Objectives: Previous research has demonstrated that there is a clear need for a Health Maintenance Tool, which can support people with SCI with different levels of health literacy and self-management capacity, particularly after discharge into the community. The tool should also support people with SCI to manage their five key areas related to bladder, bowel, skin, autonomic dysreflexia and pain, as well as provide strategies to their caregivers and primary health care providers.

Design: A mixed methods design including rapid reviews, interviews, focus-group discussions and a Delphi approach for building consensus (for bladder, bowel and skin) was undertaken. The study involved consumer group, primary care group (GPs), as well as expert group (SCI and other relevant experts). Interviews (involving consumers and GPs) and focus group discussions (involving consumers) data were analysed using thematic analysis approach using NVivo software. Delphi surveys (involving expert group) data were analysed using a consensus process and consensus were built on the
management recommendations, red flags condition, referrals and clinical pathways.

Results: Overall, 19 people with SCI, four GPs and 65 discipline and SCI-specific specialists participated in the
study. The 6 key themes derived from the qualitative analysis of the interviews and focus group discussion were (1) Where do I start? (2) Best counsel? (3) Sharing knowledge (4) Timely access for help (5) Shared decisions and (7) Promoting self-management. A total of 42, 36 and 61 statements were written for bladder, bowel and skin, respectively. Two rounds of the Delphi surveys were employed to achieve complete agreement.

Conclusions: The promotion and maintenance of optimal health and quality of life over the life span of an individual with SCI involves ongoing surveillance and prevention of secondary complications. This tool aids in supporting the self-management, provides essential knowledge and self-management strategies. A digitalised version of the tool is being proposed.

INTRODUCTION: In spite of recent advancement of medicine, an effective treatment for spinal cord injury (SCI) has not been developed yet. Accumulated evidences indicate that disruption of blood-spinal cord barrier (BSCB) contributes to the secondary damage following initial injury. Accordingly, protection of BSCB would reduce secondary damage, resulting in minimizing neurological deficits after SCI. However, the effective therapy to protect BSCB from SCI remains to be developed. The purposes of the current study are 1) to develop high-throughput screening assay (HTSA) for identifying candidate drugs to protect BSCB function, 2) to identify potential drugs to protect BSCB functions from toxic stresses and 3) to verify the protective effect of candidate drugs in mouse SCI model.

METHODS: Human brain endothelial cells (hCMEC/D3) were incubated on 96 well plates with various concentrations of hydrogen peroxide (H2O2) for 6 hours, and viability, cytotoxicity, and live/dead ratios were measured to determine the optimal condition for the HTSA. 3,200 existing drugs were screened using this newly developed HTSA, and one of the top hit drugs were subject to subsequent dose dependency and oxygen-glucose deprivation (OGD) tests. Then, mixture of endothelial cells (ECs), astrocytes, and pericytes from rat brains were cultured with or without a candidate drug under the OGD condition and trans-endothelial electrical resistance (TEER) and Na-F permeability were measured. Finally, C57BL/6 adult mice received intraperitoneal injections of a candidate drug or control. In the first experiment, the mice were followed by SCI by wire-knife one day later. The next day, subjects were perfused, and spinal cord sections were immunolabeled for IgG. In the second experiment, the mice had SCI by same method followed by 7 days of drug or control administration. After 8 weeks from injury, gait analysis (DigiGait® Mousespecifics) was performed, and the subjects were perfused for immunohistological evaluation (GFAP and NeuN).

RESULTS: 450μM was determined as the optimal concentration of H2O2 for HTSA, based on the fact that its Z’-factor, S/B ratio, and CV were 0.75, 2.9, and 4% respectively. Actual HTS identified 87 existing drugs (2.4%) as candidates for BSCB protection. One of the potential existing drugs, Berberine, an alkaloid compound extracted from natural herb, protected human ECs from the OGD stress in dose dependent manner. Moreover, Berberine maintained TEER and the Na-F permeability significantly more than a control under the OGD condition. Further, subjects treated with Berberine had significantly smaller IgG, GFAP positive area and narrower width of neuronal death (NeuN) than control subjects after SCI, and had improving effects on behavior, indicating its BSCB protection effect.

CONCLUSION: Collectively, these findings indicate that the newly developed HTSA can successfully identify candidate drugs to protect human brain ECs from toxic stresses and identified Berberine as a potential drug to protect BSCB functions from SCI. Currently, further screening is ongoing to identify other potential drugs to protect BSCB functions.

Introduction
Preoperative discrimination of spinal schwannomas and meningiomas is crucial because different surgical procedures are required for their treatment. A deep-learning approach based on convolutional neural networks (CNNs) is gaining interest in the medical imaging field. However, few studies using a CNN in the spine region have been reported. The purpose of the present study was to evaluate the performance of our CNN in differentiating between spinal schwannoma and meningioma on T2-weighted magnetic resonance imaging (T2WI) and contrast-enhanced T1-weighted magnetic resonance imaging (T1WI). We compared the performance of the CNN and that of two expert radiologists.

Methods
We retrospectively reviewed data from patients with spinal schwannoma and meningioma who had undergone magnetic resonance imaging (MRI) and tumor resection. Diagnoses were made upon histology of surgical specimens. There were 50 patients with schwannoma and 34 patients with meningioma. Sagittal T2WI and sagittal contrast-enhanced T1WI were used for the CNN training and validation. The Python programming language and deep learning framework Tensorflow from Google were used to construct the CNN architecture. To evaluate the performance of the CNN, we plotted the receiver operating characteristic (ROC) curve and calculated the area under the curve (AUC). Two board-certified radiologists reviewed MR images identical to those used to train the CNN. We calculated and compared the sensitivity, specificity, and accuracy of the diagnosis by the CNN and two radiologists.

Results
The AUC of ROC curves of the CNN based on T2WI and contrast-enhanced T1WI were 0.876 and 0.870, respectively. The sensitivity of the CNN based on T2WI was 78%; 100% for radiologist 1; and 95% for radiologist 2. The specificity was 82%, 26%, and 42%, respectively. The accuracy was 80%, 69%, and 73%, respectively. By contrast, the sensitivity of the CNN based on contrast-enhanced T1WI was 85%; 100% for radiologist 1; and 96% for radiologist 2. The specificity was 75%, 56, and 58%, respectively. The accuracy was 81, 82, and 81%, respectively.

Conclusions
In this preliminary study, we have successfully differentiated spinal meningiomas and schwannomas using the CNN with high diagnostic accuracy comparable to that of experienced radiologists. We supported the concept of applying CNN to spinal pathologies, even though the CNN was trained on a relatively small dataset of MRI images.

Introduction: Sleep problems are common in people with spinal cord injury (SCI). Most of published studies focus on diagnosis and treatment of SCI-related sleep disorders in health care providers’ perspective. This study aims to investigate a prevalence of sleep problems and its influencing factors in patients’ perspective by using data from the International Spinal Cord Injury (InSCI) Community Survey in Thailand.
Methods: This project is a part of InSCI Community Survey. Thai adults (age ≥ 18 years) with SCI who are community-dwelling were included in this study. Participants completed a set of questionnaires, including demographic and SCI-related data, the Spinal Cord Injury-Secondary Condition Scale (SCI-SCS) for detecting secondary conditions, the Model Disability Survey (MDS) for detecting psychological adaptation, the World Health Organization Quality of Life-BREF (WHOQOL-BREF) for detecting quality and satisfaction of life and the SF-36 Vitality Subscale for detecting energy and drive functions. Sleep problems were identified in those who had a sleep-domain of SCI-SCS score more than one. Chi-square was used to identify the univariate correlating factors and multivariate logistic regression analysis was used to identify independent influencing factors of having sleep problems.
Results: 320 Thais with SCI were recruited. The prevalence of having sleep problems was 56%. Using univariate analysis, having spasticity, pain, urinary tract infection and bowel problems were influencing physical factors of having sleep problems, whereas having stress-handling and interacting with people problems as well as low energy and depressed feeling were influencing psychological factors of having sleep problems (all factors p<0.05). Using multivariate logistic regression analysis, only pain problems (p=0.015), bowel problems (p=0.005), stress-handling problems (p=0.011) and depressed feeling (p=0.001) were an independent influencing factor of having sleep problems. In addition, people with SCI who having sleep problems had a significantly lower satisfaction with health score compared with those who not having (p=0.001).
Conclusions: From Thais with SCI’s perspective, sleep problems were common. It was influenced by both physical and psychological factors. To improve sleep functions and satisfaction with health of people with SCI, healthcare providers need to carefully identify and eliminate these influencing factors.

Introduction: The aim of the rehabilitation of individuals with SCI is to provide them with the highest level of independence in everyday life, and by this, to achieve the highest level of quality of life possible. However, it remains an open question if beside the intrinsic factor of functional independence also other extrinsic factors are related with the quality of life of individuals with SCI living in the community.

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 SCIM assessed in the European Multicenter Study about Spinal Cord Injury (EMSCI) including traumatic and ischemic related individuals with SCI. We aimed in analyzing the dependency between the most recent SCIM-SR, the last recorded SCIM by a health professional, the self-reported household size and income as well as the employment status on the overall perceived quality of life.
Correlation analysis was used to investigate the interdependency of the SCIM score at discharge, the SCIM-SR score at follow-up, self-reported individuals’ household size and disposable household income with the first item (QOL) of the World Health Organization WHO QOL short form inventory (WHO-QOL BREF). Contingency analysis was used investigating the impact of the employment status on the QOL.

Results: From a total of 1201 contacted individuals, 371 replies were received, corresponding a response rate of 30.9%. The average age at follow-up was 56.18 (SD 17.10) years. The average follow-up was 81.47 (SD 51.70) months. 105 individuals are classified as AIS A, 34 as AIS B, 50 as AIS C, and 167 as AIS D. The average WHO-QOL life satisfaction (0-5) was 3.43. The mean of the last SCIM (0-100) recorded by a health professional was 61.57 (SD 26.70) points, the average SCIM-SR at GerSCI follow-up was 58.80 (SD 24.33) points. In 47 cases, individuals were organized as one-person household and in the remaining 312 cases the average household size was 2.42 persons. In 111 cases individuals were employed. The average household income was between 1911 and 2339€ per month.

Correlation analysis showed a significant dependency of the SCIM scores at discharge (r= .228, p= .000), SCIM-SR score at follow-up (r= .307, p= .000) and the net-household income (r= .220, p= .000) with the reported QOL. Contingency analysis showed a significant dependency between employment status and QOL (Chi-Square(4)= 42.01, p= .000) showing a strong effect-size. No dependendy in contingency analysis to QOL was present for living alone individuals or household size.

Conclusion: Even if it remains debatable if a complex concept such as individuals’ well-being can be measured by a single item, our analysis clearly identified intrinsic and extrinsic covariates of QOL. Individuals’ quality of life correlated with the self-reported functional independence, the employment status and the available net household income.

Introduction: As a result of advances in healthcare and rehabilitation, many people with spinal cord injury (SCI) have lived several decades with their injury and into old age. Nevertheless, knowledge of living with long-term SCI into older age is very limited and there is no consensus on how to design rehabilitation interventions and follow-up programs to meet the specific needs of this group. In particular, little is known about changes over time in functioning and disability among older adults with long-term injury. We therefore initiated a large longitudinal study, the Swedish Aging with Spinal Cord Injury Study (SASCIS), including individuals at least 50 years old and at least 10 years after a traumatic or non-progressive, acquired non-traumatic SCI. The overarching aim of the SASCIS is to increase our knowledge of factors associated with healthy aging in persons with long-term SCI. The aim of the present longitudinal study from the SASCIS is to describe health-related quality of life (HRQoL) and changes over six years in older adults with long-term SCI, and investigate associations with sociodemographics (age, gender) and injury characteristics (time post injury, cause of injury, level and severity of injury).

Methods: From the original SASCIS sample (year 2011-2012) including 123 participants (29% women, injury levels C1-L5, AIS A-D, mean age 63 years, mean time since injury 24 years), 101 were still alive for the follow-up (year 2017-2018) and the final sample comprised 78 participants (32% women, injury levels C1-L3, AIS A-D, mean age 68 years, mean time since injury 31 years). Data were collected at home interviews using a study-specific questionnaire and the Spinal Cord Injury Quality of Life Questionnaire (SCI QL-23), including the domains physical and social functioning (Func), depressive feelings (Depr), perception of injury-related problems (Prob) and global QoL. Changes from baseline to follow-up were assessed using the Wilcoxon signed-rank test. Associations with changes in HRQoL (follow-up – baseline) were assessed with multivariable linear regression.

Results: The average rating of global QoL (scale range 0-100) was relatively high at both assessments (70 and 75, respectively), with large variability in all domains. There were no significant changes in any HRQoL-domain over six years, although the ratings at follow-up were slightly better in Depr and global QoL and slightly worse in Func and Prob. There were no significant associations between changes over time in Func and Prob and sociodemographics and injury characteristics. Regardless of the baseline rating of Depr and global QoL, a higher level and more severe SCI was significantly associated with positive change over time.

Conclusions: This is the first study to assess changes over time in HRQoL among older adults with long-term SCI. They exhibit large variations in all QoL-domains but maintain a relatively high and stable level of HRQoL over six years. Persons with AIS D injuries may need increased attention to mitigate negative changes in depressive symptoms and global QoL over time. Further studies are needed to identify modifiable factors associated with changes in HRQoL in older adults with long-term SCI.

Background: In 2017, new international scientific spinal cord injury (SCI) exercise guidelines (i.e. a fitness guideline and cardiometabolic health guideline) were developed by an international team. While these scientific guidelines were developed using a systematic and rigorous approach, additional knowledge translation (KT) steps were needed to translate and disseminate the guidelines to community and clinical settings. This paper presents the 5-step KT approach used to disseminate the international scientific SCI exercise to community and clinical settings across Canada.

Methods: A Canadian multidisciplinary team, including SCI researchers, people with SCI, representatives of SCI organizations, and clinicians, was established. The 5-step KT approach included: 1) Translation of the scientific SCI exercise guidelines into guidelines suitable for implementation and dissemination in clinical and community settings; 2) Development of a resource to support the implementation and dissemination of the guidelines; 3) Conduct of pilot tests (surveys and interviews) with a diverse group of potential end-users (e.g. people with SCI, family/friends/caregivers of people with SCI, clinicians, community SCI organizations) to test the usability, clarity and appropriateness of the guidelines and resource; 4) Development of a KT plan to disseminate the guidelines; 5) Monitoring and evaluation of the uptake and use of the guidelines and resource in community and clinical settings. The translation process and the development of the supporting resource (steps 1-3) were guided by an adapted version of the Appraisal of Guidelines, Research and Evaluation (AGREE) II Instrument. The development of the KT plan (step 4) was guided by a KT specialist using a structured KT support service. The dissemination and uptake of the guidelines (step 5) are being monitored and evaluated using the elements of the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation, Maintenance). Community-engagement strategies are being integrated throughout the KT activities.

Results: The first step resulted in the development of the “Canadian Spinal Cord Injury Physical Activity Guidelines”. These guidelines include a starting level and advanced level. The starting level is based on the fitness guideline. The advanced level is based on the combination of the fitness guideline and the cardiometabolic health guideline. The second step resulted in the development of online resource (www.sciguidelines.com) including educational information about the guidelines as well as motivational information on how to achieve the guidelines (e.g. activity examples, ways to overcome barriers). The third step showed that the guidelines and supporting resource were perceived as clear, useful and appropriate by potential end-users (n=90). Results related to the dissemination and uptake of the guidelines (steps 4 and 5) will be available in September 2020.

Conclusion: The systematic and community-engaged 5-step KT approach resulted in the development of the Canadian SCI Physical Activity Guidelines suitable for implementation and dissemination in clinical and community settings. This 5-step approach may help other groups across the world to disseminate the scientific SCI exercise guidelines to their local settings.

Introduction
In a clinical trial setting that is attempting to validate a therapeutic directed to the central nervous system (CNS), it is essential to correlate CNS changes to improvement in meaningful function. Most clinical measures do not have this capability, which creates serious problems for spinal cord injury (SCI) clinical trials. In response to the need for a clinical trial outcome measure that is standardized, administered by observation, and disallows compensation in scoring, work is underway to develop a SCI clinical trial outcome measure that is intended to evaluate recovery of neurotypical movement within the context of function. We describe the methods used to develop the fine motor domain of the Spinal Cord Injury Movement Index (SCI-MI), and report on initial beta-testing.

Methods
Mixed methods were used to identify, refine and test the SCI-MI fine motor domain. Consensus meetings (N=10) were conducted iteratively to identify candidate items from the Spinal Cord Injury-Functional Index (SCI-FI) that were amenable to administration and scoring by observation of performance. Of the 36 SCI-FI items, 9 were considered not amenable for a performance-based measure and/or beyond the scope of fine motor (e.g., removing something from back pocket). The remaining 27 SCI-FI items were retained for the SCI-MI and examined against an item map that was developed using the SCI-FI calibration study data. The item map provided reference for the hierarchy of items based on difficulty and discrimination. Items from other existing SCI measures were considered candidates based on item intent. Administration guidelines and scoring procedures for each item were developed through an iterative process of focus groups (N=2), beta-testing sessions with individuals with SCI (N=6), and input from experts in SCI rehabilitation. All focus group and beta testing sessions were IRB approved, video recorded, transcribed, and reviewed to inform iterative revisions the items and scoring procedures. Bi-weekly study team meetings further contributed to the iterative process used to refine the procedural guidelines for administration and scoring.

Results
The SCI-MI fine motor item pool consists of 35 unimanual and 16 bimanual items. Of the 51 items, 42 were modified from SCI-FI items, 2 were taken from the Graded Redefined Assessment of Strength, Sensibility and Prehension (GRASSP), and 7 were newly developed. Standardized administration procedures have been developed and beta-tested, including specifications about item intent. The Scoring algorithm is a 5-point scale where a score of “5” reflects neurotypical movement, “4” neurotypical movement with decreased quality, “3” and “2”, movement using some and all compensatory strategies, respectively, and “1” unable to do.

Conclusions
We have created an item pool for evaluating fine motor function. We are now confirming accuracy of administration and scoring, as a precursor to a calibration study. The calibration study will determine if the item pool meets the assumptions necessary for computer adaptive testing. Inclusion of GRASSP items may provide opportunity for future linking between the SCI-MI and GRASSP.

The study was funded by the Craig H. Neilsen Foundation

Introduction: Individuals with spinal cord injury (SCI) have an increased risk of infection and subsequent rehospitalization. Indeed, the incidence of death following SCI from septicaemia, pneumonia, influenza, and infections of the urinary tract system are significantly higher than in the general population. The heightened incidence of infection rates in individuals with SCI has been attributed, in part, to reduced sympathetic input to the immune system as a result of severed or damaged spinal nerves. Due to reduced sympathetic innervation to lymphoid organs (i.e. spleen, thymus), the immune system’s ability to respond to infection is blunted, leaving individuals immunosuppressed. It is possible that this immunosuppression could be exacerbated by exogenous stimuli, for example, a high-fat/high-carbohydrate processed meal; however, the effects of such a meal on immune function in people with SCI are unknown. The purpose of this study was to examine the effects of a high-fat/high-carbohydrate processed meal on leukocyte populations in adults with chronic SCI. It was hypothesized that the meal would increase numbers of circulating immune cells, congruent with a pro-inflammatory response.

Methods: Ten men with chronic (>1-year post-injury) traumatic SCI (M=15.5 years post-injury; 60% tetraplegic; 70% AIS-A) participated in a randomized crossover design trial with 7-day washout. Participants arrived fasted (≥ 12 hours) prior to both the control (quiet sitting, no food/drink) and experimental meal conditions (commercially available high-fat/high-carb breakfast wrap and hash brown: 880 kcal, 52g fat, 73g carbohydrates, 29g protein). Blood samples were taken in the fasted state and at 120 minutes post-baseline sample in both the control and meal conditions. Immune cell counts were assessed using multi-colour flow cytometry.

Results: Results indicate that overall, immune cells increased in number between baseline and 120 minutes in the control condition but not the meal condition. Using a linear mixed model, a significant Time x Condition interaction effect was seen in CD3+, CD4+, and CD8+ T cells as well as in CD16+ monocytes and CD65+ NK cells (p<0.05). CD14+/CD16+ monocytes and CD19+B cells showed a tendency towards a significant Time x Condition interaction (p<0.07). During the control condition, significant increases were seen in concentrations of CD3+, CD4+, and CD8+ T cells, along with CD14+ Monocytes, CD16+ Neutrophils, CD19+ B cells, and CD56+ NK cells from baseline to 120 minutes (p<0.05). No significant differences across time were seen in any of the aforementioned cells during the experimental meal condition.

Conclusions: The high-fat/high-carbohydrate experimental meal appeared to reduce the natural diurnal increase in circulating leukocytes seen in the control condition when fasting was extended by two hours. It may be possible that participants with SCI have a reduced ability to appropriately respond with an increase in immune cells following a high-calorie meal. Such blunting of the immune response may have potentially deleterious effects in a population that is already immunosuppressed. Future research could compare a fasting control condition with a range of experimental meals to determine the effects of varying food composition on immune cell numbers in individuals with SCI.