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A clinical prediction rule for ambulation
outcomes after traumatic spinal cord injury: A
longitudinal cohort study

Article in The Lancet · March 2011
DOI: 10.1016/S0140-6736(10)62276-3 · Source: PubMed

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no and 12 after injury. and June. Although on a second group of patients. 0·939–0·995. to walk is a high priority for such patients. 95% CI 0·936–0·976. individually tailored rehabilitation programmes varied in ently. John F Ditunno Jr. Dependent on level and severity of injury. within the EM-SCI network. prediction rule for a patient’s ability to walk independ. 2001. can give an early prognosis of an Balgrist University Hospital.5 Data for neurological and counselling and to design a personalised rehabilitation functional status were collected prospectively. 6. and Spinal Cord Injury Center. Temporal validation was done in a second group of Department of Rehabilitation patients from July. Netherlands. We tested the (≥18 years) patients with acute traumatic spinal cord 1004 www. 2008. and light touch sensation of Department of Rehabilitation dermatomes L3 and S1 showed excellent discrimination in distinguishing independent walkers from dependent Medicine. multicentre cohort study5 of a operative interventions to very early (<6 h after injury) representative European population with spinal cord surgical stabilisation and decompression of the spinal injury to develop an accurate and simple clinical cord.1016/S0140- 6736(10)62276-3 Methods We undertook a longitudinal cohort study of adult patients with traumatic spinal cord injury. validated prediction rule to assess a patient’s March 4. 2009. Thomas Jefferson excellent discriminating ability of the prediction rule (AUC 0·967. 6500 HB Introduction reproducibility and validity of the rule to predict an Nijmegen. for the EM-SCI Study Group Summary Lancet 2011. variables was derived from the international standards for neurological classification of spinal cord injury with a A J F Hosman MD. Philadelphia. Martin H Pouw. Because no proven effective treatment prediction rule for the ability to walk independently after is available. Model performances were quantified with respect to discrimination Epidemiology. A combination of age (<65 vs University Nijmegen Medical Centre. Funding Internationale Stiftung für Forschung in Paraplegie. 2011 chances of walking independently after such injury. gastrocsoleus (S1) muscles. PO Box 9101. with early See Comment page 972 (within the first 15 days after injury) and late (1-year follow-up) clinical examinations. Armin Curt. multivariate logistic regression model. per programme. 2011 .2 functional outcomes of patients with spinal cord injury After a spinal cord injury. (Prof A Curt MD) Correspondence to: Dr Joost J van Middendorp. Hendrik Van de Meent.thelancet. p<0·0001). within the first 15 days and at months 1. USA (Prof J F Ditunno Jr MD). A clinical prediction rule based on age and neurological (J J van Middendorp MD. individual’s ability to walk after traumatic spinal cord injury. p<0·0001). Primary outcome measure 1 year after injury was independent indoor walking M H Pouw MD). A Rogier T Donders. to December.4 However.com Vol 377 March 19. the frequency of such injury is low at 10·4–83 cases per million people worldwide. Details of applied treatments In this study we analysed data from a prospective. 377: 1004–10 Background Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to Published Online counsel patients and to plan rehabilitation. standards for neurological classification of spinal cord From the EM-SCI dataset we extracted data for all adult injury7 are used in the clinical algorithm. no treatment that results in major gathered a standardised dataset of neurological and neurological or functional recovery is available. Department of Orthopaedics. Jefferson Medical walkers and non-walkers (AUC 0·956. Radboud Findings Of 1442 patients with spinal cord injury. ≥65 years). Articles A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study Joost J van Middendorp. 2008. Biostatistics and HTA (A R T Donders PhD). Netherlands Traumatic spinal cord injury has a profound effect on individual’s ability to walk independently after injury jvanmiddendorp@gmail. Medicine (Prof A C H Geurts MD.com patients’ physical and psychosocial wellbeing. PA. 19 centres (five centres originally) have that show promise. which can be used to set rehabilitation goals and might Zurich. Temporal validation in 99 patients confirmed College.3 During rehabilitation. 492 had available outcome measures. Switzerland improve the ability to stratify patients in interventional trials. Alexander C H Geurts. Department of Orthopaedics 19 European centres between July. 2001. recovery of the ability protocol. including age and four neurological tests.2 treatment regimens are not standardised traumatic spinal cord injury is available. Age at injury6 and variables from the international focus and intensity. DOI:10. Department of based on the Spinal Cord Independence Measure. but ranged from non- longitudinal. a reliable prognosis of a as part of the European Multicenter Study on Human patient’s potential functional outcome is essential for Spinal Cord Injury (EM-SCI).1 Study design and patient population Despite advances in basic research into spinal cord repair Since July. this devastating disorder Methods imposes a substantial burden on the health-care system. We developed a reliable. University. and (area under receiver-operating-characteristics curve [AUC]). Interpretation Our prediction rule. who were admitted to one of Spine Unit. H Van de Meent MD). motor scores of the quadriceps femoris (L3). Allard J F Hosman. 3. were not recorded systematically. Nijmegen.

6 Therefore. Polyneuropathy was tested by measurement of ulnar and tibial sensory Grade B nerve conduction velocity. The study protocol was approved by the local ethics Grade D committees of all participating centres. light touch sensory (LTS) and devices) pinprick sensory (PPS) testing (0=absent.8 we included only one of the two We applied a cutoff SCIM (Spinal Cord Independence Measure ) mobility score to sensory scoring systems in the initial model. and gave informed. Patients who were unable to cooperate with Spinal Cord Society neurological standard scale7 physical examination because of cognitive impairment Grade A (as assessed by the examiner). who were admitted between July. patients and maximum time efficiency for physicians. analysed for this purpose.thelancet.11.12 age was categorised into two groups: patients younger than 65 years and those aged 65 years and older.7 Examination included motor score testing 2: Moves independently in manual wheelchair (graded on a five-point scale adapted from the Medical 3: Requires supervision while walking (with or without Research Council scale). and Panel 1: American Spinal Injury Association/International June.8 Clinical assessments were done by trained and certified neurologists and Outcome assessment rehabilitation physicians with at least 1 year of experience The ability to walk independently 1 year after injury was in examination of patients with spinal cord injury. and those without a complete neurological Grade C assessment within the first 15 days after injury were Motor function is preserved below the neurological level. oral consent before entering the study. and the patients Motor function is preserved below the neurological level. To validate this approach the final model was tested clinical prediction rule with minimum burden on with the addition of PPS scores. total lower extremity motor score10) in analyses. to walking without aids. The Spinal Cord and sensory scores were recorded in the electronic Independence Measure indoor mobility item (SCIM EM-SCI database and the quality and correctness of the item 12. 2011 1005 . 1=impaired. we included only the best scores of we did not include aggregated neurological scores each level (ie. Because the PPS scores and the LTS scores are 8: Walks without walking aids highly correlated. right or left) of the lower extremity and (eg. at least half of key muscles below the neurological level have a muscle grade of 3 or more Prognostic variables Grade E For the prognostic model we considered patients’ age and Motor and sensory function are normal variables from their initial neurological examination. or who had neuropathy or polyneuropathy segments S4–S5 were not included in the EM-SCI database.7 Muscle testing was done in the supine 7: Needs leg orthosis only position. who had a peripheral No motor or sensory function is preserved in the sacral nerve lesion. 4: Walks with a walking frame or crutches (swing) and 2=normal). including 5: Walks with crutches or two canes (reciprocal walking) voluntary anal contraction and anal sensation (0=absent 6: Walks with one cane and 1=present). and sacral sparing scores. 2008.12 The SCIM indoor mobility Patients’ American Spinal Injury Association/ item ranges from total assistance. to wheelchair use. including conus medullaris and cauda equina injuries. ability to walk <10 m) was assessed and data were monitored centrally by a data quality manager. but the separation of dull and sharp sensation scale (AIS) grades were computed automatically is absent. item 12—mobility indoors11. and excluded from the analysis. For every patient. 0: Requires total assistance Neurological examinations were done according to the 1: Needs electric wheelchair or partial assistance to operate international standards for classification of spinal cord manual wheelchair injuries. Articles injury. diabetes neurological level and includes the sacral segments S4–S5 mellitus). and has www. 2001. Motor the primary functional outcome.9 Because an differentiate between patients who are unable to walk or are dependent on assistance while walking (scores 0–3) and those who are able to walk independently (scores 4–8).7 we used only the LTS scoring system in according to the international standards (panel 1). to International Spinal Cord Society neurological standard walking with aids.7 analysis because we thought it to be the least prone to Because the aim of this study was to introduce a simple error. The multicentre follow-up more than half of key muscles below the neurological level study was done in accordance with the ethics standards have a muscle grade of less than 3 in the updated version of the 1964 Declaration of Helsinki.com Vol 377 March 19. Patients with medical records Sensory but not motor function is preserved below the showing frequent causes of polyneuropathy (eg. Older patients (≥65 years) with spinal cord injury have less potential to translate neurological improvements into Panel 2: Spinal Cord Independence Measure functional recovery than do younger patients. LTS score of 0 means that light touch sensation is absent and a PPS score of 0 means that there could be local sensation. sacral scores for analysis.

18–89) distance (10–100 m. 2011 . or <15 days after injury). We applied an exhaustive model search in which all logistic 1442 patients with spinal cord injury regression models. which was defined as the area under receiver-operating-characteristics curve 492 with available outcome measures (AUC). the potential patients with spinal cord injury. 2001.7 *Number used to calculate proportions for other characteristics. 2009 and defined as able to walk independently (panel 2). Articles independently and those who could not. AIS=American Spinal Injury Association/International Spinal Cord Society neurological standard scale. including the model with the lowest Akaike 578 no neurological examination within the information criterion and those with a maximum of four first 15 days after injury points more. This curve shows a model’s ability to discriminate between patients who can walk independently after 1 year and those who cannot. and 1006 www. 0–15) 8·0 (4·6. we did an ancillary traumatic spinal cord injury* correlation analysis between the SCIM indoor mobility Sex (male) 504 (79%) 169 (79%) outcomes and ambulation outcomes for moderate Mean age at injury in years (SD. exact method. 0–15) In spinal cord injury research. 18–92) 47 (19. 2008. If any of these models had almost equivalent 64 measures not testable performances we selected the best one on the basis of the 640 with a complete initial neurological examination number of variables included (the smaller the better) and its ease of use in clinical settings. Positive and negative predictive values were calculated Data are n (%) unless otherwise stated. and occupational therapists AIS grade C 96 (15%) 46 (21%) who assessed the SCIM measurements were not masked AIS grade D 142 (22%) 57 (27%) to the initial neurological examination results. Because the neurological candidate predictors included Table 1: Baseline characteristics in analysis are highly correlated. The Akaike information 104 non-traumatic spinal criterion was calculated for each model to assess the cord injury goodness-of-fit.12 To distinguish additional predictive value of PPS scores.12 Mean timing of examination in days after 7·7 (4·7. Patients with tetraplegia 341 (53%) 114 (53%) Outcome measurements Statistical analysis 1-year follow-up measure 374 (59%) 54 (25%) A descriptive analysis of patients’ characteristics was Only 6-month follow-up measure 118 (18%) 45 (21%) done with absolute and relative frequencies for qualitative Individuals who can walk independently† 200 (41%) 43 (43%) variables and means (SD) for quantitative variables. as previously validated. were assessed. SCIM item 14).com Vol 377 March 19. First. The performance of each prediction rule was quantified by its discriminatory ability.8 AIS grade B 88 (14%) 26 (12%) Physicians.14 The smaller the number. 6-month follow- AIS grade A 314 (49%) 85 (40%) up measurements were used. physiotherapists. SCIM item 13) and outdoors ≥65 years 108 (17%) 49 (23%) (>100 m. to December. the more 1282 adult patients with accurate the model. The relative weighting of every variable included in the final model was based on each variable’s β value in logistic regression analysis. shown excellent reliability and construct validity in Several ancillary analyses were done. range) 44 (17.8 To Adults with complete initial neurological 640 (50%) 214 (55%) gain insight into the prospects of a patient being able to examination within the first 2 weeks after walk outdoors independently.15 Calibration of predictions was Figure 1: Selection of patients assessed graphically by plotting recorded frequencies against predicted probabilities. 148 without 6-month 374 with 12-month 118 with 6-month follow-up or 12-month follow-up follow-up measurements measurements only We calculated predicted probabilities on the basis of measurements these weighted values. 2008 July. 1-year follow-up injury (SD. with a maximum of seven predictor 56 aged <18 years variables. <72 h. a cutoff SCIM Derivation group Temporal validation group (n=1282) (n=389) indoor mobility score was applied. range) measurements are generally thought to be representative Examination <72 h after injury 123 (19%) 34 (16%) for the assessment of long-term outcomes. to June. several models with almost equivalent performances can be constructed. scores 0–3 were grouped and defined as unable to walk or dependent on Setting 19 European SCI centres 13 European SCI Centres assistance while walking and scores 4–8 were grouped Inclusion period July. We identified the most accurate traumatic spinal cord injury models.11.13 For patients Severity of initial neurological deficit without 1-year follow-up measurements.thelancet. †% is proportion of from contingency tables with 95% CIs with the binomial patients with available follow-up data. the timing of between individuals who could walk indoors examination (≤24 h.

for temporal validation. most significantly related to ambulation outcomes (webappendix pp 3–6 shows complete datasets of the The prediction rule distinguished well between those See Online for webappendix best models). and LTS at S1. the total sample was divided into (S1). the Total –10 40 performance of the clinical prediction rule was assessed for individuals with traumatic spinal cord injury who were Only the best score of each motor score or light touch score (ie. The clinical characteristics of individuals included in the analysis were much the same as those of 20 individuals excluded (webappendix p 1). data collection.7 Third. figure 1). 2008. The dotted consisting of age and four neurological predictors were lines are a visual aid to determine the probability of walking independently. independently 1 year after traumatic spinal cord injury Ancillary analyses showed that neither level of injury with the weighted coefficients of the final prediction rule (p=0·659) nor timing of examination (p=0·312) had a (table 2). The final model was selected on the basis patients who were able to walk independently and those of its simplicity of use and included age (dichotomised who were not (AUC 0·956. 2008. 2009.3. The addition of being able to walk independently with this predic.thelancet. 2011 1007 . 11 different models The shaded area around the curve is the 95% CI of the prediction rule based on the regression model. LTS at L3. The www. with a minimum total score of –10 and a significant additional value with respect to prediction of maximum total score of 40. 2001. Statistical analyses were done with the SPSS software package version 16.0. We estimated the four groups that contained roughly the same number of probability of an individual being able to walk patients (figure 3). To calculate the probability an individual’s ability to walk independently. or writing of 80 the report. 100 Role of the funding source 90 The sponsor of the study had no role in study design. of aggregated lumbosacral PPS scores to the final model tion rule score. right or left) included in the EM-SCI network between July. at 65 years) and four neurological predictors: quadriceps p<0·0001. The corresponding author had full access to all the data in the study and had final responsibility for the 70 Probability of walking independently (%) decision to submit for publication. the AUC of the newly derived prediction Age ≥65 years 0–1 –10 –10 0 rule was compared with the AUC of the AIS grading Motor score L3 0–5 2 0 10 system.com Vol 377 March 19. However. webappendix p 8). Finally. 640 had completely 40 documented neurological examinations assessed within the first 15 days after injury and were included for analysis 30 (table 1. No alteration in the prognostic score was Table 2: Clinical prediction rule variables allowed after temporal validation began.1. gastrocsoleus muscle grade of the prediction rule. and June. data analysis. Of 1282 adult patients with traumatic injury in the study population (table 1). 60 Results Between July.16–19 Second. Ambulation outcome measures were available in 492 patients (77%. we calculated the agreement between Motor score S1 0–5 2 0 10 dichotomous SCIM indoor mobility outcomes and Light touch score L3 0–2 5 0 10 moderate distance and outdoor mobility outcomes with Light touch score S1 0–2 5 0 10 the kappa statistic (κ). and should be applied for the prediction rule (see Methods). December. Figure 2: Probability of walking independently 1 year after injury based on the prediction rule score After logistic regression analysis.02 and the R software package version 2. significant additional effect for PPS at L5 (p=0·017). Figure 2 provides a graphical after applying a backward selection we noted one representation of the equation. The clinical characteristics of patients with 1-year follow-up measurements were much the same as 0 those of patients with 6-month follow-up measurements –10 –5 0 5 10 15 20 25 30 35 40 and of patients without follow-up measurements Prediction rule score (webappendix p 2).10. Articles the level of injury (tetraplegia or paraplegia) were examined Range of Weighted Minimum Maximum by the addition of these variables separately to the final test scores coefficient score score model. 95% CI 0·936–0·976. To visualise the calibration femoris muscle grade (L3). data interpretation. 1442 patients with 50 spinal cord injury were admitted to one of 19 EM-SCI centres. 10 figure 1). we used the following equation: did not significantly improve its fit (p=0·339). e–3·273+0·267×score/1 + e–3·279+0·267×score.

a the calibration of the prediction rule with data from patient’s long-term probability of walking independently patients in the validation group. Between July. The vertical stripes at the lower horizontal border represent the prediction rule scores of patients who were not able to walk independently. 13 EM-SCI centres. Table 3 shows the predictive values of the AIS AIS grade A 240 (49) 91·7 (87·4–94·8) 8·3 (5·2–12·6) grading system. The prediction rule had a clear additional clinical value AIS=American Spinal Injury Association/International Spinal Cord Society neurological standard scale. because of the after injury can be calculated more accurately than it can smaller sample size. AIS grade C 76 (16) 38·2 (27·3–50·0) 61·8 (50·0–72·8) 95% CI 0·030–0·086) than was the accuracy of the AIS AIS grade D 110 (22) 2·7 (0·6–7·8) 97·3 (92·2–99·4) grading system (AUC: 0·898. Table 3: The predictive value of the AIS grading system to discriminate We recorded highly significant correlations of SCIM between the ability to walk independently or not 1 year after injury item 12 with SCIM items 13 (κ=0·962. AUC of the model with the addition of PPS scores at L5 N (%) Negative Positive was slightly higher than was the AUC of the prediction predictive value predictive value rule without this variable (0·959 [95% CI 0·940–0·978] vs (% [95% CI]) (% [95% CI]) 0·956). The discriminating ability of the prediction rule patients with traumatic spinal cord injury and their in the validation group was excellent (AUC 0·967. the first 15 days after injury were included in analysis (table 1). Although. The addition of PPS scores alone to predict the likelihood of independent walking 1008 www. p<0·0001) compared with the AUC documented neurological examinations assessed within of the prediction rule alone. Articles A B 1·0 Probability of walking independently (%) 0·8 0·6 0·4 0·2 0 –10 0 10 20 30 40 –10 0 10 20 30 40 Prediction rule score Prediction rule score Figure 3: Calibration plots of the prediction rule scores divided into four intervals (A) Data from the 492 patients in the derivation group. and December.com Vol 377 March 19. webappendix p 7). deviations from the predicted with the widely used AIS grading system. webappendix p 8). 2008. p<0·0001. for the prediction of an individual’s ability to walk independently in each of the AIS grades (webappendix p 9). 0·867–0·928. We have developed a simple clinical prediction rule up data were available for a smaller proportion of patients derived from data from a large prospective European in the validation group than in the derivation group database that can be used by physicians to counsel (table 1). p<0·0001). p<0·0001. p<0·0001. 214 patients with completely 95% CI 0·935–0·994. 2009. The vertical stripes at the upper horizontal border represent the prediction rule scores of patients who were able to walk independently. 2011 . The accuracy of the prediction rule was AIS grade B 66 (13) 60·6 (47·8–72·4) 39·4 (27·6–52·2) significantly higher (change in AUC: 0·058. 1-year follow. (B) Data from the 99 patients in the validation group. Studies10. 95% CI families during the initial phase after injury. On the basis 0·939–0·995. p<0·0001) and 14 (κ=0·862. Figure 3 shows of age and four clinical neurological parameters. The size of each point corresponds to the number of patients in the interval and the vertical bars are the 95% CIs. combined with sensory tests) are better than AIS grades the calibration was very good.thelancet. Because analysis was done before some 1-year Discussion follow-up measurements could be recorded.20 have probability of the four intervals were more apparent in the shown that lower extremity motor scores (at times validation group than they were in the derivation group. 389 adults at L5 (with weighting derived from the derivation set) to with traumatic spinal cord injury were admitted to one of the prediction rule resulted in a slightly lower AUC (0·964.

22 but they are time patients.3. we included only LTS effective treatment that results in major neurological or scores in the initial model. except for a clinical A dichotomisation of SCIM item 12 was applied as the trial20 and a European database.27 patient’s quality of walking.11.21 but. future effective treatment PPS at L5 to the prediction rule resulted in a slightly strategies might necessitate a reassessment of the higher AUC in the derivation group.25 or anal sensation. <72 h. Nonetheless.8 these studies have used primary functional outcome measure. Our validation have gained increased recognition. and a examination of patients with traumatic spinal cord temporal validation of the derived clinical prediction rule. the Although our prediction rule is more accurate and less availability of validated and detailed information about time consuming than the AIS grading system.8. flexors. although no rule to be as simple as possible. 2011 1009 . Overall. we think that the paper and read and approved the final version. a physician must have experience in the physical clinical outcome measure for ambulation (SCIM). documented. for assessment of injury severity Nonetheless. Because we wanted the prediction patients with spinal cord injury. which might have resulted in an Variables that are highly correlated with others overoptimistic prediction model. it does not provide detailed information about a injury are the reference standard. mortality) have not been who cannot participate in a reliable physical examination. whereas Kirshblum and colleagues3 Many neurological variables have been assessed for their postulated that patients with incomplete tetraplegia are predictive value of ambulation outcomes. Use of multivariate prognostic models to study accords with previous studies. with the AJFH.21 a high-volume study8 Moreover.27 Furthermore. to do patients’ initial neurological impairments assessed by accurate and reliable assessments of the four neurological trained and certified physicians.8. we noted no assessment of only one neurological predictor. injury. All authors contributed to the writing of dataset from which it was derived.28 showing that the determine outcomes after neurotrauma (eg.12 The present small samples. the clinical characteristics of consuming to test and are therefore not suitable for patients who were excluded were much the same as for inclusion in a simple prediction rule. but analysis in our study population showed that the timing of provides a statistically reliable basis for prediction of examination (<24 h. Nonetheless. an external excluded before the development of a prognostic model.9 validation study is needed to assess its generalisability. the international exist. or <15 days after injury) did not walking after such injury with an efficient and simple have a pronounced effect on the accuracy of the prediction clinical examination. www. rule. We declare that we have no conflicts of interest. the model was overfitted to the project. because some Neurophysiological variables such as somatosensory EM-SCI centres are specialised rehabilitation centres.29 By contrast with earlier reports. Zürich. such as difference in outcome between patients with tetraplegia strength of the quadriceps femoris. managed the addition of PPS at L5. Furthermore.31 resulted in a marginally lower AUC in the validation Contributors group. Because many of the EM-SCI centres are referral centres.24 strength of the hip and those with paraplegia. those who were included (webappendix p 1). injury.thelancet. Furthermore.30 Finally. ACHG.20–23 Several less likely to be able to walk independently than are studies have shown the prognostic value of the early patients with incomplete paraplegia. Switzerland. the use of a well validated tests. the exclusion of PPS scores before development of a Conflicts of interest model is a valid approach. AC. Acknowledgments most (81%) of the neurological assessments had not been This work was supported by a grant from the Internationale Stiftung für done within 72 h after injury.16 A post-hoc only accords with these previous clinical data.20. however. collected data in a large European population. and HVdM are all senior authors. There is no consensus about Forschung in Paraplegie (IFP). can be applied to predict the models have not been applied to traumatic spinal cord ability to walk independently for indoor distances only. Our prediction rule not (<24 h) versus subacute (<72 h) examinations. several potential limitations of our study and effectiveness of treatments.com Vol 377 March 19. Before application of contribute little independent information and can be the prediction rule in clinical practice. and obtained funding. the clinical efficacy of the prediction rule also from the EM-SCI consortium showed that sacral PPS needs to be established by investigation of whether its and LTS scores have a similar discriminative ability for use results in more efficient use of rehabilitation prediction of an individual’s ability to walk after traumatic resources and improved psychological wellbeing of spinal cord injury. Ours is an accurate and well validated prediction Strengths of our study include the prospectively rule for walking after traumatic spinal cord injury. JJvM and ARTD did data analysis and the preparation of the final report. Although the applied dichotomous outcome is easy standards for neurological classification of spinal cord to use. its inclusion prediction rule’s accuracy. All spinal cord injury the difference between the prognostic value of immediate centres participating in the EM-SCI network contributed to the study. Although the addition of the functional recovery is available.26 but such prediction rule. Articles after traumatic spinal cord injury.7. Details of neurophysiological assessments can be of value in patients patients lost to follow-up (eg. traumatic SCIM indoor mobility outcome is strongly correlated brain injury) that include large samples and apply external with moderate and outdoor distance outcomes. evoked potentials have been assessed for their prognostic acute-phase measurements were absent for many value on ambulation outcomes. This occurrence was probably because.

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