitive practice on strength was examined by pooling post-intervention scores from 46 studies involving 1928 participants. The SMD of repetitive practice on strength when the upper and lower limb studies were combined was 0.25 (95% CI 0.16 to 0.34, I2 = 44%) in favour of repetitive practice. Twenty-four studies with a total of 912 participants investigated the effects of repetitive practice on upper limb activity after stroke. The SMD was 0.15 (95% CI 0.02 to 0.29, I2 = 50%) in favour of repetitive practice on upper limb activity. Twenty studies with a total of 952 participants investigated the effects of repetitive practice on lower limb activity after stroke. The SMD was 0.25 (95% CI 0.12 to 0.38, I2 = 36%) in favour of repetitive practice on lower limb activity. Conclusion: Interventions involving repetitive practice improve strength after stroke, and these improvements are accompanied by improvements in activity. Review registration: PROSPERO CRD42017068658. [de Sousa DG, Harvey LA, Dorsch S, Glinsky JV (2018) Interventions involving repetitive practice improve strength after stroke: a systematic review. Journal of Physiotherapy 64: 210–221] Key words: Stroke, Strength, Repetitive practice, Systematic review, Meta-analysis

This paper presents ‘Tips’ for researchers of brain impairment who are interested in conducting randomised controlled trials. The paper is intended for researchers who are planning to undertake their first trial, but may also be of interest to more experienced trialists or clinicians who want to further their understandings of clinical trials. The Tips include suggestions for how to design, conduct, analyse and report clinical trials.

BACKGROUND: Pressure ulcers (also known as pressure sores, decubitus ulcers or bedsores) are localised injuries to the skin or underlying tissue, or both. Pressure ulcers are a disabling consequence of immobility. Electrical stimulation (ES) is widely used for the treatment of pressure ulcers. However, it is not clear whether ES is effective. OBJECTIVES: To determine the effects (benefits and harms) of electrical stimulation (ES) for treating pressure ulcers. SEARCH METHODS: In July 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. We did not impose any restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included published and unpublished randomised controlled trials (RCTs) comparing ES (plus standard care) with sham/no ES (plus standard care) for treating pressure ulcers. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence using GRADE. MAIN RESULTS: We included 20 studies with 913 participants. The mean age of participants ranged from 26 to 83 years; 50% were male. ES was administered for a median (interquartile range (IQR)) duration of five (4 to 8) hours per week. The chronicity of the pressure ulcers was variable, ranging from a mean of four days to more than 12 months. Most of the pressure ulcers were on the sacral and coccygeal region (30%), and most were stage III (45%). Half the studies were at risk of performance and detection bias, and 25% were at risk of attrition and selective reporting bias. Overall, the GRADE assessment of the certainty of evidence for outcomes was moderate to very low. Nineteen studies were conducted in four different settings, including rehabilitation and geriatric hospitals, medical centres, a residential care centre, and a community‐based centre. ES probably increases the proportion of pressure ulcers healed compared with no ES (risk ratio (RR) 1.99, 95% confidence interval (CI) 1.39 to 2.85; I(2) = 0%; 11 studies, 501 participants (512 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. It is uncertain whether ES decreases pressure ulcer severity on a composite measure compared with no ES (mean difference (MD) ‐2.43, 95% CI ‐6.14 to 1.28; 1 study, 15 participants (15 pressure ulcers) and whether ES decreases the surface area of pressure ulcers when compared with no ES (12 studies; 494 participants (505 pressure ulcers)). Data for the surface area of pressure ulcers were not pooled because there was considerable statistical heterogeneity between studies (I(2) = 96%) but the point estimates for the MD of each study ranged from ‐0.90 cm(2) to 10.37 cm(2). We downgraded the evidence to very low certainty due to risk of bias, inconsistency and imprecision. It is uncertain whether ES decreases the time to complete healing of pressure ulcers compared with no ES (hazard ratio (HR) 1.06, 95% CI 0.47 to 2.41; I(2) = 0%; 2 studies, 55 participants (55 pressure ulcers)). We downgraded the evidence to very low certainty due to risk of bias, indirectness and imprecision. ES may be associated with an excess of, or difference in, adverse events (13 studies; 586 participants (602 pressure ulcers)). Data for adverse events were not pooled but the types of reported adverse events included skin redness, itchy skin, dizziness and delusions, deterioration of the pressure ulcer, limb amputation, and occasionally death. We downgraded the evidence to low certainty due to risk of selection and attrition bias and imprecision. ES probably increases the rate of pressure ulcer healing compared with no ES (MD 4.59% per week, 95% CI 3.49 to 5.69; I(2) = 25%; 12 studies, 561 participants (613 pressure ulcers)). We downgraded the evidence to moderate certainty due to risk of bias. We did not find any studies that looked at quality of life, depression, or consumers' perception of treatment effectiveness. AUTHORS' CONCLUSIONS: ES probably increases the proportion of pressure ulcers healed and the rate of pressure ulcer healing (moderate certainty evidence), but its effect on time to complete healing is uncertain compared with no ES (very low certainty evidence). It is also uncertain whether ES decreases the surface area of pressure ulcers. The evidence to date is insufficient to support the widespread use of ES for pressure ulcers outside of research. Future research needs to focus on large‐scale trials to determine the effect of ES on all key outcomes.

Objective: To determine the inter-rater reliability of the 13-point manual muscle test (MMT) in two upper limb muscle groups of people with tetraplegiaSetting: The study was conducted at three spinal cord injury (SCI) units.Participants: Sixty people with complete or incomplete tetraplegia.Methods: The inter-rater reliability of the 13-point MMT was investigated. Strength of the elbow flexors and/or wrist extensors in people with tetraplegia was measured by two physiotherapists on the same day.Results: The weighted kappa coefficient (95% confidence interval) reflecting the agreement between the two strength assessments by two different assessors for the wrist extensors and elbow flexors were 0.96 (0.93 to 0.99) and 0.94 (0.89 to 0.99), respectively. Repeat measurements by different physiotherapists were within 1 of 13 points of each other 82% of the time for wrist extensors and 87% of the time for the elbow flexors.Conclusion: The 13-point MMT is a reliable measure of strength in the wrist extensors and elbow flexors of people with tetraplegia.

A systematic review of randomised controlled trials. To determine the effectiveness of 22 commonly administered physiotherapy interventions for people with spinal cord injuries (SCIs). The inclusion criteria contained 22 pairs of key interventions and outcomes. Each intervention and outcome was considered independently such that 22 brief reviews were conducted and summarised in this one paper. The interventions included hand, wheelchair, seated mobility, fitness, strength and gait training, as well as electrical stimulation, passive movements, stretch, cycling, exercise and transcutaneous electrical nerve stimulation (TENS). Interventions were compared with no or sham treatment, usual care or another physiotherapy intervention. The primary outcome for each review was one of the following: seated mobility, wheelchair mobility, hand function, gait, voluntary strength, joint mobility, fitness and pain. Data were extracted to determine mean between-group differences or risk ratios (95% confidence interval). Where possible, results were pooled in meta-analyses and the strength of evidence rated using Grading of Recommendations Assessment, Development and Evaluation. Thirty-eight randomised controlled trials met the inclusion criteria and were relevant to 15 of the brief reviews. The following four interventions were clearly effective: fitness, hand and wheelchair training as well as TENS; however, the strength of evidence was not high for any of these interventions. None of the other interventions were clearly effective. There is initial evidence to support four physiotherapy interventions, but there is still a long way to go to put a strong evidence base to the range of physiotherapy interventions commonly used to manage people with SCI.

Cross-sectional analysis of a mixed retrospective and prospective inception cohort study. To determine health status, quality of life and socioeconomic situation of people with spinal cord injuries (SCI) 6 years after discharge from a hospital in Bangladesh. Bangladesh. All patients alive 6 years after discharge from a hospital in Bangladesh were interviewed using the SF12 health survey, the SCI Secondary Conditions Scale, the Centre for Epidemiologic Studies Depression Scale (CESD), and the participation in society items of World Health Organisation Disability Assessment Schedule (WHODAS 2.0). Additional questions determined participants’ socioeconomic and employment status. The cohort comprised 260 participants: 145 used wheelchairs for mobility and 115 were able to walk at discharge. The median (IQR) Mental and Physical Component scores for the SF12 were 54 (49–57) and 44 (40–51) points, respectively. The median scores for the SCI Secondary Conditions Scale, CESD and WHODAS 2.0 were 8 (4–13), 7 (4–13) and 12 (6–17) points, respectively. Fourteen percent of all participants and 23% of those who used wheelchairs had a pressure ulcer at the time of interview. Forty-four percent of participants were unemployed and 65% were living below the poverty line (median (IQR) income, USD 0 (0–91)) per month. Many people with SCI in Bangladesh are unemployed and living in poverty with a reduced quality of life and participation. Pressure ulcers are a common complication.

Pretest-posttest design. To investigate mechanisms by which short-term resistance training (6 weeks) increases strength of partially paralysed muscles in people with spinal cord injury (SCI). Community-based setting, Sydney, Australia. Ten community-dwelling people with partial paralysis of elbow flexor, elbow extensor, knee flexor or knee extensor muscles following SCI (range 5 months to 14 years since injury). Muscle architecture and strength were assessed before and after participants underwent a six week strength-training program targeting one partially paralysed muscle group. The outcome of primary interest was physiological cross sectional area (PCSA) of the trained muscle group measured using magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Other outcomes were changes in mean muscle fascicle length, muscle volume, pennation angle, isometric strength and muscle strength graded on a 13-point scale. The mean increase in maximal isometric muscle strength was 14% (95% CI, −3 to 30%) and 1.5 points (95% CI, 0.5 to 2.5) on the 13-point manual muscle test. There was no evidence of a change in muscle architecture. This study is the first to examine the mechanisms by which voluntary strength training increases strength of partially paralysed muscles in people with SCI. The data suggest that strength gains produced by six weeks of strength training are not caused by changes in muscle architecture. This suggests short-term strength gains are due to increased neural drive or an increase in specific muscle tension.

Mixed retrospective and prospective cohort study. To determine 5-year survival after hospitalisation with spinal cord injury (SCI) in Bangladesh and to develop a prediction model to identify people at high risk of dying within 5 years. Bangladesh. Medical records were used to identify people with SCI admitted to a hospital in Bangladesh in 2011. Participants or their family members were contacted >5 years after discharge to determine vital status or date of death. Survival from time of discharge was estimated with Kaplan–Meier curves. A linear model of the log odds of death within 5 years of discharge was constructed and internally validated. Of the 345 people who were admitted and survived to discharge in 2011, 342 (99%) were accounted for 5 years later: 74 (22%) had died (survival = 78%; 95% CI 74–82%). Sixty nine of the 223 participants who were wheelchair-dependent at discharge had died (survival = 69%; 95% CI 62–75%). A parsimonious model predicted survival as a function of age and mode of mobility at discharge (wheelchair-dependent or ambulant). The odds of dying increased by a factor of 1.6 (95% CI, 1.3–2.0) with every decade of age and by a factor of 12.6 (95% CI, 4.8–32.9) if wheelchair-dependent. The model had good calibration and discrimination. The risk of dying after discharge from hospital with SCI in Bangladesh is high, especially among older, wheelchair-dependent people. A simple prediction model discriminates those at high risk of dying within 5 years.

The objective of this study was to determine the inter-rater reliability and validity of using a telephone-based version of the spinal cord injury–secondary conditions scale (SCI–SCS). A psychometric study was conducted. The study was conducted in Royal North Shore Hospital, Sydney, Australia. Forty people with a complete or an incomplete spinal cord injury. Inter-rater reliability was tested by comparing the telephone-based version of the SCI–SCS administered on two different days by two different telephone assessors. Validity was tested by comparing the telephone-based version of the SCI–SCS with the paper-based version of the SCI–SCS. The median (interquartile range) age and time since injury were 54 (48–63) years and 28 (14–35) years, respectively. The intraclass correlation coefficient (95% confidence interval) reflecting the agreement between the telephone-based version of the SCI–SCS administered on two different days by two different assessors was 0.96 (0.93–0.98). The corresponding value reflecting agreement between the telephone-based assessment and the paper-based assessment was 0.90 (0.83–0.95). The telephone-based version of the SCI–SCS is a simple and a quick questionnaire to administer that has both inter-rater reliability and validity. It may be useful as a way to screen for secondary health conditions in low- and middle-income countries where it is not always feasible to provide routine face-to-face follow-ups and where literacy may be a problem.

Question: Does a massive open online course (MOOC) based around an online learning module about spinal cord injuries improve knowledge or confidence among physiotherapy students more than if physiotherapy students are left to work through the online learning module at their own pace. Which method of presenting the content leads to greater satisfaction among the students? Study design: Randomised controlled trial with concealed allocation and intention-to-treat analysis. Participants: Forty-eight physiotherapy students in Bangladesh. Intervention: Participants randomised to the control group were instructed to work at their own pace over a 5-week period through a physiotherapy-specific online learning module available at www.elearnSCI.org. Experimental participants were enrolled in a 5-week MOOC. The MOOC involved completing the same online learning module but experimental participants' progress through the module was guided each week and they were provided with the opportunity to engage in online discussion through Facebook. Outcome measures: The primary outcome was knowledge, and the secondary outcomes were perceived confidence to treat people with spinal cord injuries and satisfaction with the learning experience. Results: The mean between-group difference for knowledge was 0.7 points (95% CI –1.3 to 2.6) on a 0 to 20-point scale. The equivalent results for perceived confidence and satisfaction with the learning experience were 0.4 points (95% CI –1.0 to 1.8) and 0.0 points (95% CI –1.1 to 1.2) on a 0 to 10-point scale. Conclusion: The MOOC was no better for students than working at their own pace through an online learning module for increasing knowledge, confidence or satisfaction. However, students in the MOOC group highlighted positive aspects of the course that were unique to their group, such as interacting with students from other countries through the MOOC Facebook group. Trial registration: ACTRN12614000422628. [Hossain MS, Islam MS, Glinsky JV, Lowe R, Lowe T, Harvey LA (2015) A massive open online course (MOOC) can be used to teach physiotherapy students about spinal cord injuries: a randomised trial. Journal of Physiotherapy 61: 21–27]

A descriptive audit.To audit the participation and satisfaction in a Massive Open Online Course (MOOC) for teaching physiotherapy students and physiotherapists about spinal cord injuries.Global and online.A 5-week MOOC about the physiotherapy management of spinal cord injuries was hosted by Physiopedia and run in partnership with the International Spinal Cord Society. The MOOC was based on the physiotherapy-specific module of www.elearnSCI.org, and also involved extra readings, activities and online discussion through a closed Facebook group. Participation and satisfaction was quantified through a pre- and post-MOOC knowledge assessment and an online course evaluation. Participation was also gauged through Facebook activity and internet-based usage statistics.Three thousand five hundred and twenty-three people from 108 countries registered for the MOOC and 2527 joined the Facebook group. One thousand one hundred and twenty-one completed the pre- and post-MOOC knowledge assessments, with more completing one or the other. The median (interquartile range) results for those who completed the pre and post-MOOC knowledge assessments were 70% (60-80%) and 90% (80-95%), respectively. One thousand and twenty-nine completed the online course evaluation, with more than 80% agreeing or strongly agreeing with 12 of the 13 positive statements posed to them about the course.Most participants who completed the MOOC performed well on the post-MOOC knowledge assessment and enjoyed the learning experience. However, these results may be biased if those who did not complete the MOOC were dissatisfied and/or did not sit the post-MOOC knowledge assessment.

This was a descriptive study with the primary objective of describing two Massive Open Online Courses (MOOCs) about the physiotherapy management of spinal cord injuries. We sought to determine the number of participants who registered and then completed the MOOCs, and changes in participants’ knowledge. The secondary objective was to determine whether the MOOCs increased usage of www.elearnSCI.org . The setting for this study was global and online. Two 5-week MOOCs were run in 2014 and 2016 about physiotherapy management of spinal cord injuries. The MOOCs were based on the physiotherapy module of www.elearnSCI.org . The data were collected on the number of participants who completed the MOOCs. Participants’ knowledge was assessed prior to the commencement of the MOOC and upon completion of the MOOC. In addition, Google analytics were used to determine whether the MOOCs increased usage of www.elearnSCI.org over the two 5-week periods in which the MOOCs were run. In total, 3500 and 10 000 physiotherapists and physiotherapy students registered for the MOOC in 2014 and 2016, respectively. Participants’ knowledge increased by a median (interquartile) of 15% (5 to 25% for 2014; 0 to 25% for 2016). Lessons from www.elearnSCI.org that formed part of the MOOC were accessed a median (interquartile range) of 8626 (6150 to 10 773) and 17 631 (15 262 to 22 929) times per day during the 2014 and 2016 MOOCs, respectively. MOOCs provide a relatively inexpensive way of providing education about the physiotherapy management of spinal cord injuries, but it is yet to be determined whether they improve clinical skills.

To determine from a societal perspective the cost-effectiveness and cost-utility of telephone-based support for management of pressure ulcers. Cost-effectiveness and cost-utility analysis of a randomised clinical trial. Tertiary centre in India and Bangladesh. An economic evaluation was conducted alongside a randomised clinical trial comparing 12 weeks of telephone-based support (intervention group) with usual care (control group). The analyses evaluated costs and health outcomes in terms of cm2 reduction of pressure ulcers size and quality-adjusted life years (QALYs) gained. All costs were in Indian Rupees (INR) and then converted to US dollars (USD). The mean (95% confidence interval) between-group difference for the reduction in size of pressure ulcers was 0.53 (−3.12 to 4.32) cm2, favouring the intervention group. The corresponding QALYs were 0.027 (0.004–0.051), favouring the intervention group. The mean total cost per participant in the intervention group was INR 43 781 (USD 2460) compared to INR 42 561 (USD 2391) for the control group. The per participant cost of delivering the intervention was INR 2110 (USD 119). The incremental cost-effectiveness ratio was INR 2306 (USD 130) per additional cm2 reduction in the size of the pressure ulcer and INR 44 915 (USD 2523) per QALY gained. In terms of QALYs, telephone-based support to help people manage pressure ulcers at home provides good value for money and has an 87% probability of being cost-effective, based on 3 times gross domestic product. Sensitivity analyses were performed using the overall cost data with and without productivity costs, and did not alter this conclusion.

A multicentre, prospective, assessor-blinded, parallel randomised controlled trial. The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries. One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI >3 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes. The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval −0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant. The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.

Within-participant randomised controlled trial. To determine whether strength training combined with usual care increases strength in partially paralysed muscles of people with recent spinal cord injury (SCI) more than usual care alone. SCI units in Australia and India. Thirty people with recent SCI undergoing inpatient rehabilitation participated in this 12-week trial. One of the following muscle groups was selected as the target muscle group for each participant: the elbow flexors, elbow extensors, knee flexors or knee extensors. The target muscle on one side of the body was randomly allocated to the experimental group and the same muscle on the other side of the body was allocated to the control group. Strength training was administered to the experimental muscle but not to the control muscle. Participants were assessed at baseline and 12 weeks later. The primary outcome was maximal isometric muscle strength, and the secondary outcomes were spasticity, fatigue and participants’ perception of function and strength. There were no dropouts, and participants received 98% of the training sessions. The mean (95% confidence interval (CI)) between-group difference for isometric strength was 4.3 Nm (1.9–6.8) with a clinically meaningful treatment effect of 2.7 Nm. The mean (95% CI) between-group difference for spasticity was 0.03/5 points (−0.25 to 0.32). Strength training increases strength in partially paralysed muscles of people with recent SCI, although it is not clear whether the size of the treatment effect is clinically meaningful. Strength training has no deleterious effects on spasticity.

Objective: To determine whether the addition of electrical stimulation to progressive resistance training increases the voluntary strength of the wrist muscles in people with tetraplegia. Design: Assessor-blind within-subject randomised controlled trial. Setting: Two Australian spinal cord injury units and the community. Participants: Sixty-four wrists of 32 people with tetraplegia and bilateral weakness of the wrist extensor or flexor muscles (grade 2 - 4 Medical Research Council grades). Interventions: Participants' wrists were randomly allocated to one of two conditions. Wrist muscles of the experimental arm received electrical stimulation superimposed on progressive resistance training. The wrist muscles of the contralateral arm received sham electrical stimulation superimposed on progressive resistance training. Both arms received 6 sets of 10 contractions three times a week for eight weeks such that the only difference between arms was the application of electrical stimulation. Main Measures: The primary outcome was maximal voluntary isometric strength. Secondary outcomes were a fatigue resistance ratio representing voluntary and electrically-stimulated endurance. Measurements were taken at the start and end of the eight-week treatment period. Results: The mean treatment effect (95% Confidence Interval) of electrical stimulation for voluntary strength was 0.04 Nm (95% CI, -0.5 to 0.6; p =0.89). The mean treatment effect (95% CI) for fatigue ratio representing voluntary endurance and electrically-stimulated endurance was -0.01 (95% CI, -0.1 to 0.1; p =0.78) and -0.07 (95% CI, -0.3 to 0.1; p =0.47), respectively. Conclusions: Voluntary strength of the wrist is not enhanced by the addition of electrical stimulation to progressive resistance training programs in people with tetraplegia.

Background and Purpose. The extensibility of the paralysed flexor pollicis longus (FPL) muscle is an important determinant of an effective tenodesis grip in people with C6 and C7 tetraplegia. Therapists believe that splinting can reduce the extensibility of the FPL muscle and thus improve hand function. However, there remains much controversy around the optimal position of splinting and its effectiveness is yet to be verified. The aim of the present study was to determine whether a three-month thumb splinting protocol reduces extensibility of the FPL muscle in people with tetraplegia. Method. An assessor-blinded, within-subject, randomized controlled trial was undertaken. Twenty people with tetraplegia and bilateral paralysis of all thumb muscles were recruited from a sample of convenience. One randomly selected hand of each subject was splinted each night for three months. The splint immobilized the FPL muscle in a relatively shortened position by positioning the carpometacarpal and metacarpophalangeal joint of the thumb in flexion. The other hand remained unsplinted for the duration of the study. Carpometacarpal angle was measured with the application of a standardized torque by a blinded assessor at the beginning and end of the three-month study period. A device specifically designed for this purpose that stabilized the wrist and other joints of the thumb in full extension was used. Results. No subject withdrew from the study. The three-month splinting protocol had a mean treatment effect on carpometacarpal joint angle of 0° (95% CI, −6° to 6°). Conclusion. Splinting the FPL muscle in a relatively shortened position each night for three months does not reduce its extensibility. Copyright © 2006 John Wiley & Sons, Ltd.

Background and Purpose. Weakness in partially paralysed muscles is a disabling impairment for people with neurological conditions. Strength training programmes are widely administered to address this impairment. There is a common belief that the effectiveness of strength training programmes can be enhanced by the addition of electrical stimulation. The purpose of this systematic review was to assess the effi cacy of electrical stimulation for increasing voluntary strength in people with neurological conditions. Method. Eligible randomized trials of electrical stimulation were identifi ed by searches of computerized databases. The search yielded 11 267 abstracts, of which 60 were retrieved. Two assessors independently reviewed full text versions of these articles. Results. Eighteen studies satisfi ed the inclusion criteria. These studies involved participants with spina bifi da (n = 1), cerebral palsy (n = 1), peripheral nerve lesion (n = 1), multiple sclerosis (n = 1), spinal cord injury (n = 3) and stroke (n = 11). The mean (SD) PEDro score for trial quality was 4.9 (1.0) out of 10. Meta- analyses of studies involving similar patients were not done because of insuffi cient data or lack of homogeneity. The results of all studies were analysed individually. Conclusion. Several studies suggest a modest benefi cial effect of electrical stimulation in patients with stroke. It is not clear whether patients with other types of neurological disabilities benefi t from electrical stimulation in the same way. Copyright © 2007 John Wiley & Sons, Ltd.

The objective of this study was to determine the reliability of measuring wound undermining in people with spinal cord injury (SCI). A psychometric study. The study was conducted at the Indian Spinal Injuries Centre, New Delhi, India. Thirty people with a complete or incomplete SCI and a pressure ulcer with wound undermining were recruited. Wound undermining was measured using the four cardinal points from a clock face (with 12 O'clock defined as towards the head). Inter-rater reliability was tested by comparing the wound undermining scores from two different assessors. Intra-rater reliability was tested by comparing the wound undermining scores from the same assessor on two different days. The intraclass correlation coefficients (95% confidence interval) for inter-rater and intra-rater reliability were 0.996 (0.992–0.999) and 0.998 (0.996–0.999), respectively. Repeat measurements by the same and different assessor were within 0.3 cm of each other, 80% and 83% of the time, respectively. Measurements of wound undermining have excellent reliability.

Repeat measures design. The purpose of this study was firstly, to describe a simple clinical tool that can be used to measure the extensibility of the flexor pollicis longus (FPL) muscle; secondly, to test its reliability; and thirdly, to attain some ‘normative’ data of the extensibility of the FPL muscle in a representative sample of people with tetraplegia. A spinal cord injury unit in Sydney. A total of 37 people (62 hands) with C4–C7 tetraplegia. Angle of the carpometacarpal (CMC) joint of the thumb was measured in all subjects with the application of a series of thumb extensor torques. A device specifically designed for this purpose was used to standardize the torque and objectively quantify the CMC joint angle. In addition, repeat measurements were taken 3–5 days later in one subgroup of 13 subjects (one hand per subject) and 3 months later in another subgroup of 13 subjects (one hand per subject). Intraclass correlation coefficients and percent close agreement scores were derived to quantify the 3–5 days and 3-month reliability between repeat measurements. The median CMC angle of the thumb with the application of a 0.044 Nm torque was 63 degrees (range, 20–93 degrees). The intraclass correlation coefficients with the application of a 0.044 Nm torque were 0.88 (95% CI, 0.65–0.96) for measurements taken 3–5 days apart, and 0.90 (95% CI, 0.67–0.97) for measurements taken 3 months apart. This study describes a simple and reliable way of measuring the extensibility of the FPL muscle in people with tetraplegia. This assessment tool and the ‘normative’ data provided in this study can be used to further investigate the contribution of the passive mechanical properties of the FPL muscle to hand function of people with C6 and C7 tetraplegia.

The purpose of this study was to determine the effects of a 12-week standing program on ankle mobility and femur bone mineral density in patients with lower limb paralysis following recent spinal cord injury . An assessor-blinded within-subject randomised controlled trial was undertaken. Twenty patients with lower limb paralysis following a recent spinal cord injury were recruited. Subjects stood weight-bearing through one leg on a tilt-table for 30 minutes, three times each week for 12 weeks. By standing on one leg a large dorsiflexion stretch was applied to the ankle and an axial load was applied to the bones of the weight-bearing leg. Ankle mobility and femur bone mineral density of both legs were measured at the beginning and end of the study. Ankle mobility (range of motion) was measured with the application of a 17 Nm dorsiflexion torque. Femur bone mineral density was measured using dual energy X-ray absorptiometry (DEXA). The effect of standing was estimated from the difference between legs in mean change of ankle mobility and femur bone mineral density. The results indicated a mean treatment effect on ankle mobility of 4 degrees (95% CI 2 to 6 degrees) and on femur bone mineral density of 0.005 g/cm 2 (95% CI −0.015 to 0.025 g/cm 2 ). Tilt-table standing for 30 minutes, three times per week for 12 weeks has a small effect on ankle mobility, and little or no effect on femur bone mineral density. It is unclear whether clinicians and patients would consider such effects to be clinically worthwhile.

Cross-sectional descriptive study of randomised controlled trials involving physical interventions for people with spinal cord injury (SCI) published between 2003 and 2013. To determine how well randomised controlled trials of physical interventions for people with SCI adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines. University of Sydney, Sydney, NSW, Australia. A search was conducted for randomised controlled trials designed to determine the effectiveness of physical interventions for people with SCI published between 2003 and 2013. The CONSORT checklist for the reporting of randomised controlled trials was used to determine how well each trial adhered to the guidelines. Two independent reviewers rated each trial on each of the 37 items on the CONSORT checklist using the following criteria: ‘fully reported’, ‘partially reported’, ‘not reported’, ‘not relevant’ or ‘not reported but unable to determine if relevant/done’. Fifty-three trials were retrieved. None of the trials ‘fully reported’ all items of the CONSORT guidelines. The median (IQR) number of items that was ‘fully reported’ was 11/37 (7–20). The median (IQR) number of items that was either ‘fully reported’ or ‘not relevant’ or ‘not reported but unable to determine if relevant’ was 20/37 items (17–27). The reporting of randomised controlled trials in SCI is only partially adhering to the CONSORT guidelines. Journals can help lift standards by encouraging authors of randomised controlled trials to adhere to the CONSORT guidelines.

Objective: To develop a web-based educational resource for health professionals responsible for the management of spinal cord injury (SCI). The resource: www.elearnSCI.org is comprised of seven learning modules, each subdivided into various submodules. Six of the seven modules address the educational needs of all disciplines involved in comprehensive SCI management. The seventh module addresses prevention of SCI. Each submodule includes an overview, activities, self-assessment questions and references. Development of the resource: Three hundred and thirty-two experts from The International Spinal Cord Society (ISCoS) and various affiliated societies from 36 countries were involved in developing the resource through 28 subcommittees. The content of each submodule was reviewed and approved by the Education and Scientific Committees of ISCoS and finally by an Editorial Committee of 23 experts. Key features: The content of the learning modules is relevant to students and to new as well as experienced SCI healthcare professionals. The content is applicable globally, has received consumer input and is available at no cost. The material is presented on a website underpinned by a sophisticated content-management system, which allows easy maintenance and ready update of all the content. The resource conforms to key principles of e-learning, including appropriateness of curriculum, engagement of learners, innovative approaches, effective learning, ease of use, inclusion, assessment, coherence, consistency, transparency, cost effectiveness and feedback. Conclusion: www.elearnSCI.org provides a cost effective way of training healthcare professionals that goes beyond the textbook and traditional face-to-face teaching. Spinal Cord (2013) 51, 176-182; doi:10.1038/sc.2012.177

A randomized controlled trial. To determine the effectiveness of electrical stimulation (ES)-evoked muscle contractions superimposed on progressive resistance training (PRT) for increasing voluntary strength in the quadriceps muscles of people with spinal cord injuries (SCI). Sydney, Australia. A total of 20 people with established SCI and neurologically induced weakness of the quadriceps muscles participated in the trial. Participants were randomized between experimental and control groups. Volunteers in the experimental group received ES superimposed on PRT to the quadriceps muscles of one leg thrice weekly for 8 weeks. Participants in the control group received no intervention. Assessments occurred at the beginning and at the end of the 8-week period. The four primary outcomes were voluntary strength (Nm) and endurance (fatigue ratio) as well as the performance and satisfaction items of the Canadian Occupational Performance Measure (COPM; points). The between-group mean differences (95% confidence interval (CI)) for voluntary strength and endurance were 14 Nm (1–27; P=0.034) and 0.1 (−0.1 to 0.3; P=0.221), respectively. The between-group median differences (95% CI) for the performance and satisfaction items of the COPM were 1.7 points (−0.2 to 3.2; P=0.103) and 1.4 points (−0.1 to 4.6; P=0.058), respectively. ES superimposed on PRT improves voluntary strength, although there is uncertainty about whether the size of the treatment effect is clinically important. The relative effectiveness of ES and PRT is yet to be determined.

Systematic review. To provide a quantitative analysis of all randomized controlled trials designed to determine the effectiveness of physical interventions for people with spinal cord injury (SCI). Sydney, Australia. A search was conducted for randomized controlled trials involving physical interventions for people with SCI. Two reviewers independently rated methodological quality using the PEDro scale and extracted key findings from the trials. Four thousand five hundred and forty three abstracts were identified of which 31 trials met the inclusion criteria. Trials examined the effectiveness of fitness and strength training (n=7), gait training (n=5), hand therapy (n=3), stretch (n=4), acupuncture (n=3), hand splinting (n=2) and other related therapies (n=7). Six trials reported a between-group mean difference with a clearly important treatment effect on at least one outcome measure. These trials supported the use of fitness, strength and gait training as well as acupuncture. There is initial evidence supporting the effectiveness of some physical interventions for people with SCI. However, there is a pressing need for high-quality trials to determine the effectiveness of all physical interventions commonly administered in clinical practice.

Assessor-blinded within-subject randomized controlled trial.To determine the effects of 6 months of regular passive movements on ankle joint mobility in people with spinal cord injury.Community, Australia.A total of 20 people with tetraplegia living in the community had one ankle randomized to a control group and the other to an experimental group. Carers administered passive movements to participants' experimental ankles for 10 min, 10 times a week for 6 months. The control ankles were left untreated. The primary outcome was passive ankle dorsiflexion range of motion.Adherence was high (mean adherence rate of 96%). Ankle dorsiflexion range of motion decreased by a mean (s.d.) of 2 degrees (4) in control ankles and increased by 2 degrees (4) in experimental ankles. The mean (95% confidence interval, CI) effect on ankle dorsiflexion range of motion was 4 degrees (95% CI, 2-6 degrees ).Regular passive movements have small effects on ankle joint mobility. It is unclear if these effects are clinically worthwhile.

Introduction Pressure ulcers are a common and severe complication of spinal cord injury, particularly in low-income and middle-income countries where people often need to manage pressure ulcers alone and at home. Telephone-based support may help people in these situations to manage their pressure ulcers. The aim of this study is to determine the effectiveness and cost-effectiveness of telephone-based support to help people with spinal cord injury manage pressure ulcers at home in India and Bangladesh. Methods and analysis A multicentre (3 sites), prospective, assessor-blinded, parallel, randomised controlled trial will be undertaken. 120 participants with pressure ulcers on the sacrum, ischial tuberosity or greater trochanter of the femur secondary to spinal cord injury will be randomly assigned to a Control or Intervention group. Participants in the Control group will receive usual community care. That is, they will manage their pressure ulcers on their own at home but will be free to access whatever healthcare support they can. Participants in the Intervention group will also manage their pressure ulcers at home and will also be free to access whatever healthcare support they can, but in addition they will receive weekly telephone-based support and advice for 12 weeks (15–25 min/week). The primary outcome is the size of the pressure ulcer at 12 weeks. 13 secondary outcomes will be measured reflecting other aspects of pressure ulcer resolution, depression, quality of life, participation and satisfaction with healthcare provision. An economic evaluation will be run in parallel and will include a cost-effectiveness and a cost-utility analysis. Ethics and dissemination Ethical approval was obtained from the Institutional Ethics Committee at each site. The results of this study will be disseminated through publications and presented at national and international conferences. Trial registration number ACTRN12613001225707.

Study design: Repeated measures design. Objective: To assess the reliability of a device designed to measure ankle mobility in the clinical setting. Setting: Spinal Cord Injury Unit, Sydney, Australia. Methods: Consecutive sample of 15 patients with paraplegia and tetraplegia with injuries of less than 1 year duration was studied. Ankle mobility was measured on two separate occasions 2 or 3 days apart. Stretch torque was standardised and ankle range of motion measured with an inclinometer attached to the footplate. Intraclass correlation coefficients and percent close agreement scores were used to assess agreement between mean measurements obtained on days 1 and 2. Results: The intraclass correlation coefficient was 0.95 (95% CI, 0.91–0.98). Measurements obtained on day 1 were within 3° of the measurements obtained on day 2 77% of the time and within 6° 97% of the time. Conclusion: The footplate is a reliable and simple way to measure ankle mobility in people with spinal cord injuries. Sponsorship: The Motor Accident Authority of NSW

Questions Is an 8-week progressive resistance exercise program effective for increasing strength in the wrist muscles of people with tetraplegia? Is it effective for improving muscle endurance and participants' perceptions about use of their hands for activities of daily living? Design Randomised controlled trial with concealed allocation, assessor blinding, and intentionto-treat analysis. Participants Thirty-two people with tetraplegia and neurological weakness of their wrist flexor or extensor muscles. Intervention The wrist muscles of one randomly-chosen hand were trained 3 times a week for 8 weeks. The control group received no intervention. Outcome measures The primary outcome was strength measured as maximal voluntary isometric torque in Nm. The secondary outcomes were muscle endurance measured as fatigue resistance and participants' perceptions about use of their hands using the Canadian Occupational Performance Measure. Results The mean effect on maximal voluntary isometric torque was 0.2 Nm (95% CI –0.5 to 0.8). This represents an 8% increase of mean initial strength; less than the 20% deemed clinically worthwhile at the commencement of the study. The mean effect on fatigue resistance was 0.1 (95% CI 0.0 to 0.2). The mean effect on participants' perceptions of performance was –0.3 (95% CI –1.9 to 1.2) and satisfaction was –0.3 (95% CI –1.6 to 1.0). Conclusion The results indicate that progressive resistance exercise has no effect on participants' perceptions about hand function. However, it is not yet clear whether progressive resistance exercise programs improve strength and endurance in muscles with neurologically-induced weakness following tetraplegia.