Introduction
The increasing processing power of smartphones and tablet computers and the price drop of inertial measurement units (IMUs) allows for gait analysis in everyday conditions. Real-time calculation of movement parameters opens new therapeutic options by providing patients with sensory impairments feedback (FB) about the deviations from a physiological gait pattern. Within the research project RehaGait, a mobile feedback therapy system with shoe-mounted IMUs that wirelessly communicate with a tablet computer was developed. The aim of the clinical evaluation of RehaGait was to investigate the feasibility and to generate preliminary data on the efficacy of this novel therapy in end users with incomplete spinal cord injury (iSCI).

Methods
In a non-controlled proof-of-concept study, feedback (FB) by tablet computer-generated verbalized instructions was given to individuals with iSCI for normalization of one individually selected gait parameter (stance/swing phase duration, stride length, or foot-to-ground angle). The training phase consisted of 3 consecutive visits. Four weeks post training a follow-up visit was performed. Visits started with an initial gait analysis (iGA) without FB, followed by 5 FB training sessions of 2-3 min and a GA at the end (pGA). A universal evaluation and FB scheme based on equidistant levels of deviations from the mean normal value (1 level = 1 standard deviation (SD) of the physiological reference for the FB parameter) was used for assessment of gait quality as well as for automated adaptation of training difficulty. The frequency of verbal feedback was dependent on the mean norm deviation (max. every third stride). Overall changes in level over iGAs were detected using a Friedman’s Test. Post-hoc testing was achieved with paired Wilcoxon Tests. The users’ satisfaction was assessed by a customized questionnaire.

Results
Individuals with iSCI (11f, 53±18 years, 6 cervical, 6 thoracic, 3 lumbar) were all classified as AIS D at the time point of inclusion (57±132 months post injury) with a lower extremity motor score of 40.7±6.7.
Foot-to-ground angle was most often used as feedback parameter (N=11) and increased significantly towards the physiological reference (p = 0.0186) on the ipsilateral side between iGA1 and iGA3, as well as between iGA1 and iGA2 (p = 0.0244). On the contralateral body side, no significant increase was found. The groups had a high initial level (median 4, range 3-5) and experienced the highest reduction in levels on the first training visit. From the pGA after training visit 3 to the GA at follow-up 4 weeks post training, the group showed a further decrease of 1 level.
Participants (N=14) reported to be very satisfied (mean Visual Analogue Scale = 0.9 (max. 1.0) with the system and rated efficacy as most important priority of its use.

Conclusion
The study results show that mobile, real-time, verbalized feedback is feasible and that ambulatory persons with iSCI can actively normalize the feedback gait parameter with the RehaGait system. Positive carry-over effects persist after the therapy. The results form a first basis for using real-time feedback in task-specific motor rehabilitation programs.

Introduction
Persons with spinal cord injury (SCI) are prone to develop an inactive lifestyle after injury, demanding the promotion of physical activity to improve health and physical fitness. Little is known about alterations in physical fitness and activity levels after an incomplete SCI. The objective of the study was to investigate the changes in physical capacity and activity level during the first year after discharge from inpatient rehabilitation in ambulatory persons with SCI.

Methods
Thirty persons (25 males and 5 females, 18-69 years of age) receiving inpatient rehabilitation at Sunnaas Rehabilitation Hospital, with incomplete SCI (AIS D) were followed for 12 months. Those who were able to walk for 5 minutes on a treadmill (at 3 km/hour walking speed) without assistive walking aids were included. Participants were originally recruited to take part in a twelve-week RCT with aerobic exercise intervention at high or moderate intensity. Due to similar between-group effects of the interventions and a high drop-out rate, the groups were merged for one year follow-up analyses.
Measurements were performed during the last week of inpatient rehabilitation and at one year follow up, including a maximal exercise test on a treadmill (peak oxygen uptake; peak VO₂), a 6-minutes-walking-test (6MWT) and seven days of continuously activity monitoring (in their home situation), measuring total daily energy expenditure (TDEE) and daily number of steps.

Results
Twenty of the participants performed both pre- and posttest. One year after discharge, the mean peak VO₂ had increased significantly by 0.26 liter/minute (95% CI: 0.01 – 0.51) Due to a significantly body weight increase (2.6 kilograms, 95% CI: 0.54 – 4.56), the mean peak VO₂ in ml/kg/minute had not change significantly (+ 1.9 ml/kg/minute, 95% CI: -1.0 – 5.0). Furthermore, participants walked on average 91 meters (95% CI: 5 – 52) more during the 6MWT. They did not show a significantly increased TDEE (+ 162 kilocalories, 95% CI: -34 – 358) or daily number of steps a day (+ 461 steps, 95% CI -1108 – 2033).

Conclusions
Ambulatory persons with SCI are able to increase their physical capacity levels during the first year after discharge from inpatient rehabilitation, despite unchanged activity levels. This might be important in order to maintain a physically active lifestyle.

In the control of assistive exoskeletons for walking, the possibility of adapting robotic assistance based on specific residual functional and motor abilities of the user is crucial to optimize Human-Robot Interaction. Moreover, specific training of the users in exploiting robotic support might have a significant impact on the resulting walking capabilities. In the context of the European Union research program FP7-ICT (SYMBITRON grant #611626), the Achilles exoskeleton was used to assist ankle plantar/dorsiflexion during walking in subjects with Spinal Cord Injury (SCI). A sensorized insole lying in the foot shell is used to detect foot contact and hence gait phases. Achilles includes a compliant linear actuator for accurate control of ankle assistive torques. On top of the low-level torque controller, a high-level NeuroMuscular Controller (NMC) is implemented. NMC is based on a reflex-based neuromechanical simulation of walking. The controller uses joint angles and gait phases sensors as inputs and produces as output joint torques to be delivered by the exoskeleton. This controller allows for exerting appropriate assistance at different walking speeds.
We tested the Achilles exoskeleton on four SCI subjects, with cervical/lumbar lesions, AIS level C/D. Achilles assistance, provided bilaterally, was customized for each subject according to the resulting gait speed and to subjects’ perception of safety, usability and comfort. Ten experimental sessions were performed to train the subjects in improving their capability of exploiting exoskeleton assistance and in increasing their walking performance. Walking speed, measured using Achilles, was considered the primary outcome of the training efficacy. Before the training (T0), after 5 (T1) and after 10 training sessions (T2), gait speed was measured by force plates (P6000, BTS Bioengineering, Italy). Step length/width and stance phase percentage as well as 10 Meter Walking Test (10MWT) and 6 Minute walking test (6MWT) were also recorded. Furthermore, 10MWT was performed with and without the use of the Achilles, before and after each training session. At T0 and T2 force, spasticity and pain assessment were evaluated by means of clinical scales.
The tuning of the controller setting appeared to be in line with functional clinical needs: in case of reduced force, a higher level of NMC assistance was selected. Results showed that all subjects improved gait speed, particularly between T0 and T1. Step length increased already at T1, while step width reduced, thus suggesting a better balance control. Stance phase duration was also more physiological at the end of the training. Results of tests without the use of Achilles highlighted a progressive improvement in the performance, more evident during the first 5 training sessions, suggesting an early effect of training on gait performance, even during unassisted walking. 6MWT also improved, already at T1. No significant variations for muscle force, spasticity and pain were recorded.
Results suggest that Achilles training was effective in improving users’ capability of walking at higher speed and 5 sessions were already sufficient to allow a better exoskeleton control. Moreover, even if Achilles is an assistive exoskeleton, a slight unexpected rehabilitation effect was also observed.

Introduction:
Cervical injuries can be treated with anterior or posterior stabilization alone or combined anterior and posterior approach. There is no consensus over line of management in cervical spine injured patients. There is high Biomechanical and clinical data conflict regarding the appropriate approach and method of fixation in traumatic cervical spine injuries especially when it comes to junctional injuries. The primary objective of this study was to report the incidence of radiographic failure following anterior cervical osteosynthesis in cervical trauma patients and to look for factors that would predispose to this loss of alignment.

Methods:
Inclusion criteria included all Cervical traumatic injured patients admitted at Indian Spinal Injuries center in one year treated by only anterior approach under single surgeon. Pathological and other non-contiguous cervical spine fractures are excluded from this study. Radiographic failure was defined as a change in translation of greater than 4 mm and/or change in angulation of greater than 11 degrees between the immediate postoperative films and the most recent follow-up.

Results:
84 patients were included in this study and we have reported 10 failure cases following anterior only approach. Out of 84 patients,72 were male patients and 12 were female patients. A 8.4% incidence of radiographic loss of alignment is reported in our case series following cervical anterior plate fixation in traumatic cervical spine injuries . Failures were most commonly seen in young adults, especially in second and third decades of life. Flexion distraction type of injury showed the maximum number of failures (60%) following single approach in our series. Six failures were seen at C6-C7 level followed by 4 at C5-C6 level. Failures were seen in patients who underwent copectomy alone.

Conclusion:
Concern regarding mechanical failure of single level cervical spine injuries should be high when they are treated with single approach. Corpectomy in presence of facet fracture’s or bilateral facet dislocation is an indication for combined fixation.Corpectomy at junctional area is also an indication for combined fixation.

Introduction
In 2011 a clinical prediction rule for ambulation outcomes 1-year after traumatic spinal cord injury which was reported by van Middendorp, et al. This method has attracted international attention not only because it consists of only five factors, namely age, motor scores of the quadriceps femoris (L3) and gastrocsoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1, but also because it is easy to use from the acute phase. Many reports have verified prediction accuracy in the U.S. and countries in Europe, however, there are no verification reports using large scale clinical data in Japan.
The purpose of this study is to verify the accuracy of the prediction rule by van Middendorp applied to Japanese patients using clinical data of patients with traumatic spinal cord injury in Japan.

Methods
556 patients admitted to the Spinal Cord Injuries Center in Japan between January 2012-March 2019 with traumatic spinal cord injury, and age 18 years and older were targeted. Patients were excluded if they had a non-traumatic SCI, if they did not have a neurological assessment within 15 days post injury or a follow-up mobility status measure at 6-months or later post injury. These criteria were set to match the inclusion and exclusion criteria used by van Middendorp et al. as closely as possible. Independent walking 1-year after injury was judged as follows. To distinguish between individuals who could walk indoors independently and those who could not, a cutoff the Spinal Cord Independence Measure indoor mobility item score (SCIM item12, ability to walk<10 m) was applied; scores 0–3 were grouped and defined as unable to walk or dependent on assistance while walking and scores 4–8 were grouped and defined as able to walk independently. Using the prediction rule by van Middendorp, the area under the ROC curve (AUC) was calculated according a receiver-operating characteristics (ROC) curve. All data related to this study was extracted from the Japan Single-center Study for Spinal Cord Injury Database (JSSCI-DB). Statistical analyses were done with the MATLAB software package version 2019a.

Results
Final effective data were 151 persons (122 men: 29 women, average age 59±15). Among these, 66 persons were 65 years or older (44%), and 43 persons (28%) could independently walk 1-year after injury. AUC obtained by this study was 0.884, with a 95% confidence interval (CI, 0.826-0.926). This was a lower tendency than the van Middendorp model (AUC 0.956, CI 0.936-0.976), but moderate accuracy was observed.

Conclusion
The prediction rule by van Middendorp had moderate accuracy even in patients with traumatic spinal cord injury in Japan and considered useful as a tool to comprehensively predict patient outcome. Since this was a single facility study, future verification which includes multiple facilities, in order to establish a more accurate prediction rule that targets patients with traumatic spinal cord injury in Japan, is desired.