Objective: To describe the level of functional independence using spinal cord independence measure – self report (SCIM-SR) scores across 22 countries in relation to socio-demographics and injury characteristics, and its effects on to their activities and participation. The specific aims are as below:
Aim 1: To describe the level of functional independence in 22 countries using SCIM total score and sub-scores based on socio-demographics and injury characteristics.
Aim 2: To identify the effect of level of functional independence on participation in societal activities.

Design: Cross-sectional survey was undertaken in the community dwelling people with spinal cord injury (SCI).

Methods: The short version of the SCIM-SR was included in the survey. SCIM-SR score were derived (out of 66) and these scores were then rescaled to 100 for clinical interpretability. In addition, rescaled SCIM-SR scores were also categorised into 10 deciles for descriptive summary. Twelve items measuring activities and participation were included and were anchored on a Likert scale from ‘no problem’ to ‘extreme problem’. The results of the activities and participation items were presented as a mean total number of activities (out of 12). Data were presented as summary statistics (aim 1). We tested the causal effects of functional independence on activities and participation outcome by using directed acyclic graph (aim 2) to construct a plausible network of explanatory factors and determine minimal sufficient sets of adjustment factors. Correlated data analysis methods were used to account for clustering by country and/or region (mixed modelling or generalised estimating equation models).

Results: 12,591 persons with traumatic or non-traumatic SCI aged ≥18 years from 22 countries of six WHO regions completed the survey. The participants included males (73%) with traumatic and complete injury accounting for 81% and 38%, respectively. 63% are paraplegic. The median (IQR) age and duration post-injury was 52 (40-63) years and 9 (4-19) years, respectively. The median (IQR) SCIM-SR total score (out of 100) for the sample was 65 (41-80). The results of the survey demonstrated that participants in the lowest SCIM-SR decile (i.e., 0-10) reported moderate to extreme problem in performing a median of 9 on 12 activities and participation items. The result also suggested that with every 10 unit increase in SCIM-SR total score there is 11% (13 to 9%) reduction in the activity and participation items, when adjusted for age, assistance in daily activity, level and completeness of injury, duration post-injury and country of residence (important factor), using a negative binomial model (best fitted model).

Conclusions: The study found that there is an effect of functional independence on person’s level of activities and participation depending the country of origin. It is important that the inter-relationships between functional independence and activity and participation will then be further explored using path-analysis and structural equation modelling while taking into consideration factors including country of origin, sociodemographic and injury characteristics. This will allow us to better understand different level of functional independence and how it impacts overall participation for creating an effective Learning Health System for SCI.

Introduction: SCI imposes significant physical and health burden involving multiple organ systems and functional domains. At the organ level acute phase responses occur in the context of many physiological disturbances. Haemodynamic instability is a serious and common complication of SCI, which is additionally important in the context of acute phase response because it greatly reduces substrate exchange. Our preliminary analysis of pre-hospital triage records of a small SCI cohort uncovered significant univariable association between mean arterial pressure (MAP) and neurological function, inviting the notion that multivariable analysis should be used to ascertain whether such a relationship persists after controlling for the influence of potential confounders. The present larger-scale cohort study examined the influence of MAP on pre-hospital haemodynamic instability and neurological function, controlling for potentially confounding patient- and injury-related factors. Notably, after adjustment for age, injury level and time to first hospital there was a significant association between the lowest recorded (minimum) MAP observed in the prehospital period and preservation of motor function at acute admission with lower MAP readings associated with less-favourable motor functioning. This suggests the likely further benefit of countering detrimental hypotension by finding effective ways to apply early haemodynamic resuscitation.
Design: Multi-site, observational, retrospective
Aims: To examine the influence on the relationship between pre-hospital haemodynamic instability and neurological function of patient-, injury- and process of care-related variables.
Methods: Demographic, ASIA Impairment Scale (AIS) grade, triage interval and the physiological data of adults admitted with acute traumatic SCI were extracted from case-notes held at the Royal Adelaide and Royal Melbourne Hospitals, Australia. In assessing the relationship between pre-hospital MAP and admission AIS grade the statistical model controlled for age, gender, injury level (tetraplegia) and time elapsed between retrieval and hospital admission.
Results: The data of 107 SCI-ed patients, 40.7±20.5 years, 88 male, 65 AIS A or B, 84 tetraplegia were analysed. Mean triage interval was 2.0±1.6 hrs. Minimum (77.9 ± 19.0 mmHg) and mean preadmission MAP (83.4 ± 17.0 mmHg) values fell below recommended guidelines for maintenance of MAP between 85 and 90 mmHg. In multivariable analysis adjusted for age, injury level and time interval a 1 mmHg increase in minimum MAP was associated with a 6% increase in the odds of AIS grade C or D at admission (adjusted OR=1.06; 95% CI[1.02, 1.1]; p=0.002) Alternatively, a 5mmHg increase in minimum MAP associated with an average increase of 34% in the odds of grade C or D (adjusted OR=1.34; 95% CI 1.11, 1.61; p=0.002).
Conclusions: The spinal cord is exquisitely sensitive to CNS blood flow on which it is dependent for its health and integrity. In multivariable analysis systemic haemodynamic parameters were strong predictors of neurological function during acute phase response. An important consideration of using aggressive hemodynamic resuscitation is that increases in systemic blood pressure do not have to be large to impart considerable benefit with respect to preservation of neurological function. Strategies to use haemodynamic resuscitation to regulate organ level responses may need to take into account pre-hospital changes, which perhaps can be augmented pharmaceutically.

Introduction: Patients with complete paraplegia after spinal cord injury (SCI) are difficult to walk by themselves. Gait training with conventional orthoses requires excessive upper limb usage. Hybrid Assistive Limb (HAL) is a wearable robot suit that can assist voluntary hip and knee joint motion according to the wearer’s bioelectric activation.
HAL is able to sense very weak muscle activities; however, it is not applicable for patients with complete paraplegia without detectable muscle activation. We consider choosing other remaining muscle activities instead of paralyzed muscle as the trigger for paralyzed limb motion and we developed a new method: heterotopic triggered HAL method (T-HAL). This study aims to describe voluntary gait and voluntary knee extension using T-HAL method in patients with complete quadri/paraplegia after SCI.
Methods: Eleven patients, 18-67 years old, C5-T11, AIS A-B, were enrolled in this study. HAL session consisted of two parts: the first was voluntary ambulation using upper limb triggered HAL. In addition, for cases who could contract hip flexor, the second was done for active knee extension using hip flexor activation. Surface electromyography (EMG) was used to evaluate muscle activity of hip flexor and quadriceps femoris (Quad) in synchronization with a Vicon motion capture system. Clinical assessment with motion analysis was performed during HAL gait and voluntary hip flexion and knee extension test was also evaluated before and after HAL. The modified Ashworth scale (MAS) score was also evaluated before and after each session.
Result: In all cases, EMG before the intervention showed no activation in either Quad. However, periodic activation of the lower limb muscles was seen during HAL ambulation. In 2 cases, T10-11, active contraction in both Quads was observed after the intervention. Four cases with severe spasticity demonstrated significant decreases in the MAS score after the sessions compared to pre-session measurements.
Conclusion: T-HAL method might be a feasible option for rehabilitation in patients with complete quadri/paraplegia caused by SCI.

[Background] We are developing Qolo, a new personal mobility device for those with motor impairment in their lower limbs. It assists sit-to-stand and stand-to-sit postural transitions as well as navigation in standing posture with hands-free operation. Its mechanism to assist the postural transition is implemented with passive gas springs without using electric actuators, making it compact, light-weight and low cost. Hands-free navigation is operated by trunk manipulation in standing posture. The purpose of this study is to report clinical assessment of the device in voluntary sit-to-stand and stand-to-sit posture transitions and standing mobility of people with paraplegia due to complete and incomplete spinal cord injury (SCI).
[Methods] Qolo supports knee and hip motion of sit-to-stand and stand-to-sit transitions in accordance with antero-posterior tilting of the trunk. The alignment and specification of the gas springs and exoskeletal structure of Qolo is designed so that it extends the knee joint to assist sit-to-stand transition when the center of mass of the user is shifted forward and it flexes smoothly the knee joint when shifted backward. Eleven participants with SCI (age: 20-62y, 7 males and 4 females, acute 1 and chronic 11, neurological level: C5-L3, AIS: A-C, MMT Hip Ext.: 0-3, Knee Ext.: 0-5) were asked to conduct stand-up and sit-down postural transitions and navigate in a standing posture using Qolo. Feasibility of the assisted motions were evaluated.
[Results] Using the initial prototype of Qolo, lumbar and lower thoracic level participants (L3C and T10C, Hip MMT >=1, Knee MMT >=3) were able to conduct smoothly sit-to-stand and stand-to-sit posture transitions voluntarily. However, for the other participants (lumber level, AIS A and cervical level, AIC C) the spring force of the initial prototype was not enough, and therefore the springs were strengthened. Using the improved version of Qolo, all remaining nine participants, including lumbar level complete injury (T4A-T12A, Hip MMT<=1, Knee MMT<=1) and cervical level incomplete injury (C5C), were able to conduct voluntary and smooth sit-to-stand and stand-to-sit transitions, as well as navigation in standing posture on a flat floor using the hands-free control interface. One participant (T4A) needed a rigid trunk orthosis in combination with Qolo to carry out the motions.
[Conclusions] The results suggest that the improved version of Qolo is capable of assisting sit-to-stand and stand-to-sit posture transitions and standing mobility of people with lower limb motor impairment due to lumbar, thoracic and cervical level SCI. In this regard, Qolo has potential of providing an option of standing life for wheel chair users. Future investigations include improvement of belts and harnesses, and applicability of the device into the daily life environment.

Introduction: Most studies on neurological recovery after traumatic spinal cord injury (tSCI) assess treatment effects using the American Spinal Injury Association Impairment Scale (AIS grade) or motor points recovery. To what extent neurological recovery is considered clinically meaningful is unknown. This study investigated the perceived clinical benefit of various degrees of neurological recovery one year after C5 AIS-A tSCI.
Methods: By means of a web-based cross-sectional survey SCI patients and physicians evaluated the benefit of various scenarios of neurological recovery on a scale from 0-100% (0% no benefit - 100% major benefit). Recovery to AIS-C and D, was split into C/C+ and D/D+, which was defined by the lower and upper limit of recovery for each grade.
Results: A total of 79 patients and 77 physicians participated in the survey. Each AIS grade improvement from AIS-A was considered significant benefit (all p<0.05), ranging from 47.8% (SD 26.1) for AIS-B to 86.8% (SD 24.3) for AIS-D+. Motor level lowering was also considered significant benefit (p<0.05), ranging from 66.1% (SD 22.3) for C6 to 81.7% (SD 26 26.0) for C8.
Conclusion: Meaningful recovery can be achieved without improving in AIS grade, since the recovery of functional motor levels appears to be as important as improving in AIS grade by both patients and physicians. Moreover, minor neurological improvements within AIS-C and D are also considered clinically meaningful. Future studies should incorporate more detailed neurological outcomes to prevent potential underestimation of neurological recovery by only using the AIS grade.