Introduction: In addition to paralysis and sensory loss, acute spinal cord injury (SCI) is accompanied by various other complications (eg. neuropathic pain, spasticity), which are managed with a variety of medications. Despite decades of clinical application, little is known about the impact of these medications on neurological recovery and the effectiveness of emerging therapies (e.g., stem cells).
Methods: We performed a secondary analysis of a completed clinical trial (Sygen) and an observational study (SCIRehab) to provide a comprehensive, structured overview of what constitutes “standards of acute pharmacological care” after SCI. We conducted an in-depth literature review to gather biological evidence of concomitantly administered medications with disease-modifying properties. Lastly, we searched the existing literature to determine which of the identified concomitant medications may alter the effectiveness of emerging investigational treatment strategies due to overlapping mechanisms of action.
Results: A total of 505 (Sygen) and 601 (SCIRehab) unique medications that were administered to treat secondary complications arising from 23 organ systems as well as for surgical and medical procedures. Individuals with SCI received, on average, a staggering 33 (range 1-61) unique medications over the first months post injury. Moreover, 230 studies were identified that provide evidence of disease-modifying properties (i.e., beneficial or detrimental) of 64 medications. Lastly, 201 concomitant medications were found to alter the efficacy of pharmacological, including Rhiluzole and Minocycline, as well as cell-based treatment strategies (e.g., Schwann Cells).
Conclusions: Our study revealed a dramatic polypharmacy after SCI that potentially impacts recovery and the effectiveness of novel treatments of SCI.

Introduction: As part of a Phase I clinical trial to assess the safety of autologous human Schwann cells (ahSC) in persons with chronic spinal cord injury (SCI), participants engage in a multimodal conditioning program pre- and post-ahSC transplantation. This includes a home-based strength and endurance training program with the goals of conditioning individuals prior to undergoing surgery and preventing lack of fitness and post-transplantation detraining from confounding potential ahSC therapeutic effects. This abstract describes the development of the home-based training program and outcomes for the first four participants of the phase I ahSC trial. Methods: The home-based program uses resistance bands and dumbbells and was modelled after a laboratory-based circuit resistance training protocol that improves muscle strength and cardiorespiratory endurance in both fit and unfit individuals with SCI. Two men with paraplegia completed an 8-week laboratory based ‘test’ of the home-based program (development phase). Each training session was performed 3 times weekly on non-consecutive days, lasted approximately 50 minutes, and incorporated both cardiovascular and strength training. Participants began by completing a 2 minute warm up at a low intensity on a stationary arm cycle, followed by 10 minutes at a vigorous intensity. They then performed three sets of 10-20 repetitions with no more than 20 seconds between each set for the six upper body strength exercises. Participants finished by completing 10 minutes of endurance arm exercise on the stationary cycle. The first four participant cohort of the ahSC trial (chronic thoracic injuries, 2 male and 2 female) completed the program at home for 12 weeks pre- and 20 weeks post-ahSC transplant (deployment phase). Results: In the development phase, both participants improved their peak aerobic capacity (VO2peak) (≥17%), peak power output (POpeak) (≥8%) and time to exhaustion (TTE) (≥7%). In the deployment phase, pre-transplant training induced a small fitness gain for the two male participants (≥6% POpeak and ≥9% TTE). All four participants detrained during the 4 week post-transplant recovery period. Average TTE and POpeak decreased by 14 and 9% respectively. After post-transplant re-training, all four participants increased TTE (4-24%), three increased VO2peak (≥11%), and two increased POpeak (≥7%). Conclusions: Home-based strength and condition programs can be successfully included in therapeutic SCI trials and can be effective to achieve target fitness goals. There were significant development and deployment challenges, such as maintaining stability of the wheelchair and individual while a using a load sufficient to elicit a training response, which any group wishing to mimic this program or approach should be prepared to address. Development and implementation of these programs requires substantial content knowledge and experience.

Introduction
A study from New Zealand in 2012 indicated that women with tetraplegia declined the possibility un-dergo upper-limb surgery to a higher degree than men. In New Zealand at that time mostly bilateral surgery is performed. In most other countries unilateral surgery is performed. There is no comparable data available investigating the womens ratio in other settings.
Since most people with spinal cord injury are men, general outcome after UL-surgery might not reflect women’s outcome. Women’s outcomes after hand surgery in tetraplegia have not yet been explicitly explored.

Aim
Describe the demographics of woman undergoing reconstructive hand surgery in Sweden and their functional and experienced outcomes.

Methods
All patients who underwent tendon transfer to restore grip- or triceps function or spasticity correcting surgery at C.A.R.E., Sahlgrenska University Hospital, Sweden, during 2006-2015 were included. Retrospectively analyse of functional and activity changes between pre- and post operatively on those who attended 12 months follow up. Age, time after injury and type of surgery were analysed.
Outcome measures for all surgeries were Canadian Occupational Performance measure (COPM). For triceps reconstruction muscle strength in triceps and for grip- and spasticity correcting surgery Grasp and release test (GRT), Jamar- and Pinch strength were recorded.

Results
During the time period 26% of the surgeries were performed on women (51 women and 145 men). There was no difference in time between injury and surgery or age at surgery between genders. Nor any differences between performed surgery types. In outcome, men got stronger in grip and pinch strength while women improved slightly more in skills, defined by grasp and release test (GRT). All participants improved significant in their prioritized activity performance and satisfaction with perfor-mance (COPM).

Discussion
One fourth of the surgeries performed were performed on women, which is similar to the incidence rate. We can therefore presume that women in Sweden choose to undergo surgery to the same extend as men. Additionally there were no delay to surgery or differences in type of surgery depending on gender. Both genders improve significantly from surgery, but in slightly different aspects.

Introduction: Patients who have artificial ventilation dependence are usually treated with mechanical ventilation. If their phrenic nerves and diaphragms are still functional, implanted diaphragm pacing (DP) can provide them a more natural respiration. Compared to classic mechanical ventilation, DP can increase autonomy, reduce health costs and infection risk, and can also help to significantly improve speech and recover some olfactory sensation. But existing DP systems cannot monitor patient’s induced respiration and stimulate at constant intensity and frequency. Therefore, many patients implanted with a DP system prefer to switch to a mechanical ventilation during night for safety reasons. A respiratory monitoring method based on recordings from tracheal sounds by microphone is introduced. This method aims at being ambulatory and non-invasive. Even though methods based on tracheal sounds have been studied earlier, especially for obstructive sleep apnea, there is still no monitoring application for all-day long real-time use, and even less for implanted phrenic nerve stimulation.

Methods: Tracheal sounds of one subject with tetraplegia under implanted phrenic stimulation (AtroStim®) were rec-orded for 30 seconds. Sounds were recorded by a microphone (pro-signal, ABM-705-RC) inserted into a 3D printed bell-shape support, which was stuck over patient’s neck. Recorded signals were filtered and pre-amplified by a custom made analog card, then saved and processed in a computer. One real-time processing algorithm is proposed in this study. This algorithm detected all respiratory events (inspiration, expiration and pauses/apneas) in both temporal and frequency domains, and then combined the results of these two detections for a better accuracy.

Results: For this recording, all 9 induced inspirations and 8 expirations were detected successfully. Four strong noises similar to respiratory events were eliminated. Stimulation signals were also recorded thanks to radiofrequency transmis-sion from stimulation system. The synchronization of stimulation periods and inspiration phases could be observed. There were also one small induced inspiration at the beginning of one stimulation period and another bigger induced inspiration at the middle of the stimulation period, and this phenomenon was not noticed before. One hypothesis is that the minimum stimulation intensity was set too high so that some muscle fibers could be active since the first minimum pulse of stimulation. Another hypothesis is that there may exist an asynchronisation between the stimulation of left and right lungs, one may contract earlier than another.

Conclusions: The proposed method can record respiratory information from tracheal sounds and allows the monitor-ing of electrical stimulation signals. The synchronization of respiratory sounds and stimulation signals, can help to veri-fy if patient’s inspiration is correctly induced, it can also help engineers to optimize stimulation parameters. The pro-posed detection algorithm showed a great accuracy, but was only applied on one recording of 30 s, more recordings with subjects implanted with phrenic nerve stimulation system are needed to validate the approach in different envi-ronments (noisy, speeches, movements …).

Introduction: At the 57th ISCoS Meeting in Sydney, a workshop for definition of clinical practice guidelines for patients with acute traumatic central cord syndrome (CCS) was organized. During an interprofessional discussion, it turned out that there is no consensus about the long-term neurological outcome and life satisfaction of patients with CCS.
A literature review done recently in March 2019 revealed that no evidence-based data about the correlation of the long-term neurological outcome, the functional independence and life satisfaction for patients with CCS exist.

Methods: In 2018, the German Spinal Cord Injury Survey (GerSCI) as part of the international InSCI study group performed a nationwide ICF-based multicenter survey. For three SCI centers (Bayreuth, Heidelberg and Ulm), the ICF-based GerSCI data including a self-reported spinal cord independence measure (SCIM-SR) were matched to each participant’s functional assessments of the European Multicenter Study about Spinal Cord Injury (EMSCI). Patients with CCS were identified based on the criterion of an upper extremity motor score (UEMS) of at least 10 points less than the lower extremity motor score (LEMS) at the latest available ISNCSCI examination (6 or 12 months after injury). Life satisfaction (WHO-QOL), functional independence measured by the SCIM-(SR), and impairment due to spasticity and pain were compared by Spinal Cord Injury Secondary Cormorbity Scale (SCISCS) between the CCS and non-CCS group.
In a first step a linear regression was performed for patients’ SCIM-SR at follow-up during the GerSCI-study with the latest documented SCIM from the EMSCI database. In a second step differences in life satisfaction, impairment of spasticity and pain as well as in the development within the SCIM-score between the CCS / non-CCS were analyzed by using the Mann-Whitney-U-Test.

Results: From a total of 359 patients, 23 (6.4%) met the criterion of CCS. The average follow-up for the CCS / non-CSS group was 66.61 (SD 52.55) / 82.49 (SD 51.56) months. The average age at GerSCI follow-up for the CCS / non-CCS group was 55.79 (SD 17.26) / 61.74 (SD 13.76) years. The rate of tetraplegia for the non-CCS group was 44.9%. The average WHO-QOL life satisfaction (0-5) was 3.50 for the CCS-group and 3.42 for the non-CCS-group. A Mann-Whitney-U-testing showed no significant difference for the WHO-QOL between the groups. While patients with CCS showed an improvement of their SCIM-SR to the 6/12-months SCIM scores of 6.25 points (SD 13.56), an average deterioration of -2.87 points (SD 16.82) was seen in the non-CCS group. This differences between the groups are statistical significant (p = 0.02; Mann-Whitney-U-Test). There was no difference in the perceived impairment due to pain and spasticity (SCISCS) between the groups.

Discussion: In contrary to the expert opinion expressed at the 2018 ISCoS Meeting, patients with CCS do not show a deterioration of functional outcome or life satisfaction over time. Actually, the CCS group reported a significant improvement of their SCIM scores compared to a deterioration in the sample with non-CCS SCI.

Introduction: Pregnancy in women with SCI presents unique challenges for both patient and healthcare provider. It requires close monitoring since it exacerbates many of the symptoms associated with SCI which affects pregnancy, delivery, the postnatal period and subsequently the children. Knowledge gaps exist in many areas of obstetrical and pediatric management for this patient group.

Aim: To study neonatal outcomes, growth development and duration of breastfeeding during the first six months of life in infants born to mothers with SCI.

Methods: This is a retrospective cohort study based on medical records. Participation was voluntary and mothers were recruited from the Spinalis Foundation’s networks. Inclusion criteria: Mothers with acquired SCI. Exclusion criteria: Mothers with SCI during pregnancy, intrauterine fetal death, congenital spinal cord injury. Mothers who met inclusion criteria and were included in the study submitted questionnaires regarding SCI level and completeness. The nationally adapted growth-chart for newborn males and females respectively was used as reference.

Results: A total of 67 delivery records and 32 medical records from child health care centers were collected and analysed with birth years ranging from 1976 to 2018 and located throughout Sweden. Term infants of both sexes with SCI mothers were smaller at birth regarding height and weight, when compared to reference data. The infants had a catch up within three months when no difference was to be observed. There was no difference in time spent fully or partially breastfeeding between the higher- (SCI at or above Th6) and lower lesion (SCI below Th6) group. However, the higher-lesion group had a shorter overall duration of breastfeeding than the lower-lesion group.

Conclusion: To our knowledge, this is the first study to investigate development during the first six months in children with SCI mothers. We conclude that the children, although term, are significantly smaller at birth compared to the reference population. The current data set is too small to identify possible background factors. The higher-lesion group stopped breastfeeding sooner after birth which is in line with previous research regarding breastfeeding with SCI. Further studies are warranted to corroborate these findings and elucidate possible reasons.

Introduction

Cachexia is a loss of lean tissue mass, involving a weight loss greater than 5% of body weight in 12 months or less. It is prevalent in most major diseases and is related with mortality and morbidity as well as poor quality of life. Many patients with spinal cord injury (SCI) experience rapid weight loss after injury, which might be associated with increased metabolic demand from severe trauma. Respiratory failure, decreased caloric intake related with swallowing difficulty and psychological factors may also contribute to weight loss after SCI. However, in these rehabilitation processes, the importance of weight management is frequently neglected. Therefore, this study aims to reveal the prevalence of cachexia in adults with SCI and weight changes and its associated factors following intensive rehabilitation therapy.

Methods
The medical chart of SCI patients who were admitted to tertiary university hospital for rehabilitation treatment from 2016 to 2017 was reviewed. Patients within 6 months after the onset, with available records of initial and follow-up body weight and body composition analysis by bioelectrical impedance were included.
Finally 114 SCI patients were included. Patients were divided into 3 groups by disease chronicity: acute (≤ 2 weeks), subacute (between 2-8 weeks), and chronic (> 8 weeks). Participants were also classified into 3 groups based on the weight change after the injury by comparing body weight prior to and after the injury at admission. The groups were defined as follows: cachexia, weight loss ≥ 5% body weight; precachexia, weight loss < 5%, and no weight loss. The prevalence of cachexia and precachexia, weight change after rehabilitation and its associated factors were analyzed.

Results
About 60% of subacute (63.7%) and chronic (59.3%) SCI patients and 25.0% of acute SCI patient within 2 weeks after onset showed cachexia. After an intensive rehabilitation treatment including nutritional care, cachexia group showed significant weight change (gain) compared to both precachexia and no-wt. gain groups (p<0.01). In cachexia group, percentage of weight change (weight gain) was negatively associated with the initial body weight (r=-0.412, p=0.001) and BMI (r=-0.482, p=0.000), and significantly positive association with the percentage increase of skeletal muscle mass (r=0.370, p=0.002).

Conclusions
The percentage of cachexia was consistently high in all groups of SCI. These results imply more concern on nutritional supplement is necessary in SCI patients depending on their metabolic demand in relation to physical condition and intensity of rehabilitation therapy. Further studies with more patients with various features of SCI injury (level, severity and chronicity) are necessary to demonstrate the risk factors of cachexia and related factors for better outcome.

Introduction: We previously demonstrated that step training leads to reorganization of neuronal networks in the lumbar spinal cord of rodents after a hemisection (HX) injury and step training, including increases excitability of spinally evoked potentials in hindlimb motor neurons.

Methods. In this study, we investigated changes in RNA expression and synapse number using RNA-Seq and immunohistochemistry of the lumbar spinal cord 23 days after a mid-thoracic HX in rats with and without post-HX step training.

Results. Gene Ontology (GO) term clustering demonstrated that expression levels of 36 synapse-related genes were increased in trained compared to non-trained rats. Many synaptic genes were upregulated in trained rats, but Lrrc4 (coding NGL-2) was the most highly expressed in the lumbar spinal cord caudal to the HX lesion. Trained rats also had a higher number of NGL-2/synaptophysin synaptic puncta in the lumbar ventral horn.

Conclusions. Our findings demonstrate clear activity-dependent regulation of synapse-related gene expression post-HX. This effect is consistent with the concept that activity-dependent phenomena can provide a mechanistic drive for epigenetic neuronal group selection in the shaping of synaptic networks and, thus, their functional properties with locomotor training after spinal cord injury.

Introduction
Deep sensory has considerable influence on independent walking ability with spinal cord injury, however, no previous studies are reported on the relationship between deep sensory impairment and walking ability in patients with spinal cord injury. The objective of this study was to analyze the impact of lower extremity deep sensory (knee joint movement sensation) impairment on walking ability of patients with incomplete cervical spinal cord injury (CSCI).

Methods
Between 2005 and 2016, we retrospectively reviewed 922 patients who were retrieved from our database. Patients who met following criteria were eligible; 1) admission within the first 2weeks and follow-up 6months post-injury, 2) CSCI, 3) Lower Extremity Motor Score (LEMS) at least 42 points. A LEMS threshold of 42 points or higher was set for all Patients because prior work has established that a LEMS of over 41.5 is necessary for functional walking in patients with incomplete CSCI. Given this, our use of patients with LEMS scores equal to or greater than 42 points ensured that lower extremity deep sensory impairment was the focus in terms of factors which impacted their walking ability. All the data utilized in the present study were based on patient outcomes as measured at 6 months post-injury. Patients were classified into two groups: deep sensory normal group and impaired group. We compared walking ability scores and independence levels of indoor mobility and outdoor mobility among two groups. Indoor and outdoor mobility from the Spinal Cord Independence Measure Ⅲ (SCIM) and the Walking Index for Spinal Cord Injury Ⅱ (WISCI) were utilized of walking ability scores. Indoor and outdoor mobility scores of 4 points and more in SCIM were classified as independent walking. Mann-Whitney U test was used to assess differences in walking ability score and LEMS, Upper Extremity Motor Score (UEMS) between the two groups. Fisher’s exact test was used for the comparison of walking independence level.

Result
63 patients were included in analysis (Normal group: 47 subjects, Impaired group: 16 subjects). Statistical analyses of LEMS and UEMS were conducted to confirm that no significant differences existed in extremity functionality of both groups (LEMS: p=0.16, UEMS: p=0.86). The walking ability scores was significantly lower in the impaired group compared with the normal group in all evaluations of indoor mobility (p<0.01), outdoor mobility (p<0.01), and WISCI (p<0.001). Only 10 out of 16 subjects from the impaired group attained walking independence (62%) compared to 42 out of 47 subjects in the normal group (89%), with a significantly worse indoor mobility independence level in the impaired group than in the normal group (p<0.05). Outdoor mobility independence levels of the impaired group were significantly lower than those of normal group (p<0.01), with only 8 out of 16 impaired group subjects attaining independence (50%) compared with 41 out of 47 normal group subjects (87%). These indicated that the independence levels of outdoor mobility were especially reduced.

Conclusions
The effect of lower extremity deep sensory impairments was a critical factor on walking ability in patients with incomplete CSCI.