The Long Backboard vs the Vacuum Mattress.

Correspondence: Neil McDonald, PCP, MPhil Winnipeg Fire Paramedic Service Winnipeg, Manitoba, Canada E-mail: [email protected] Madshidfar et al are to be applauded for the initiative behind ‘‘Long Backboard versus Vacuum Mattress Splint to Immobilize Whole Spine in Trauma Victims in the Field: a Randomized Clinical Trial’’. We have three concerns related to this paper. The first concern relates to the measurement of spine motion. In a systematic review of studies assessing cervical range-of-motion, Voss et al detail the range of techniques used to measure head and neck motion in the scientific literature. That there is no standard technique to do so speaks to the difficulties in measuring vertebral movement in an objective and valid way. Nevertheless, technological advances have facilitated recent trends towards real-time measurement of motion in clinically relevant settings. Madshidfar and colleagues use none of these recent or earlier methods. They measure spine motion only by clinician or researcher observation. We disagree with the authors’ assertion that this method yields an objective result. Although a number is assigned, the measurement remains a subjective rating of accumulated motion, without any interor intra-rater reliability. Second, the study lacks essential information and skips best practices in the reporting of interventional trials. The authors have failed to establish the baseline comparability of the study groups with respect to mechanism of injury, other traumatic injuries, preexisting conditions, mental status, duration of immobilization, and timing of the outcome measurements. Most importantly, readers need to know whether any patients actually had a spinal column or spinal cord injury. Furthermore, the instructions given to patients may bias and/or confound results. What were these instructions? How were they given? When were they given? How were they received? Were the same instructions given to both groups of patients? Third, and perhaps most disturbingly, this experimental design raises serious ethical questions that remain unaddressed. The standard of care for trauma patients with possible spine injuries is clear: immobilization. Is it appropriate for an actual trauma patient, for whom immobilization is indicated and undertaken, to then be instructed to move? How were the risks of participation framed and communicated? What strategy was used to obtain informed consent within a study that departs so profoundly from the accepted standards of care? The current paper shows a number of methodological gaps that, when taken together, caution against acceptance of its findings. We welcome and value further research on these questions.