Development of the Canadian Spinal Cord Injury Best Practice (Can-SCIP) Guideline: Methods and overview

Figures & data

Figure 1 Can-SCIP recommendations adaptation and development cycle.

Table 1 Section 1 & 2 domains.

Recommendations for the Components of the Ideal SCI Care System	Recommendations for the Management of SCI Health Conditions
Pre-hospital and Emergency	Activity-Based Therapy
Diagnostic Imaging	Autonomic Dysreflexia
Early Acute Care	Bladder
Education and Support of People with SCI and their Families Across the Continuum	Bone Health
Cross Continuum Education of Clinicians and Staff Working with People with SCI	Bowel Health
Specialized Inpatient Rehabilitation	Cardiometabolic Health
Specialized Inpatient Rehabilitation	Emotional Wellbeing
Community-Based Rehabilitation	Mobility & Walking
Vocational Rehabilitation	Neuropathic Pain
Comprehensive Health and Wellness	Respiratory Health
	Sexual Health, Relationships & Fertility
	Skin Integrity
	Upper Limb
	VTE Prophylaxis

Table 2 Summary of criteria for levels of evidence reported in the Can-SCIP guideline.

Grade of recommendation	Descriptor
A	Recommendation supported by at least 1 meta-analysis, systematic review, or randomized controlled trial of appropriate size with relevant control group.
B	Recommendation supported by cohort studies that at minimum have a comparison group, well-designed single-subject experimental designs, or small sample size randomized controlled trials.
C	Recommendations supported primarily by expert opinion based on their experience through uncontrolled case series without comparison groups that support the recommendations are also classified here.

Notes: Adapted from Hebert et al.⁴⁰

Figure 2 PRISMA study flow diagram.

Table 3 SCI clinical practice guidelines selected for inclusion.

Guideline name	Abbreviation	Year	Phase of care	Topic area(s) covered	Country of origin
Spinal Cord Injury (2009) Evidence-Based Nutrition Practice Guideline^Citation41	NUTR	2009	Cross-Continuum	Nutrition	United States
Sexuality and Reproductive Health in Adults with SCI^Citation42	CSCM	2010	Rehab/Community	Sexuality	United States
Home Mechanical Ventilation: A Canadian Thoracic Society CPG^Citation43	CTS	2011	Community	Respiratory	Canada
Evidence-Based Guideline Update: Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical Motor Evoked Potentials^Citation44	NUWER	2011	Acute Care	Surgical Monitoring	United States
Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease^Citation45	NICE	2012	Cross-Continuum	Bladder	United Kingdom
Canadian BPG for the Prevention and Management of Pressure Ulcers in People with SCI: A Resource Handbook for Clinicians^Citation46	PU-ONF	2013	Cross-Continuum	Skin	Canada
Clinical Guideline for Standing in Adults Following Spinal Cord Injury^Citation47	CGFS	2013	Rehab/Community	Standing Therapy	United Kingdom & Ireland
Development of Clinical Guidelines for the Prescription of a Seated Wheelchair or Mobility Scooter for People with TBI or SCI^Citation48	OTA	2013	Cross-Continuum	Wheelchair/ Mobility Device	Australia
Management of Acute Combination Fractures of the Atlas and Axis in Adults^Citation49	ATL-ATX	2013	Acute	Surgical Management	United States
Initial Closed Reduction of Cervical Spinal Fracture-Dislocation Injuries^Citation50	CNS-FXDIS	2013	Acute	Fracture Treatment	United States
Deep Venous Thrombosis and Thromboembolism in Patients with Cervical SCI^Citation51	CNS-DVT	2013	Cross-Continuum	Venous Thrombo-Embolism (VTE)	United States
Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries: 2013 Update^Citation52	CNS	2013	Acute	Medical/Surgical Management	United States
Pressure Ulcer Prevention and Treatment Following SCI, 2nd edition^Citation53	PU-PVA	2014	Cross-Continuum	Skin/Nutrition	United States
The Prevention and Management of Pressure Ulcers in Primary and Secondary Care^Citation54	NICE PU	2014	Community	Skin	United Kingdom
Prevention and Treatment of Pressure Ulcers: Individuals with Spinal Cord Injury^Citation55	NPUAP	2014	Cross-Continuum	Skin	United States
Prevention of Venous Thromboembolism in Individuals with SCI^Citation56	CSCM	2016	Cross-Continuum	VTE	United States
The CanPain SCI CPG for Rehab Management of Neuropathic Pain after SCI: Recommendations Treatment^Citation57	CANPAIN TREAT	2016	Cross Continuum	Pain	Canada
The CanPain SCI CPG for Rehab Management of Neuropathic Pain after SCI: Screening and Diagnosis Recommendations^Citation58	CANPAIN DIAG	2016	Cross-Continuum	Pain	Canada
The CanPain SCI CPG for Rehab Management of Neuropathic Pain after SCI: Recommendations for Model Systems of Care^Citation59	CANPAIN SYS CARE	2016	Cross-Continuum	Pain	Canada
Provincial Guidelines for Spinal Cord Assessment^Citation60	CCO	2016	Cross-Continuum	Medical	Canada
Spinal injury: Assessment and Initial Management^Citation61	NICE	2016	Acute	Medical/Surgical	United Kingdom
A Review and Update on the Guidelines for the Acute Management of Cervical SCI – Part II^Citation62	REVIEW PAR	2016	Acute	Medical/Surgical	United States
Evidence-based Scientific Exercise Guidelines for Adults with SCI: An Update and a New Guideline^Citation63	GINIS	2017	Rehab/Community	Exercise	Canada & United Kingdom
CPG for the Management of Patients With Acute SCI and Central Cord Syndrome: Recommendations on the Timing (≤24 h Versus >24 h) of Decompressive Surgery^Citation64	DECOM	2017	Acute	Surgical	International
CPG for the Management of Patients With Acute SCI: Recommendations on the Use of Methylprednisolone Sodium Succinate^Citation65	MSS	2017	Acute	Medical Management	International
CPG for the Management of Patients With Acute SCI: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis^Citation66	ANTICOAG	2017	Acute	VTE	International
CPG for the Management of Patients With Acute SCI: Recommendations on the Role of Baseline Magnetic Resonance Imaging in Clinical Decision Making and Outcome Prediction^Citation67	MRI	2017	Acute	Diagnostic Imaging	International
CPG for the Management of Patients With Acute SCI: Recommendations on the Type and Timing of Rehabilitation^Citation68	TIME	2017	Cross-Continuum	Rehabilitation	International
Rehabilitation in Health Systems^Citation69	WHO	2017	Cross-Continuum	Rehabilitation	International
International Perspectives on SCI^Citation70	WHO INT	2013	Cross-Continuum	Rehabilitation	International
Urodynamics in Patients with SCI: A Clinical Review and Best Practice Paper^Citation71	URO	2017	Cross-Continuum	Urinary Tract	International
Guidelines for the Rehabilitation of Patients with Metastatic Spinal Cord Compression^Citation72	MSCC	2017	Acute	Surgical/Medical Decompression	United Kingdom
Norwegian Guidelines for the Prehospital Management of Adult Trauma Patients with Potential Spinal Injury^Citation73	NOR	2017	Pre-Hospital	Spinal Immobilization	Norway
Wounds Canada Best Practice Recommendations^Citation74	WOUNDCAN	2017	Cross-Continuum	Skin Care	Canada
Neuropathic Pain in Adults: Pharmacological Management in Non-Specialist Settings (CG173)^Citation75	PALRM	2018	Community	Pain	United Kingdom
Identification and Management of Cardiometabolic Risk after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers^Citation76	NASH	2018	Cross-Continuum	Cardiometabolic Diabetes	United States
Diagnosis, Management and Surveillance Neurogenic Lower Urinary Tract Dysfunction^Citation77	CUA	2019	Cross-Continuum	Urinary Tract	Canada
Bone Mineral Density Testing in Spinal Cord Injury: The 2019 ISCD Official Positions^Citation33	BMD	2019	Cross-Continuum	Bone Health	International
Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows^Citation78	PVA AD	2020	Cross-Continuum	Autonomic Dysreflexia	United States
Management of Neurogenic Bowel Dysfunction in Adults after Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers^Citation79	PVA BOWEL	2020	Cross-Continuum	Bowel	United States
Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury: Clinical Practice Guideline for Healthcare Providers^Citation80	PVA EWB	2020	Cross-Continuum	Mental Health & Substance Use Disorders	United States

Table 4 Can-SCIP domain summary – Section 1.

Recommendations for the components of the Ideal SCI care system	Total recommendations	Recommendation derivation			Level of evidence
		Adopted as is	Revised	Newly derived	Level A	Level B	Level C
PRE-HOSPITAL AND EMERGENCY	39	15	24	0	2	19	18
Extrication & Transportation of Patients with Acute Cervical SCI	10	2	8	0	0	9	1
Assessment and Management in Pre-Hospital Settings	2	1	1	0	0	0	2
Assessment for Thoracic or Lumbosacral SCI	1	1	0	0	0	0	1
When to Carry Out Full In-Line Spinal Immobilization	2	1	1	0	0	0	2
How to Carry Out Full In-Line Spinal Immobilization	2	1	1	0	0	1	1
Receiving Information in Hospital Settings	2	1	1	0	0	0	2
Emergency Department Assessment and Management	12	7	5	0	2	8	2
Neurological Exam Following Acute Cervical SCI	1	0	1	0	0	1	0
Recording Information in Hospital Settings	1	0	1	0	0	0	1
Timing of Decompressive Surgery (≤24 h After Injury) in Patients with Acute Spinal Cord Injury	3	1	2	0	0	0	3
Providing Information on Transfer from an Emergency Department	1	0	1	0	0	0	1
Communication with Tertiary Services	2	0	2	0	0	0	2
DIAGNOSTIC IMAGING	18	11	5	2	6	2	10
Introductory Recommendations	2	0	2	0	0	0	2
Suspected Spinal Cord or Cervical Column Injury	4	3	1	0	0	0	4
Suspected Thoracic or Lumbosacral Column Injury Only	2	0	2	0	0	2	0
Diagnostic of Vertebral Artery Injuries Following Non-Penetrating Cervical Trauma	2	2	0	0	1	0	1
Radiographic Assessment in Awake, Asymptomatic Patient	4	3	0	1	3	0	1
Radiographic Assessment in Obtunded or Unevaluable Patient	4	3	0	1	2	0	2
EARLY ACUTE CARE	9	2	3	4	2	4	3
Early Medical Management	6	1	1	4	0	3	3
Role of the Registered Dietitian	1	0	1	0	0	1	0
Nutrition Assessment: Energy Needs in the Acute Phase	1	1	0	0	1	0	0
Preventing Pressure Injuries During the Acute Care Phase	1	0	1	0	1	0	0
EDUCATION AND SUPPORT OF PEOPLE WITH SCI AND THEIR FAMILIES ACROSS THE CONTINUUM	6	0	6	0	0	0	6
CROSS CONTINUUM EDUCATION OF CLINICIANS AND STAFF WORKING WITH PEOPLE WITH SCI	4	1	2	1	1	2	1
SPECIALIZED INPATIENT REHABILITATION	8	2	2	4	1	0	7
COMMUNITY-BASED REHABILITATION	7	0	0	6	0	0	7
Community-Based Rehabilitation	3	1	1	1	0	0	3
Community Care	4	0	0	4	0	0	4
VOCATIONAL REHABILITATION	2	0	0	2	1	0	1
COMPREHENSIVE HEALTH & WELLNESS	3	0	0	3	0	0	3
TOTAL	96	32	43	21	13	27	56

Table 5 Can-SCIP domain summary – Section 2.

Recommendations for the SCI health conditions	Total # of recommendations	Recommendation derivation			Level of evidence
		Adopted as is	Revised	Newly derived	Level A	Level B	Level C
ACTIVITY BASED THERAPY	6	1	5	0	2	0	4
AUTONOMIC DYSREFLEXIA (AD)	88	80	0	8	0	10	78
Blood Pressure Following SCI	1	1	0	0	0	0	1
AD	42	34	0	8	0	10	32
AD & Sexuality	9	9	0	0	0	0	9
AD And Cystoscopic (Transurethral and Suprapubic) Urological Procedures and Sperm Retrieval Procedures Performed in the Clinic Setting	11	11	0	0	0	0	11
AD In Pregnancy, Labor and Delivery, and the Postpartum Period	6	6	0	0	0	0	6
Induced AD (“Boosting”)	1	1	0	0	0	0	1
Orthostatic Hypotension	4	4	0	0	0	0	4
Thermodysregulation	10	10	0	0	0	0	10
Hyperhidrosis	4	4	0	0	0	0	4
BLADDER	45	17	24	4	9	14	23
Screening, History and Physical Assessment Voiding Diary	6	3	3	0	0	0	6
Urodynamics	4	4	0	0	1	1	2
Urinary Tract Infection	7	1	5	1	1	3	3
Bladder Management	2	1	1	0	0	2	0
- Genitourinary Sequelae of Neurogenic Lower Urinary Tract Dysfunction	5	1	4	0	0	1	4
- Conservative Therapy	3	3	0	0	0	0	3
- Medical Therapy	5	1	3	1	1	2	2
- Intravesicular Botox	6	2	3	1	5	1	0
- Surveillance	6	1	5	0	0	4	2
- Surgery	1	0	0	1	0	0	1
BONE HEALTH	10	4	0	6	5	3	2
Assessment of Fracture Risk	1	1	0	0	0	1	0
DXA Testing	2	2	0	0	0	2	0
Prevention of Osteoporosis	1	1	0	0	0	0	1
Treatment of Osteoporosis	6	0	0	6	5	0	1
BOWEL	40	40	0	0	2	22	16
Assessment of Neurogenic Bowel Dysfunction (NBD)	8	8	0	0	0	4	4
Basic Bowel Management (BBM)	6	6	0	0	0	4	2
Adaptive Equipment	2	2	0	0	0	1	1
Diet, Supplements, Fiber, Fluids, and Probiotics	7	7	0	0	1	1	5
Oral Medications	1	1	0	0	0	0	1
Use of Suppositories, Enemas, and Irrigation	6	6	0	0	1	4	1
Impact of Posture and Activity on NBD	2	2	0	0	0	2	0
Use of Functional Electrical Stimulation (FES)	1	1	0	0	0	1	0
Surgical Intervention to Manage NBD	4	4	0	0	0	4	0
Managing Medical Complications of NBD	3	0	0	0	0	1	2
CARDIOMETABOLIC	17	7	8	2	2	2	13
CMD risk management and Exercise	6	3	1	2	1	1	4
- Nutrition Screening for People Living in the Community	1	0	1	0	0	1	0
Obesity – Nutrition Assessment, Treatment, Bariatric Surgery	2	1	1	0	1	0	1
Hypertension	4	1	3	0	0	0	4
Dyslipidemia	2	1	1	0	0	0	2
Diabetes Nutritional Support After SCI	2	1	1	0	0	0	2
EMOTIONAL WELLBEING	54	44	0	10	5	0	49
Screening, Assessment and Treatment	8	0	0	8	0	0	8
Diagnostic-Specific Disorders: Anxiety Disorders	6	6	0	0	0	0	6
Diagnosis-Specific Disorders: Major Depressive Disorder	9	7	0	2	5	0	4
Diagnosis-Specific Disorders: Substance Use Disorders	7	7	0	0	0	0	7
Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)	8	8	0	0	0	0	8
Suicide	16	16	0	0	0	0	16
MOBILITY AND WALKING	5	1	0	4	1	2	2
NEUROPATHIC PAIN	25	3	21	1	8	2	15
Introduction and Screening for Neuropathic Pain	2	0	2	0	1	0	1
Diagnosis of Neuropathic Pain Clinical Assessment	7	1	6	0	0	0	7
Treatment of Neuropathic Pain and Delivery of Care	5	0	5	0	0	0	5
Recommendations for Neuropathic Pain Treatment	10	2	8	0	6	2	2
Non-Pharmacological Therapies	1	0	0	1	1	0	0
RESPIRATORY	10	0	4	6	0	1	9
Lung Volume Recruitment	1	0	0	1	0	0	1
Abdominal Binder and Abdominal Muscle Simulation	2	0	0	2	0	0	2
Pharmacological Agents for Respiratory Function	1	0	0	1	0	1	0
Respiratory Muscle Training	1	0	0	1	0	0	1
Home Mechanical Ventilation	5	0	4	1	0	0	5
SEXUAL HEALTH, RELATIONSHIPS AND FERTILITY	53	3	42	8	4	11	38
Introductory Recommendations	5	0	5	0	0	0	5
Education	7	0	6	1	0	1	6
Relationships	3	1	2	0	0	0	3
Sexual History & Assessment	6	0	3	3	1	1	4
Optimizing Sexual Well-Being, Body Image and Sensuality	5	1	3	1	1	1	3
Physical and Practical Considerations – Bladder	4	0	4	0	0	4	0
Physical and Practical Considerations – Bowel	2	0	2	0	0	0	2
Physical and Practical Considerations – Sensation	2	0	0	2	0	0	2
Physical and Practical Considerations – Mobility, Spasticity & Contractures	2	0	2	0	0	0	2
Physical and Practical Considerations – Skin Integrity	1	0	1	0	0	0	1
Physical and Practical Considerations – Autonomic Dysreflexia	1	0	1	0	1	0	0
Treatment of Sexual Dysfunction	7	0	6	1	0	0	7
Fertility – Men	1	1	0	0	1	0	0
Fertility – Women	2	0	2	0	0	2	0
Fertility – Men & Women	1	0	1	0	0	1	0
Contraception	1	0	1	0	0	0	1
Pregnancy	3	0	3	0	0	1	2
SKIN INTEGRITY	97	42	48	7	19	23	55
Prevention	7	0	6	1	1	4	2
Human Factors Affecting Pressure Injury Prevention	6	0	5	1	0	4	2
Prevention Strategies Across the Continuum of Care	7	1	6	0	3	1	3
Wheelchair Pressure Redistribution and Support Surfaces - Other Pressure Redistribution and Support Surfaces	3	1	2	0	1	1	1
Recumbent Positioning	8	4	4	0	0	0	8
Support Surfaces – Mattress	5	5	0	0	0	0	5
Sitting Support Surfaces & Other Seating	16	10	6	0	0	4	12
Self-Management	0	0	0	0	0	0	0
Education and the Person with SCIs Involvement in Care	3	3	0	0	0	0	3
Risk & Risk Assessment	1	1	0	0	1	0	0
Body Weight & Nutrition	4	3	1	0	2	2	0
Assessment of the Person with a Pressure Ulcer	4	0	3	1	0	1	3
Assessment Using the 24-hour Approach	2	1	1	0	1	0	1
Reassessment of Seating Systems	2	0	2	0	0	0	2
Assessment of Mobility	9	0	8	1	0	2	7
Treatment Principles	2	2	0	0	0	0	2
Non-Surgical Treatment	3	2	1	0	2	0	1
- Creating a Physiologic Wound Environment	1	1	0	0	1	0	0
- Debridement	1	1	0	0	0	1	0
- Selection of Wound Care Dressing	1	1	0	0	1	0	0
- Electrical Stimulation	2	1	1	0	2	0	0
Surgical Treatment	7	3	1	3	2	2	3
Hematologic and Biochemical Parameters of Healing	2	1	1	0	1	1	0
Nutrition Intervention for Prevention of Pressure Ulcers	1	1	0	0	1	0	0
UPPER LIMB	12	0	1	11	4	5	3
VTE PROPHYLAXIS	8	5	3	0	0	1	7
Prophylaxis	1	0	1	0	0	0	1
Screening Patients for Asymptomatic Deep-Vein Thrombosis	1	1	0	0	0	1	0
Diagnosis	1	0	1	0	0	0	1
Mechanical Methods of Thromboprophylaxis	1	1	0	0	0	0	1
Thromboprophylaxis	3	2	1	0	0	0	3
Thromboprophylaxis in Hospitalized Chronic SCI Patients	1	1	0	0	0	0	1
WHEELED MOBILITY	19	2	16	1	3	4	12
TOTAL	489	249	172	68	64	99	326

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