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Hossain M.S.1, Rahman M.A.1, Harvey L.A.2, Islam M.S.1, Bowden J.L.2, Muldoon S.3, Herbert R.D.4
1Centre for Rehabilitation of the Paralysed, Savar, Bangladesh, 2University of Sydney, Sydney Medical School, Sydney, Australia, 3Livability Ireland, Enniskillen, Fermanagh, Ireland, 4Neuroscience Research Australia and UNSW Australia, Sydney, Australia
Background: People who sustain spinal cord injuries (SCI) in low and middle-income countries (LMIC) often develop life-threatening complications and die within two years of hospital discharge. Pressure ulcers are particularly problematic. Established models of community-based support used in high-income countries are often not economically feasible in LMIC. Our team has developed a low cost model of community-based support which involves using physiotherapists as case managers over the first two years when patients are discharged home. The physiotherapists telephone patients every two weeks and visit them in their home in an effort to provide ongoing support and advice and to help detect early signs of pressure ulcers and other complications.
Purpose: The aim of this feasibility study was to determine if it was possible to test our model of care in a large randomized controlled trial (ACTRN12613001137785).
Methods: Thirty wheelchair dependent people with recent SCI were recruited from the Centre for Rehabilitation of the Paralysed in Bangladesh in 2014. They were randomised to a control or intervention group prior to discharge. Intervention participants were allocated a physiotherapist who acted as their case manager. The physiotherapist telephned the patient every fortnight in the first year and every month in the second year, and visited the patient in their home on three occasions. The physiotherapist provided advice on all aspects of care and constantly monitored patients for early signs of pressure ulcers and other complications. Control participants received usual care which sometimes consisted of one telephone call and/or a home visit. All patients were assessed by a blinded assessor prior to discharge and 2 years after discharge. The primary outcome was all-cause mortality; secondary outcomes were prevalence of pressure ulcers and other complications, quality-of-life and participation.
Results: There were no notable difficulties running the trial and no significant protocol deviations. The phone calls and home visits were delivered according to the protocol 87% and 100% of the time, respectively. Follow-up data were 99% complete. The intervention was delivered as planned and outcome data were attained on all participants. Importantly, all participants were located in the community 2 years after discharge. Two participants had died and another five participants had life-threatening pressure ulcers.
Conclusion(s): We have now commenced a 5-year randomised controlled trial involving 410 participants. The primary outcome is all-cause mortality at 2 years and based on this feasibility study.
Implications: High quality evidence to show that our low cost model of community-based support helps those with SCI survive following discharge from hospital in LMIC will have widespread implications for reducing mortality and improving quality of life. Central to our model of care is using physiotherapists as case managers working across all aspects of care for people with SCI.
Funding acknowledgements: This trial was funded by two bridging grants from the University of Sydney.
Topic: Neurology: spinal cord injury
Ethics approval: Ethical approval for this pilot was received from the Bangladesh Medical Research Council.
All authors, affiliations and abstracts have been published as submitted.
