Introduction
The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are the gold standard classification of spinal cord injury (SCI) level and severity, using the American Spinal Injury Association (ASIA) Impairment Scale (AIS). The AIS score, which categorizes motor and sensory impairments, is widely used in research and has been found to predict functional, and perhaps autonomic, outcomes after SCI. However, calculating an AIS score involves a complex clinical assessment completed by trained clinicians in a rehabilitation setting; this makes obtaining an AIS score for community-residing people with SCI difficult. The purpose of this presentation is to discuss the evaluation of a self-report method, developed in Canada, to determine AIS in community-residing people with SCI.

Methods
Data for this analysis were collected from people with SCI as part of an ongoing study taking part in five sites across four countries: Australia, Brazil, Netherlands and USA (Colorado and Michigan). After receiving approval from each site’s respective Institutional Review Board or Privacy Board, people with SCI were consented and enrolled into the study and completed an in-person or telephone interview. The interview included seven self-report questions regarding self-perceived functional and physical motor and sensory abilities; an algorithm was applied to responses to calculate an AIS score. We then measured the level of agreement between the self-report data and the medical record data [level of injury (cervical, thoracic, lumbar), level of injury (tetraplegic, paraplegic), injury completeness (complete, incomplete), and AIS score (A, B, C, D)] using a Cohen’s kappa statistic. The association between the calculated AIS score to the medical record AIS score was assessed with a Somers’ D index.

Results
A total of 221 people with a traumatic onset of injury who were residing in the community was included in this analysis. The sample was predominantly male (78.3%) and married (54.3%). Average age at the time of the study was 48.7 years (sd=14.0) and average age at onset of injury was 33.8 years (sd=15.5); average years of education was 13.8 years (sd=4.2). The level of agreement was very strong for level of injury between the self-report and medical record. The kappa score was 0.95 for level of injury (tetraplegic, paraplegic) and 0.92 for level of injury (cervical, thoracic, lumbar). Injury completeness and AIS score had substantial agreement with kappa scores of 0.69 and 0.73 respectively. The Somers’ D between the calculated AIS variable to the medical record-abstract AIS was 0.77, indicating a high level of association and predictability.

Conclusions
We conclude that agreement between self-report and medical record level of injury and AIS is fairly consistent for community-residing people with traumatic SCI and that using the self-report questions is a promising method to generate an AIS score in community-residing people with traumatic SCI. Future research to further examine and validate these results is required.

Introduction
Cervical myelopathy constitutes a frequent degenerative disorder of the spinal cord affecting spinothalamic conduction. Since the existence of modality-specific labelled lines within the spinothalamic system has been suggested, a multi-modal approach will yield important topographical information regarding spinal pathologies. Furthermore, modality-specific afferent sparing might be reflected in the somatosensory phenotype of affected subjects. The specific aim was to relate modality-specific, segmental electrophysiological measures of spinothalamic integrity to clinical signs and symptoms of neuropathic pain.

Methods
Twelve subjects with focal cervical myelopathy underwent quantitative sensory testing within the most affected dermatome corresponding to the MRI-defined myelopathy. Contact heat evoked potentials (CHEPs), cold evoked potentials (CEPs), pinprick evoked potentials (PEPs), and dermatomal somatosensory evoked potentials (SSEPs) were acquired from the affected as well as a control dermatome above the level of lesion (shoulder). The neuropathic pain phenotype was characterized using the Neuropathic Pain Symptom Inventory and painDETECT® questionnaires.

Results
All subjects presented with a “snake-eye appearance” cervical myelopathy upon MRI with at-level alterations of mechano-nociception in 50% of cases, and pathological cold- and warm/heat sensation in 42% or 33% of cases, respectively. Dermatomal SSEPs were preserved in all subjects. CHEPs and CEPs were concurrently impaired in 42% of subjects, whereas PEPs were impaired in only 17% of these subjects. Evoked potential preservation could be related to clinical characteristics of neuropathic pain.

Conclusions
Multi-modal neurophysiology reveals altered spinothalamic conduction in subjects with focal cervical myelopathies as complementary and confirmatory readouts alongside subjective quantitative sensory testing. The data supports the existence of modality-specific labelled lines within the spinothalamic system that may dissociate depending on lesion topography.
The association with the clinical neuropathic pain phenotype may provide further insights into the pathophysiology of central pain. Residual conduction within the spinothalamic tract might predict the development of central neuropathic pain.

Introduction
More than 50% of individuals with a spinal cord injury (SCI) are affected by chronic neuropathic pain at and/or below the neurological level of injury. Causes of chronic neuropathic pain are postulated to lie in abnormal balance within the nociceptive system, i.e., between anti- and pro-nociceptive mechanisms. Sensitization along the nociceptive neuraxis, as a pro-nociceptive mechanism, contributes to the clinical representation of hyperalgesia and allodynia in individuals with neuropathic pain. Temporal summation of pain (TSP), the behavioural analogue of spinal wind-up, is believed to reflect this central sensitization. TSP and other pain modulatory processes, such as pain adaptation, can be studied by application of tonic heat stimulation in humans. The objective of this study was to investigate differences in tonic heat pain modulation, i.e., adaptation and TSP, in individuals with and without neuropathic pain following SCI.

Methods
Tonic heat pain modulation was studied in three groups with a total of 53 individuals: thoracic SCI individuals with (SCI-NP, n=23) and without neuropathic pain (SCI-nonNP, n=14), and age- and sex-matched healthy controls (HC, n=16). The assessment was performed at the volar forearm in order to investigate a sensory intact area. A thermode was heated to 45°C, and the participants were instructed to rate the pain intensity on a numeric rating scale. Subsequently, they had to keep the pain level constant for two minutes by adjusting the temperature of the thermode (participant-controlled temperature). Pain adaptation and temporal summation were the primary readouts of the obtained tonic heat profiles. In addition, neuropathic pain was characterized using pain drawings capturing pain extent and intensity.

Results
Individuals with SCI and neuropathic pain show the highest percentage of TSP occurrence (SCI-NP: 88%, SCI-nonNP: 63.6%, HC: 80%). The magnitudes of TSP were 0.40°C ± 0.37 in HC, 0.35°C ± 0.32 in SCI-nonNP, and 0.64°C ± 0.45 in SCI-NP. Statistical analysis revealed a significant increase of TSP magnitude within the SCI-NP compared to the SCI-nonNP group (p=0.044). Furthermore, the area under the curve of the TSP was also increased in SCI-NP compared to SCI-nonNP (p=0.044). Correlations between pain intensity and extent with TSP magnitude in the SCI-NP group revealed no significance (rho=0.22, p=0.396, and rho=0.177, p=0.498, respectively). Pain adaptation was found in 93% of HC, 100% of SCI-nonNP, and 94% of SCI-NP, and the amplitude of adaptation was not significantly different between the three groups (HC: 1.35° ± 0.52, nonNP: 1.36° ± 0.51, NP: 1.53° ± 0.70 (p=0.654).

Conclusions
Increased TSP was found in individuals with SCI and chronic neuropathic pain compared to the ones without neuropathic pain. This temporal summation might act as a proxy for central sensitization, reflecting a disturbance of pain modulation towards a pro-nociceptive state. The method of tonic heat assessment by participant-controlled temperature is a promising tool to investigate dynamic pain modulation processes in a more objective manner than pure rating-based approaches. Therefore, this method might improve pain phenotyping of individuals with SCI and neuropathic pain.

Introduction
Traumatic spinal cord injury (SCI) causes devastating motor and sensory deficits. Damage to the somatosensory system after SCI yields central neuropathic pain (NP) in 53% of patients. The pathophysiology of NP involves a complex interaction of dysfunctional endogenous pain modulation and central sensitisation. The spatial extent of pain has been shown to positively correlate with increases of resting-state functional connectivity (rsFC) in chronic pelvic pain patients with widespread pain. However, it is still unknown whether the extent of chronic NP related to SCI correlates to rsFC. We hypothesize that SCI-NP patients will show abnormal rsFC in pain processing regions which will also be associated to their spatial extent of NP.

Methods
A total of 37 subjects (18 healthy controls: age=55.4+11.1 years, 3 females and 19 chronic SCI-NP; age=56.9+10.0 years, 3 females, 11 sensorimotor complete lesions) underwent resting-state functional magnetic resonance imaging. For pain characterisation, pain drawings and questionnaires were implemented to assess the quality, intensity and location of NP (and nociceptive pain) within each patient. Pre-processed functional images were analysed with the CONN toolbox using a region of interest approach based on motor and pain processing functions reported in prior literature: e.g. motor (M1) and somatosensory cortex (S1); thalamus; prefrontal cortex (PFC), periaqueductal gray (PAG) and regions of the insular cortex. Age, sex, total intracranial volume, time since injury and pain medication where used as nuisance covariates in group-level analysis. Results were deemed significant at a family-wise error (FWE) corrected level p<0.05. Fisher-transformed correlation coefficients of significant results were extracted and assessed using Spearman’s correlation analysis with motor scores and NP characteristics.

Results
No age or sex differences were seen between the two groups (p=0.69, p=0.94, respectively). Compared to healthy controls, SCI-NP showed decreased rsFC of left M1 to bilateral paracentral lobules and increased rsFC of the PAG to left M1 and left dorso-lateral PFC (dlPFC) (all p-FWE p<0.05). A negative correlation was found for the left dlPFC to PAG with the extent of NP (rs=-0.57, p=0.01), while no correlation with maximum pain intensity was observed (rs=-0.15, p=0.53). In addition, rsFC from left M1 to left and right paracentral lobules correlated positively with lower extremity motor scores (rs=0.57, p=0.02 and rs=0.62, p<0.01, respectively).

Conclusion
SCI patients with greater extent of NP show lower functional coupling of brain regions involved in pain modulation. In addition, compared to controls, SCI-NP patients show an overall increased rsFC of the left dlPFC to PAG, major structures involved in descending modulation of nociceptive information. Taken together, this might indicate that a greater extent of NP is associated with dysfunctional coupling of descending modulatory landmarks reflecting an imbalance of facilitatory and inhibitory modulatory mechanisms. In line with this finding, a correlation between decreased rsFC of the PAG-to-ACC with pain facilitation in fibromyalgia patients and healthy subjects was previously reported. Based on our results, characterising the pain extent in SCI patients alongside neuroimaging readouts may be a valuable tool to determine neuroplastic changes within pain modulatory networks associated with central NP.

Introduction: There is much controversy about the potential impact of spinal cord injury (SCI) on brain’s anatomy and function, which is mirrored in the substantial divergence of findings between animal models and human imaging studies. Given recent advances in quantitative magnetic resonance imaging (MRI) we sought to tackle the unresolved question about the link between the presumed injury associated volume differences and underlying brain tissue property changes in a cohort of chronic complete SCI patients.
Methods: Using the established computational anatomy methods of voxel-based morphometry and voxel-based quantification we performed statistical analyses of grey matter volume and parameter maps indicative for brain’s myelin, iron and free tissue water content in complete SCI patients (n=14) and healthy individuals (n=15).
Results: Our whole-brain analysis showed significant white matter volume loss in the rostral and dorsal part of the spinal cord consistent with Wallerian degeneration of proprioceptive axons in the lemniscal tract in SCI subjects, which correlated with spinal cord atrophy assessed with quantification of the spinal cord cross-sectional area at cervical level.
Conclusions: The latter finding suggests that Wallerian degeneration of the lemniscal tract represents a main contributor to the observed spinal cord atrophy, which is highly consistent with preclinical ultrastructural/histological evidence of remote changes in the central nervous system secondary to SCI. Structural changes in the brain representing remote changes in the course of chronic SCI could not be confirmed with conventional VBM or VBQ statistical analysis. Whether and how MRI based brain morphometry and brain tissue property analysis will inform clinical decision making and clinical trial outcomes in spinal cord medicine remains to be determined.

Introduction: Neurogenic bladder and bowel are some of the most important problems affecting the lives of persons with SCI including their physical health, relationships, sexuality and overall wellbeing. Objective: The objective of this presentation is to examine current data on bladder and bowel dysfunction and complications and patients’ decisions with respect to their methods of management.
Methods:A mixed method approach was used. SCI patients (n=300) were interviewed about their methods of management, complications and impact on life activities. Logistic models were used for the quantitative analysis. A subset of patients (n=40) discussed how they made decisions about their bladder and bowel care. More in-depth interviews were conducted with selected patients and video clips made to illustrate these decisions and impact on their quality of life. NVivo software was used for qualitative analyses. A Response Shift theoretical model guided the qualitative data analysis providing a mechanism to assess behavior patterns to adapt to changes in health across life trajectories.
Results: Bladder (42%) and bowel (43%) incontinence were the most prevalent problems reported. Treated Urinary tract infections (UTIs) were reported by 56.4% of the sample during the past year while 58% reported urinary incontinence monthly. Factors associate with UTIs included being >55 years old, female, having complete injuries, using opioids and also having bowel incontinence. Fear of re-infection by catheter was mentioned in several cases impacting decisions of bladder management method. From a bowel perspective, major complications included: 25% abdominal bloating, 23% liquid incontinence, 20% solid incontinence; 25% abdominal pain. Risk factors for bowel incontinence included irregular timing of bowel program, presence of constipation, excessive diuretics, high frequency of urinary incontinence. Patients' decisions with respect to managing their bladder and bowel to avoid accidents and increase social participation are discussed through alive video clips and patients’ testimonials. Of special interest are issues related to decisions about getting a colostomy. Patient decisions were made mainly based on how easy these were to implement, cost of implementing them and availability of resources. Social and physical attributes were also considered. Trusting their doctors and having support from family and friends was a key factor when making informed decisions. Results show that the presence of complications related to neurogenic bladder and bowel in SCI is a critical issue for clinical care impacting these patients’ quality of life and well-being, including their decisions with respect to how best address these. Overall, decisions were guided by the need for physical independence and autonomy for most patients. Implications for clinical practice guidelines will be discussed.