SCI Care: What Really Matters
SCI Care: What Really Matters
Evaluating the role of structured rehabilitation in mild degenerative cervical myelopathy- the ReMiDY trial
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Caroline Treanor chats with Dr. Michael Fehlings about degenerative cervical myelopathy (DCM) structured rehabilitation approaches as well as the highly anticipated upcoming ReMiDY trial.
Learning objectives:
- What is degenerative cervical myelopathy (DCM) and why is it important?
- Discussed the ReMiDY trial and the importance of evaluating structured rehabilitation for DCM
- Covered enhanced recovery after surgery (ERAS) protocols for DCM and the role of structured rehabilitation
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Welcome And Guest Introduction
SPEAKER_00Hello, I'm Michael Phalings, professor of neurosurgery at the University of Toronto and editor-in-chief of Spinal Cord, which is the signature publication of the International Spinal Cord Society, or ISCOS. I have the pleasure of uh hosting a podcast series in which we feature uh articles from the spinal uh cord that I feel are are particularly uh noteworthy. And uh today very pleased uh to uh discuss um uh uh an article which has recently been published in uh spinal cord by Carolyn Treener and colleagues uh related uh to a proposed uh randomized uh trial called the Remedy Trial in Degenerative Cervical myelopathy. Uh Carolyn, welcome. And um thank you. Just uh by way of brief introduction, uh so Carolyn Treener is a researcher with the Department of Physiotherapy at Beaumont Hospital in Dublin, Ireland, and the School of Physiotherapy at the Royal College of Surgeons in Ireland. She's pursuing a professional doctorate uh supported by the Royal College of Surgeons in Ireland Strategic Academic Recruitment or STAR program. And Carolyn is also a member of the RECODE PERIOperative rehabilitation incubator. Her work focuses on the development of um an evaluation of novel rehabilitation interventions for degenerative cervical myelopathy or DCM, which is uh addressing one of the uh top research priorities in this
Why DCM Is Rising
SPEAKER_00field. So welcome, Carolyn. So uh firstly, uh Carolyn, tell us a bit about DCM or degenerative cervical myelopathy and and why is this an important topic uh to study Carol?
SPEAKER_01Thank you, Professor Phelan's uh for the kind introduction. So of DCM is the number one cause of non-traumatic spinal cord injury. So um, in outside of the kind of uh spinal cord trauma units, it's the most common type of spinal cord injury that we see. Um, and because of the aging population, it's anticipated that the number of people who present for clinical care for myelopathy is going to increase. So this is a kind of a growing burden of disease that we need to um to develop the resources to manage. And that includes both um providing options to high-quality surgical care for those who need it, but also to non-surgical care options.
SPEAKER_00I see.
The Remedy Trial Evidence Gap
SPEAKER_00Um so tell us a bit about the proposed uh trial uh called the Remedy Trial. And you published the um uh the protocol recently in spinal cord.
SPEAKER_01Yeah, so I think that there is a really high-quality clinical practice guideline which informs our management of people with DCM. And this um guideline has been uh for for people with moderate to severe DCM, the guideline recommends uh surgical intervention. And it also recommends surgical intervention for people with progressive DCM or those who are at high risk of progression. So, for example, if they've got coexisting symptomatic ridiculopathy or circumferential core compression. But when it comes to people with mild DCM, the guideline can only suggest either surgery or a trial of structured rehabilitation. But what's interesting is that there are no studies investigating the effectiveness of structured rehabilitation and also the safety of structured rehabilitation of people with mild DCM. And this creates a this is obviously a very significant knowledge gap. And uh RECODE, which is a kind of a community of clinicians and people with DCM, have identified developing rehabilitation interventions for people with DCM as being one of the top research priorities. So this is a real unmet need from in terms of as clinicians, our treatment options for patients, but also for people with DCM, are really key to you know possibly exhaust non-surgical treatment before they they escalate to surgical care.
SPEAKER_00Yeah, thank you. And um, you know, I think that degenerative cervical myelopathy is a a topic of which people are increasingly aware, and I think this is of major interest to those in the spinal cord um uh injury injury field.
Designing Safe Structured Rehabilitation
SPEAKER_00Um I thought the uh the the trial design had a number of uh novel features. So can you uh perhaps just uh uh talk to us uh a little bit about the way you've uh designed the trial, and maybe if you can talk to us a little bit about what what is meant by uh uh uh structured rehabilitation, yeah.
SPEAKER_01So I think that um I suppose as a clinician working in a spinal surgical service, I I think I've always found that it a lot of the time when you read uh the the a description of interventions in in research trials, they're not very well developed. And there's not always a very strong scientific rationale. And I think rehabilitation for people with DCM is is a complex intervention, and therefore we need to use um kind of strong frameworks to develop uh complex interventions to meet the needs of these patients. And the Medical Research Council in the UK have developed a framework for developing a complex intervention, and we also have the tidier checklist, which is a uh allows us to really describe in detail the scientific rationale for the development of the intervention and the specific components, for example, the dosage of the uh intervention, like what type of clinician is going to deliver the intervention, how long the intervention should be delivered for. And and I think the the thing about uh developing rehabilitation interventions for people with mild DCM is that it needs to be that the actual reality of the condition needs to be considered when you're developing the intervention. So by definition, people with mild DCM have established spinal cord compression. So the typical therapeutic approaches for people with mechanical neck pain need to be modified to take into account the fact that these people are presenting with symptoms and signs of a spinal cord injury. And it's really important that we don't exacerbate the injury in our attempts to try and uh to address some of the um symptoms that they're presenting with. And I think that, you know, when we think about people with mild ECM, they present like degenerative cervical myelopathy is a degenerative condition that affects the cervical spine. And if we think about other degenerative conditions, for example, osteoarthritis of the hip and knee, like these people, people with a mild version of the condition can also can often really benefit from rehabilitation because they present with symptoms like pain, stiffness, local muscle weakness that can actually be uh improved with exercise. So I think that there is a really strong need to test the ability of exercise to have an impact on the symptoms that people at MIDE CM are presenting with.
SPEAKER_00Yeah, I think you make a very uh you know, a very strong case to, you know, examine, you know, a protocol-driven structured rehabilitation program. And certainly as a neurosurgeon who treats these patients, uh, you know, I really value the interaction with the non-operative colleagues. And even when patients have surgery, um, you know, we we recommend pretty much all patients that they undergo a course of structured rehabilitation. Um, and then you know, there's a concept, of course, as well, of prehabilitation for those undergoing, you know, surgical uh uh intervention.
SPEAKER_01But I want yeah, well, yeah, and and I think actually one thing I think it is important to say as well is that uh by definition, uh mild DCM is a type of incomplete spinal cord injury. And we know that people with incomplete uh spinal cord injuries have a lot of neurological preservation below the level of injury, so they are actually ideal candidates for rehabilitation. And there is a lot of uh you know good research happening in the field of incomplete traumatic spinal cord injury that I think is great application to this population that's never been explored, either both in terms of this kind of mild, specific mild DCM population, but also the post-surgical rehabilitation of people uh who have surgery for moderate to severe DCM.
SPEAKER_00Yeah, very good. You know, it seems like um uh you know the interest in DCM or degenerative cervical myelopathy is uh is really taking off, which is heartening for me uh to see.
ERAS Pathways For DCM Surgery
SPEAKER_00I might uh pivot a bit and make reference to another project that in fact you are leading and you and I are collaborating on, which is uh to develop ERAS or enhanced recovery after surgery protocols for those undergoing uh surgery for DCM. And in fact, you published the protocol uh for this also in its final uh chord last year. Can you tell um us a little bit about um what you're hoping to achieve uh through these uh ERAS care pathways?
SPEAKER_01Yeah, and I think you know, I suppose there is strong recognition that uh there are a significant proportion of people with DCM who do require surgical management. And but and we know from there's lots of different surgical approaches have been investigated for their effectiveness in people with DCM. And what we're seeing is that in terms of neurological recovery, there's a broad recognition that the surgical strategy needs to be individualized, and there's no evidence that one approach is superior to the other. But what we do see is wide variation in things like length of stay, their post-operative management, so the use of things like bracing and steroids and in the post-operative care of people with DCM, what sort of a facility they're being discharged to. So we see some people who have surgery for severe DCM, which by definition means that they have relatively significant neurological impairment and they're discharged home two days later, whereas in other jurisdictions they're discharged to rehabilitation facilities. We also see a big difference in things like the incidence and severity of complications and the long-term functional outcome achieved. So, and also what's interesting is that when we look at the mortality rate associated with DCM surgery, it's kind of 0.6%, which is a relatively high rate for elective degenerative spine surgery. So, you know, we have people who need to have surgery, but we can see that there's not always a guarantee that they're going to have a good surgical outcome. So, you know, are there evidence-based strategies that we can use to try and optimize their outcome? And interestingly, uh, two big large registry studies, one from CSOR, which is the Canadian Spinal Outcome Research Network, and one from North Spine, which is the Norwegian Spine Registry, have uh published uh re uh research kind of reporting the kind of complication rates in in real-world clinical settings in high-income countries. And what we're seeing is that the the complication rates that they're reporting are in the region of 30%, which is much higher than what would be previously expected. So I think we need to recognize that this is, you know, there are a significant risk profile associated with surgery for TCM. So we need to be using every strategy at our disposal to try and optimize their outcome.
SPEAKER_00Yeah, very good. And I think it it you know it's an opportunity to provide, you know, evidence-based uh care pathways. And you know, we we we see quite a high heterogeneity and complication rates. And um and I think there, you know, there is an opportunity to to really to develop personalized approaches uh you know to the to the management. Perhaps just to close, um, you know, I made reference earlier to the uh Rico DCM uh project. Can you can you tell us a little bit what what is RECO a DCM and and you know why is this an important undertaking?
SPEAKER_01Yeah, so Rico DCM is essentially a kind of a large international community of expert clinicians and researchers who are working collaboratively to try and improve the outcomes of people with DCM through high-quality clinical research. And what they've done, which I think is a really excellent place to start, if they've uh in collaboration with people with DCM, they've established the top 10 research priorities. And then so to try and focus the community to uh address the the research questions that are of most importance to people with the condition. Uh and I think what they've what what the RECO community has done then is they've tried to prioritize some of those research priorities. So they've established research incubators, there's one focused on diagnostic criteria, which is absolutely essential. So even when you look at all the surgical trials of people with DCM, it's difficult to find two trials that have used the same eligibility criteria because there is no agreed diagnostic criteria. So that's a really important place to start. They've also established a rehabilitation incubator to focus on things like the developing ERIS guidelines, developing uh rehabilitation protocols for patients post-operatively, and they've also uh developed another really important incubator focusing on natural history. So, what happens to patients if we if we don't do anything? Because I think if to justify um an invasive treatment like surgery, we have to be confident that patients would deteriorate without this uh intervention. So I think these are this has been a really excellent uh undertaking to try and focus the community in it in it into addressing the research questions that are of the most importance.
SPEAKER_00Very good.
RECODE DCM Priorities And Incubators
SPEAKER_00Well, you know, I really enjoyed um you know uh our conversation, and we could obviously talk uh but much longer, but I would encourage uh those listening to this podcast uh to read um uh uh the the article on the remedy at uh trial that has been recently published in spinal cord and that is actually open open
Where To Read And Next Steps
SPEAKER_00access. So I'm gonna close out um this conversation. Carolyn, thank you very much uh for joining on this podcast. I've had the pleasure of speaking to Carolyn Treener, who's a researcher and an academic physiotherapist at the Beaumont Hospital Dublin, Ireland, and with the uh Royal College of Surgeons in Ireland, and a um uh you know a uh an important uh investigator in the field at the generative cervical myelopathy. On that note, uh I will close out this um uh a podcast and uh would welcome uh uh all of you to listen to other podcasts um in our uh ISCOS series. Thank you.