SCI Care: What Really Matters
SCI Care: What Really Matters
Michael Fehlings in discussion with Dr Carlotte Kiekens regarding Dr Kiekens' recent Spinal Cord publication
Dr. Michael Fehlings - Professor of Neurosurgery, Robert Campeau Family Foundation-Dr. CH Tator Chair in Brain and Spinal Cord Research, Vice Chairman Research), Co-Director Spine Program, Department of Surgery, University of Toronto and Editor in Chief of Spinal Cord.
Dr Carlotte Kiekens - Head of the Physical and Rehabilitation Medicine Unit at Ospedale San Giuseppe, IRCCS MultiMedica in Milan, Italy
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The SCI Care: What Really Matters podcast aims to provide valuable insights and the most up-to-date information for those providing care to people with spinal cord injury (SCI) worldwide. The vision of the International Spinal Cord Society (ISCoS) is to "facilitate healthy and inclusive lives for people with spinal cord injury or dysfunction globally".
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Hello, I'm Michael Thalings, professor of Neurosurgery at the University of Toronto and Editor-in-Chief of Spinal Cord, which is the signature journal of the International Spinal Cord Society, or ISCOS, and welcome to our regular podcast series in which we highlight an Editor's Choice article in spinal cord.
Speaker 1:And I'm delighted to have as our guest today Professor Carlotta Kikens, an internationally recognized physical and rehabilitation medicine specialist, who is at the IRCCS research unit in the Gagliazzi Orthopedic Hospital in Milan. She's also co-director of the Cochrane Rehabilitation Unit, which she co-founded in 2016, and is also a chair of the International Society of Physical Rehabilitation Medicine WHO Liaison Committee and has been very active in terms of the application of evidence to the use of rehabilitation to facilitate the lives of individuals with various physical challenges. Welcome, carlotta, and Professor Keekins gave the 2024 ISCOS lecture and she has recently put together a beautiful article published in Spinal Cord highlighting the key points of her lecture, and the article is entitled Empowering the Lives of People with Spinal Cord Injury Unlocking the Transformative Potential of the World Health Assembly's Resolution on rehabilitation. Welcome, carlotta, and I wonder if perhaps you could kindly summarize the first part of the article, which is really kind of focused on the impact that the WHO has really defined for rehabilitation at the international level.
Speaker 2:Thank you very much, professor Failings, for this opportunity to advocate further for the resolution and this work. A little detail I'm no longer the chair of the liaison committee. I stepped down after the ESCOS lecture, but you couldn't know but I'm still involved as an advisor. So, indeed, the first part of my lecture and the article talked about mainly Rehabilitation 2030 and the resolution. Rehabilitation 2030 is an initiative by the World Health Organization that was launched in February 2017 because of the increasing needs for rehabilitation globally, not only, but also for people with spinal cord injury, and this is due to aging populations, non-communicable diseases prevalence that increases. Still ongoing injuries. However, only 50% of the global population has actual access to the rehabilitation services they would need.
Speaker 2:Some important papers were published in the Lancet regarding the global burden of disease studies. The Lancet regarding the global burden of disease studies and the 2019 study showed that 2.4 billion people, so one out of three persons globally would need rehabilitation at some point. These numbers are even increasing. In 2021, it was already 2.6 billion. When we look at spinal cord injury, in 2023, there were about 20 million people living with spinal cord injury. So the prevalence and 900,000 new cases occur each year. We think that it's going better that we're doing prevention of injuries, which is true, but the epidemiology is changing and we have more aging people and the absolute numbers continue to increase, as well for prevalence as for incidence.
Speaker 2:So Rehabilitation 2030 is a global initiative of the World Health Organization which involves a lot of stakeholders within the field of rehabilitation to strengthen rehabilitation worldwide, to upscale the services. There were three meetings, so the one starting one in 2017, then there was a second one in 2019 and the third one in 2023. There's a whole thing, a lot of things that have been going on. I refer to them in the paper if you want to dive deeper into it, but mostly a lot of tools have been developed to help health ministries and countries to assess the situation in their country and also to improve the services. There have been tools around workforce, around health information systems, around financing emergency preparedness, and another one, which is quite relevant also for spinal cord injury, is a package of interventions for rehabilitation. This was done for 20 health conditions and is a set of prioritized interventions, evidence-based, that should be considered when a country wants to start or improve or assess their services for a health condition, and one of those 20 health conditions is spinal cord injury.
Speaker 2:Another milestone was the resolution. So there was, in 2017, started a global rehabilitation alliance, of which also ISCOS was an active member, and they worked through lobbying, through a lot of activities with 18 countries to for a resolution which is by nine at that point, 194 countries, including at that point, also the USA a resolution on strengthening rehabilitation in health systems, and this is a very strong document that we all can use with our health ministries to lobby to advocate for rehabilitation. Rehabilitation Alliance was transformed in a World Rehabilitation Alliance hosted within the WHO, again with many stakeholders, of which also ISCOS, to further advocate for the implementation of this resolution. So I think that's a little bit in a nutshell, the first part around Rehab 2030 and the resolution, thank you.
Speaker 1:So that's a you know kind of a very important uh initiative which, uh, I think, frames the context of the importance of rehabilitation and it's really quite remarkable that almost two and a half billion people are felt to require rehabilitation services around the world. That's quite a remarkable figure figure. In the second part of the article you make specific reference to the concept of knowledge translation implementation. This is clearly very critical. It's one thing to adopt various resolutions and to indicate, yes, that rehabilitation services are very important, that rehabilitation services are very important, but in the second part of the article you make specific reference to the Cochrane Initiative, for example, and the importance of knowledge translation. So perhaps you could make some commentary on that.
Speaker 2:Yes. So the WHO, and also within the resolution, always calls for evidence-based interventions within rehabilitation. So this implies different things One is to have evidence, to have evidence available, and the second one is to use it and to implement it. To have evidence available and the second one is to use it and to implement it and implementation of whatever evidence. Also, implementation of resolutions is very difficult, because that's usually the most important but the most difficult part, because implementing something new means changing our behavior and, as we know, human beings are very resistant to that because it asks energy, it asks effort. So that is why we worked with Cochrane Rehabilitation a lot on knowledge, translation and dissemination, hoping then for implementation.
Speaker 2:So Cochrane Rehabilitation was launched in 2016 as a field within the Cochrane Collaboration. Very briefly, the Cochrane Collaboration is a worldwide network mainly producing systematic reviews and meta-analysis free of conflict of interest, so it's, let's say, the highest level of evidence that is available and it's usually used by policymakers and the World Health Organization. Within the Cochrane collaboration, there are the review groups producing the reviews, there are methods groups, there are geographic groups and then there are fields working around the dimension, and our dimension would be rehabilitation because, as the audience certainly knows, rehabilitation is transversal over most parts of healthcare. We deal with neurological conditions, musculoskeletal conditions, cardiorespiratory cancer and many others. So that is why we created Cochrane Rehabilitation to be a bridge between, on the one hand, the Cochrane Collaboration, where there's a lot of evidence and reviews high-quality reviews, and our stakeholders, meaning clinicians, students, policymakers and researchers. Because we and, on the other hand, we also wanted to work within Cochrane to improve the quantity and quality of the evidence, because evidence is growing exponentially. When you search in PubMed, for example, for rehabilitation, there are 800,000 hits. If you look for spinal cord injury, there are 50,000 hits. Nobody can keep up with the exponentially increasing evidence. That's why we need good synthesis of this evidence which also appraises the quality.
Speaker 2:But unfortunately, in particular in the field of spinal cord injury, we often have low quality of evidence, empty review. So when we do a review, sometimes on a specific topic, we don't even find any quality evidence. And this is because spinal cord injury is the population is heterogeneous. It's still a relatively low incidence compared to, for example, cardiovascular disease or other big diseases, and so rehabilitation is also a very complex intervention. It's much more difficult to study with RCTs than the pharmacological interventions, for example, and that is why we also wanted to work on the improvement of the quality of as well the primary research as the secondary research and therefore we had a lot of initiatives on methodology, like study designs when RCTs are not possible.
Speaker 2:But on the other hand, going back to the first direction of the bridge, we wanted to do knowledge, translation and dissemination and therefore we created a comprehensive website. We published Cochrane Corners, which are little articles in journals about Cochrane systematic reviews. We produced block shots, which is a block shot is a one slide with a very short summary of the results of a Cochrane systematic review the results and on the effect and also on the harms. We use all social media, we produce newsletters, gave lectures and workshops in conferences, so all means of knowledge dissemination we did.
Speaker 2:And producing also products for different audiences, because we cannot tell something in the same way to a policymaker, as a patient, as a researcher. Everybody needs their specific product. So that's what we try to do with Cochrane Rehabilitation as a field. And then in 2024, last year, we broadened our scope and the Cochrane Rehabilitation field became a thematic group due to a lot of changes within the Cochrane Collaboration and we are now the Cochrane Thematic Group Rehabilitation, functioning and Disability, because functioning as a third health indicator within the whole healthcare field. We also want to promote that also within the Cochrane Collaboration the Cochrane collaboration.
Speaker 1:Well, this is really a remarkable story that you've been talking to us about and you know many of us, as clinicians and researchers, are really not kind of aware of some of these processes that are in place to try to implement policies at an international level. So I think this has been really quite informative and thank you for your efforts. Perhaps in the closing few minutes, are you able to summarize for us perhaps a few key take-home messages that our audience might wish to take away from your article.
Speaker 2:Yes, I can do so, also because I made a little table in the paper was suggested by chief editor, for which I'm very thankful. So the first recommendation would be to advocate all together, unite all the professions, all the stakeholders, to advocate together for the implementation of the resolution. It's a very powerful document and everybody can use it to advocate for rehabilitation services, to advocate for research, for financing within their countries, with the ministries of health, with the ministries of education, with other policymakers. So I think that's important. That's something that everybody can do. I think another very important point is that we need data, collecting data, also functioning data, not only disease-related data, but functioning data on people with SCI is very important. There are already some initiatives, like the INSCE study and the learning health system. But if we have data, and in the future with big data, big observational studies, with artificial intelligence, that will certainly leverage some of the methodological problems we have due to the small population and heterogeneous population.
Speaker 2:And then, yeah, integrate evidence in your daily practice, Change behaviors, stay aware Also. So I'm a physician and when I had residents, I always also encouraged them to challenge their supervisors, because evidence changes so fast. What we learned as a physician certainly me 30 years ago is totally outdated, but even now it changes every five years. Nothing is true anymore. So we also have to challenge our supervisors and update everybody, and there I think young people can really help us. And yeah, we should enhance knowledge, translation strategies, get the evidence out in an understandable, available, comprehensible way and collaborate with all stakeholders, unite all the professions for the benefit of our patients, I think, together also with our patients. That's the last, perhaps important point involve patients and public. It's a hot topic, it's easily said, but it's not so easily done. So I would also encourage to involve our patients or ex-patients in our clinical as well as in our research work.
Speaker 1:Thank you for providing a very cogent and succinct summary of what I think is a very interesting and important article on the whole concept of empowering the lives of people with spinal cord injury and the whole concept of trying to to look at transformative change through the world health organization and collaboration with with key stakeholders, but also making this, I think, relevant for you know, the clinicians related to the ongoing knowledge translation. So I'm going to close out this podcast. Professor Keekins, many thanks for taking a few minutes to summarize the key messages from your 2024 ISCOS lecture, which has been recently beautifully summarized in an article in Spinal Cord, and on that note I will close out this Spinal Cord podcast.
Speaker 2:Thank you very much.