Introduction: The aging society in industrialized, high-income countries is characterized by shifting patterns of etiology, pre-morbidity and associated complications of traumatic spinal cord injury (tSCI) restricting therapeutic opportunities and advocating for more individualized approaches in surgical and rehabilitative care and clinical research.

Methods: In a level 1 trauma center with specialized SCI care in Germany, 321 consecutive patients were enrolled from 2011 to 2017 for differential explorative analysis of age-related effects on etiology, pre-morbid conditions, surgical management, SCI-specific complications, neurological outcome, and socioeconomic aspects of tSCI. The study population was divided by median and quartiles into ‘young’ (14.1 to 42.4 years), ‘middle age’ (42.5 to 57.3 years), ‘older’ (57.4 to 74.1 years) and ‘very old’ (74.2 to 98.2 years) cohorts. Outcome analyses were stratified for the ASIA impairment scale (AIS). Adjusted logistic regression models were calculated to estimate whether associations of age with AIS conversions were independent of sex, injury severity, neurological level, additional traumatic brain injury, delay in hospital admission, and crucial outcome modifying factors (e.g. pulmonary infections).

Results: The median age in the study population is 57.3 years. The frequency distribution of age plateaus between 45 and 65 and peaks at 80 years. The major cause of tSCI is shifting from traffic accidents in ‘young’ (38.8%) and ‘middle age’ patients (39.5%) to falls in the ‘older’ (66.3%) and ‘very old’ patients (83.7%). Age is significantly associated with higher rates of pre-morbidities, secondary referral to specialized SCI care, delay in spinal surgery, prevalent pulmonary and gastrointestinal infections as well as elevated mortality. In the adjusted regression model for analysis of neurological outcome, the risk for non-conversion in the AIS in incomplete tSCI is exemplified by an OR of 7.31 (95% CI, 1.75-30.53) in ‘very old’ compared to ‘young’ patients (p=0.006). Furthermore, in complete tSCI the total stay in acute care is prolonged in ‘older’ patients with a median of 123.3 (interquartile range, 92-171.2) compared to 112.9 days (74.9-142.0) in ‘young’ patients. In incomplete tSCI the length of stay in ‘very old’ patients is 57.4 (49.8-77.3) days versus 39 (18.7-61.3) days in ‘young’ patients. The cumulative treatment costs in complete tSCI are higher with a median of 113,500 (interquartile range 67,500-151,800) EUR in ‘older’ patients versus 98,400 (50,900-120,500) EUR in ‘young’ patients. In incomplete tSCI patients the costs are 47,100 (36,000-58,900) EUR in ‘very old’ versus 31,100 (23,000-50,500) EUR in ‘young’ patients. The majority of complete tSCI patients of all age groups is staying in a rehabilitation center (72 of 90, 80%) or their private residence (13 of 90, 14.5%) after discharge from acute care and only a minority of cases (5 of 90, 5.5%) is living in a nursing home or hospital. The results analyzing incomplete tSCI patients are similar and the majority of patients is eligible for inpatient rehabilitation including the ‘very old’ cohort.

Conclusions: The aging society impacts on management algorithms, complications, neurological outcome, and treatment costs of tSCI. Age-associated increase in economic burden must be weighed against the comparatively high rehabilitation potential of elderly tSCI patients.

Objective: The impact of pediatric onset spinal cord injuries (SCI) acquired is particularly pronounced given their long lifespan and potential consequences for psychosocial development and secondary health conditions. The objective of this study is to explore a wide spectrum of outcomes of 30-year survivors of pediatric onset SCI and to delineate factors associated with quality of life, employment, and independent living.

Design/Participants/Methods: Structured telephone interviews completed approximately annually on 490 adults who had sustained pediatric onset SCI. Subjects of this presentation include 63 individuals who survived for at least 30 years. Participants completed measures relating to injury characteristics, secondary health conditions, and psychosocial functioning (education, employment, independent living, marriage, children, and quality of life). Data analyses included descriptive statistics and univariate analyses of factors associated with quality of life (Diener’s Satisfaction with Life (SWLS)), employment, and independent living.

Results: For the 63 participants, mean age at their last interview = 44.3 years (SD = 6.5, range = 30-52); mean duration of injury = 33.6 years (SD = 3.2, range = 30-46); 62% male; 48% tetraplegia, 62% complete injuries. Most common secondary health conditions were: pressure injuries (29%), urinary tract infections (UTI) (65%), pain (88%), chronic medical conditions (41%), depressive symptoms (33%), anxiety (14%), and poor sleep quality (63%). 56% had achieved a bachelor’s degree or higher, 54% were employed, 79% lived independently, 38% were married, and 22% had children. Employment was associated with younger age of injury, shorter injury duration, complete lesions, paraplegia, college degree, marriage, living independently, and fewer secondary health conditions (pressure injuries, pain, UTI, hospitalizations, poor sleep). Living independently was associated with being employed, college education, marriage, having children, and fewer secondary health conditions (anxiety, poor sleep, pain, pneumonia). Higher quality of life was associated with employment, marriage, and fewer secondary health conditions (anxiety, depression, pain, hospitalizations, chronic medical problems).

Conclusion: Thirty-year survivors of pediatric onset SCI experienced a significant number of secondary health conditions, demonstrated a high level of educational achievement, and a relatively low level of employment, independent living, and marriage. Despite these challenges, they experienced a relatively high level of life satisfaction. This data should help inform management of those with pediatric onset SCI throughout their lifespan with the goal of improving psychosocial outcomes and minimizing secondary health conditions.

Introduction: The acute care hospitalization represents a crucial part of the clinical pathway following a traumatic spinal cord injury (TSCI). Not only is it where the surgical treatment is being performed, but it also represents a unique period to optimize functional recovery early in the rehabilitation process. While current guidelines recommend initiating the rehabilitation process as early as possible following TSCI, the role of the acute rehabilitation team is still largely unknown.Accordingly, the aim of this study was to identify factors predicting functional outcome at discharge from acute care following a TSCI, focusing on modifiable factors that could be addressed and optimized.In addition, modifiable factors associated with the acute care length of stay (LOS) were investigated as a secondary objective.

Methods: A prospective cohort study including 61 patients admitted to a single Level-1 SCI-specialized trauma center between March 2017 and October 2018 was completed. The primary outcome was the functional score at discharge from acute care, as measured by the Spinal Cord Independence Measure (SCIM-III). The secondary outcome was acute care length of stay. Univariate and multivariate linear regression analyses were performed to determine the association between non-modifiable factors and the total SCIM score, whereas univariateand hierarchical multivariate linear regression analyses were used for modifiable factors (surgery and admission delay, occurrence of acute complications, length of stay (LOS), daily therapy time (occupational and physical therapy)). The same analyses were performed for the LOS.

Results:The mean total SCIM score at discharge was 42.1 ±25.2 after a mean acute care LOS of 22.7 ±14.4 days. Severity and level of the TSCI are significantly correlated with total SCIM score in bivariate analyses. Longer LOS is significantly associated with poorer functional outcome at discharge from acute care. When controlled for the severity of the TSCI, greater admission delay to our SCI-specialised level-1 trauma center and the occurrence of medical complications (pressure injury, pneumonia and urinary tract infection) resulted in longer acute care LOS.

Conclusions:This is the first study to describe and identify modifiable factors influencing the early process of functional recovery following a TSCI. Our results highlight the importance of early transfer to SCI-specialized trauma centers. Indeed, the presence of skilled comprehensive medical and rehabilitation teams who better understand the specifics of TSCI management and where all caregivers actively participate in the functional recovery of patientsis crucial.In light of our results, we suggest that the acute rehabilitation team may optimize the functional status early in the recovery process by focusing on medical complications prevention, prompt medical stabilization and by promoting a multidisciplinary approach towards achieving patients’ functional goals.Finally, functional gains during the acute care hospitalisation might be underestimated by current functional scales as interventions done during acute rehabilitation are aimed towards ensuring the patient has strong foundations to undertake efficient IFR in order to maximise functional recovery potential.

Introduction
In the field of spinal cord injury (SCI), there are multiple, independent databases containing information on neurological and functional recovery, but data cannot be pooled or compared due to differences in how function is measured. For example, the two largest databases, the United States based Spinal Cord Model Systems (Model Systems) and the European Multicenter Study about Spinal Cord Injury (EMSCI) use slightly different functional outcome assessments. A crosswalk (where scores from two separate assessments are linked or converted to a common metric) is needed to allow comparisons. Thus, the primary objective was to create a crosswalk between the Functional Independence Measure (FIM) and the Spinal Cord Independence Measure III (SCIM III) for items reflecting voluntary motor function.

Design/Method
Common person equating, in which the instruments are administered to the same group of individuals, was used to create and validate the crosswalk. The Swiss Network of Spinal Cord Injury database (Swiss) (n = 663) was used to develop the crosswalks. The Rick Hansen Spinal Cord Injury Registry (n = 557) and data from the United States based SCIM III reliability study (n=390) were used as validation databases. Only FIM and SCIM III Items reflecting voluntary functional movement were considered, as they reflect a similar construct. Three conceptually different crosswalk methods were used. 1) Expert panel evaluation where experts in the field establish equivalency for similar items and scores from FIM and SCIM III, developing a third common scale. Individual FIM and SCIM III administrations were then re-coded to the common scale; 2) Equipercentile equivalency in which a crosswalk was developed based on aligning total score distributions and rank ordering both FIM and SCIM total scores; 3) Rasch analysis based on co-calibrated item difficulties was used to co-calibrate the items from both instruments to develop the crosswalk.

Results
The expert panel evaluation method resulted in a correlation of 0.911 between the expert panel recalculated FIM and SCIM III scores.
The equipercentile method produced a correlation of 0.901 (p<0.01) between the original SCIM III scores and the equipercentile FIM to SCIM III converted scores. The correlation between the original FIM scores and the equipercentile SCIM III to FIM converted scores was 0.918 (p<0.01).
Rasch analyses resulted in a correlation of 0.917 for FIM to Rasch FIM scores, while the correlation for SCIM III to Rasch SCIM III scores was 0.897.

Conclusion
We demonstrated three viable methods to create a FIM/SCIM III crosswalk such that data collected on items reflecting functional movement with one measure can be converted to the other measure. This will allow comparisons of functional recovery across multiple databases reflecting different systems of care and rehabilitation approaches. The optimal crosswalk table will be presented.

Support
This project is supported by the Center for Large Data Research & Data Sharing in Rehabilitation and the Rick Hansen Institute.

Rehabilitation of subjects suffering from spinal cord injury (SCI) is a holistic and multidisciplinary process: it should take into account the functional recovery of damaged neural circuits and, at the same time, allow the acquisition of the best individual independence and the social reintegration.
Generally, the clinical assessment of cervical SCI subjects is performed according to the international standards for neurological classification (ISNCSCI) by upper extremity motor score (UEMS) assessment, but also the Graded Redefined Assessment of Strength Sensibility and Prehension (GRASSP) scale has been developed for a specific evaluation of strength, sensitivity and prehension. It consists of several sub-tests aimed at assessing strength in a greater number of muscles than the ISNCSCI, sensitivity, complex and fine hand movements. A further clinical scale, the Spinal Cord Independence Measure III (SCIM III), is specific for assessing functional recovery. Until now, very few studies assessed the evolution of neurological and functional recovery in cervical SCI subjects in order to identify a relationship between functional and neurological recovery and in relationship to different kinds of therapies
The aim of this longitudinal prospective open cohort study was to evaluate the progression of neurological and functional recovery in cervical SCI analysing also the relationship with conventional physiotherapy and occupational therapy the patients undergone to. To this scope, 7 subjects with cervical lesion (AIS level C or D), recruited at Spinal Cord Unit of IRCCS Fondazione Santa Lucia were enrolled and evaluated for at least 4 months. Every 2 weeks from admission until the time of discharge, patients were evaluated by the UEMS of the ISNCSCI scale and GRASSP scale (specific strength and sensitivity tests) for neurological assessment. GRASSP scale (specific hand function tests) and SCIM III scale were selected for functional assessments. Furthermore, the physical/occupational therapy effort the subjects undergone to were recorded per the amount (hours) and type of treatments. All subjects started physical therapy immediately, while occupational therapy one month after admission.
Comparison between neurological and functional recovery showed comparable time course and both progressively increased over the time starting from the first assessment. However a higher recovery degree was seen for the functional one. In fact UEMS improved by about 14,5%, GRASSP subscore for strength by about 25% and GRASSP subscore for sensibility by about 20%. As concern functional recovery improvement, it was about 35% for the prehension capacity and 24% for the prehension execution, while SCIM score upgraded of 18.7%. No relationship was found between the kind (and intensity) of rehabilitation (conventional therapy/occupational therapy) and neurological or functional outcome.
From data analysis, it seems that GRASSP is more sensitive than UEMS and SCIM to detect neurological and functional improvements. It could be hypothesized that the higher increase in functional recovery may be related to the patients' ability to develop and identify compensation strategies according to their residual sensorimotor capacities. Furthermore, this functional recovery seems not related to the type of therapy, but from the total amount of treatments.

BACKGROUND: the last decades have seen a dramatic change in the epidemiology of spinal cord injuries (SCI) in the Western world. In parallel with the aging of the general population, the age of new cases of SCI has also increased by about 20 years. Existing studies on the effect of age on outcomes seem to demonstrate that age has a negative effect on neurological and functional outcomes, but these data usually derive from retrospective studies, from a single center and with a limited set of outcome measures. Objective: the aim of the study is to investigate the effect of age on neurological and functional outcome of patients with traumatic SCI.

METHODS: data have been derived from the European Multicenter Study database about Spinal Cord Injury (EMSCI) which includes data of patients from 25 European centers. Patients are assessed at five time intervals after injury: within 15 days from injury, at 1, 3 and 6 months and 1 year. Each evaluation includes neurological data according to the International Standards for Neurological Classification for Spinal Cord Injury and the functional ones according to Spinal Cord Independence Measure. The walking ability is assessed with the Walking Index for spinal Cord Injury, the 10 Meters Walk Test and the 6 Minutes Walk Test. Statistics: patients have been divided into two age groups (< or > than 50 years) and selected according to a matching procedure based on lesion severity and neurological level of injury to obtain groups of patients as comparable as possible with the only difference of age. The comparison between the groups has been performed with the ANOVA with a within-group procedure to evaluate the progression of the groups and between groups to compare the outcome of the different age groups at each time interval.

RESULTS: the matching produced two cohorts each one made of 428 subjects (NLI: 299 cervical, 131 thoracic, 56 lumbar; AIS: 152 A, 36 B, 94 C, 144 D; age was 30.15 years in the young group and 63.9 in the old one). Both groups showed a significant improvement of neurological and functional status along time. No differences by age were detected for neurological measures, while significantly higher functional and walking scores were observed in the younger group compared to the older one.

DISCUSSION: Our results confirmed the negative effect of age on functional outcomes of patients with traumatic SCI. These findings are relevant to program rehabilitation admissions, to answer patient questions on the prognosis and to decide on the allocation of resources during rehabilitation stay and after discharge from rehabilitation. Our study has the advantage of: being derived form a large number of centers and having a high number of subjects that would increase the generalizability of the results and allow more refined analysis (for example to evaluate how age affect different groups of patients: tetra or para, complete and incomplete ones); being based on a complete set of measures to assess functional outcomes.