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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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 Articles
Lancet 2011; 377: 100410
Published Online
March 4, 2011
DOI:10.1016/S0140-
6736(10)62276-3
See Comment page 972
Spine Unit, Department
of Orthopaedics
(J J van Middendorp MD,
A J F Hosman MD,
M H Pouw MD); Department of
Epidemiology, Biostatistics and
HTA (A R T Donders PhD); and
Department of Rehabilitation
Medicine (Prof A C H Geurts MD,
H Van de Meent MD), Radboud
University Nijmegen Medical
Centre, Nijmegen, Netherlands;
Department of Rehabilitation
Medicine, Jeerson Medical
College, Thomas Jeerson
University, Philadelphia, PA,
USA (Prof J F Ditunno Jr MD);
and Spinal Cord Injury Center,
Balgrist University Hospital,
Zurich, Switzerland
(Prof A Curt MD)
Correspondence to:
Dr Joost J van Middendorp,
Department of Orthopaedics,
PO Box 9101, 6500 HB
Nijmegen, Netherlands
jvanmiddendorp@gmail.com
1004
A clinical prediction rule for ambulation outcomes after
traumatic spinal cord injury: a longitudinal cohort study
Joost J van Middendorp, Allard J F Hosman, A Rogier T Donders, Martin H Pouw, John F Ditunno Jr, Armin Curt, Alexander C H Geurts,
Hendrik Van de Meent, for the EM-SCI Study Group
Summary
Background Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to
counsel patients and to plan rehabilitation. We developed a reliable, validated prediction rule to assess a patients
chances of walking independently after such injury.
Methods We undertook a longitudinal cohort study of adult patients with traumatic spinal cord injury, with early
(within the rst 15 days after injury) and late (1-year follow-up) clinical examinations, who were admitted to one of
19 European centres between July, 2001, and June, 2008. A clinical prediction rule based on age and neurological
variables was derived from the international standards for neurological classication of spinal cord injury with a
multivariate logistic regression model. Primary outcome measure 1 year after injury was independent indoor walking
based on the Spinal Cord Independence Measure. Model performances were quantied with respect to discrimination
(area under receiver-operating-characteristics curve [AUC]). Temporal validation was done in a second group of
patients from July, 2008, to December, 2009.
Findings Of 1442 patients with spinal cord injury, 492 had available outcome measures. A combination of age (<65 vs
65 years), motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of
dermatomes L3 and S1 showed excellent discrimination in distinguishing independent walkers from dependent
walkers and non-walkers (AUC 0956, 95% CI 09360976, p<00001). Temporal validation in 99 patients conrmed
excellent discriminating ability of the prediction rule (AUC 0967, 09390995, p<00001).
Interpretation Our prediction rule, including age and four neurological tests, can give an early prognosis of an
individuals ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might
improve the ability to stratify patients in interventional trials.
Funding Internationale Stiftung fr Forschung in Paraplegie.
Introduction reproducibility and validity of the rule to predict an
Traumatic spinal cord injury has a profound eect on individuals ability to walk independently after injury
patients physical and psychosocial wellbeing. Although on a second group of patients.
the frequency of such injury is low at 10483 cases per
million people worldwide, this devastating disorder Methods
imposes a substantial burden on the health-care system.1 Study design and patient population
Despite advances in basic research into spinal cord repair Since July, 2001, 19 centres (ve centres originally) have
that show promise, no treatment that results in major gathered a standardised dataset of neurological and
neurological or functional recovery is available.2 functional outcomes of patients with spinal cord injury
After a spinal cord injury, a reliable prognosis of a as part of the European Multicenter Study on Human
patients potential functional outcome is essential for Spinal Cord Injury (EM-SCI).5 Data for neurological and
counselling and to design a personalised rehabilitation functional status were collected prospectively, per
programme.3 During rehabilitation, recovery of the ability protocol, within the rst 15 days and at months 1, 3, 6,
to walk is a high priority for such patients.4 However, no and 12 after injury. Because no proven eective treatment
prediction rule for the ability to walk independently after is available,2 treatment regimens are not standardised
traumatic spinal cord injury is available. within the EM-SCI network. Details of applied treatments
In this study we analysed data from a prospective, were not recorded systematically, but ranged from non-
longitudinal, 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. Dependent on level and severity of injury,
prediction rule for a patients ability to walk independ- individually tailored rehabilitation programmes varied in
ently. Age at injury6 and variables from the international focus and intensity.
standards for neurological classication of spinal cord From the EM-SCI dataset we extracted data for all adult
injury7 are used in the clinical algorithm. We tested the (18 years) patients with acute traumatic spinal cord
www.thelancet.com Vol 377 March 19, 2011

injury, including conus medullaris and cauda equina
injuries, who were admitted between July, 2001, and
June, 2008. Patients who were unable to cooperate with
physical examination because of cognitive impairment
(as assessed by the examiner), who had a peripheral
nerve lesion, or who had neuropathy or polyneuropathy
were not included in the EM-SCI database. Polyneuropathy
was tested by measurement of ulnar and tibial sensory
nerve conduction velocity. Patients with medical records
showing frequent causes of polyneuropathy (eg, diabetes
mellitus), and those without a complete neurological
assessment within the rst 15 days after injury were
excluded from the analysis. The multicentre follow-up
study was done in accordance with the ethics standards
in the updated version of the 1964 Declaration of Helsinki.
The study protocol was approved by the local ethics
committees of all participating centres, and the patients
gave informed, oral consent before entering the study.
Prognostic variables
For the prognostic model we considered patients age and
variables from their initial neurological examination.
Older patients (65 years) with spinal cord injury have
less potential to translate neurological improvements into
functional recovery than do younger patients.6 Therefore,
age was categorised into two groups: patients younger
than 65 years and those aged 65 years and older.
Neurological examinations were done according to the
international standards for classication of spinal cord
injuries.7 Examination included motor score testing
(graded on a ve-point scale adapted from the Medical
Research Council scale), light touch sensory (LTS) and
pinprick sensory (PPS) testing (0=absent, 1=impaired,
and 2=normal), and sacral sparing scores, including
voluntary anal contraction and anal sensation (0=absent
and 1=present).7 Muscle testing was done in the supine
position. Because the PPS scores and the LTS scores are
highly correlated,8 we included only one of the two
sensory scoring systems in the initial model.9 Because an
LTS score of 0 means that light touch sensation is absent
and a PPS score of 0 means that there could be local
sensation, but the separation of dull and sharp sensation
is absent,7 we used only the LTS scoring system in
analysis because we thought it to be the least prone to
error. To validate this approach the nal model was tested
with the addition of PPS scores.
For every patient, we included only the best scores of
each level (ie, right or left) of the lower extremity and
sacral scores for analysis.8 Clinical assessments were
done by trained and certied neurologists and
rehabilitation physicians with at least 1 year of experience
in examination of patients with spinal cord injury. Motor
and sensory scores were recorded in the electronic
EM-SCI database and the quality and correctness of the
data were monitored centrally by a data quality manager.
Patients American Spinal Injury Association/
International Spinal Cord Society neurological standard
www.thelancet.com Vol 377 March 19, 2011
Articles
Panel 1: American Spinal Injury Association/International
Spinal Cord Society neurological standard scale7
Grade A
No motor or sensory function is preserved in the sacral
segments S4S5
Grade B
Sensory but not motor function is preserved below the
neurological level and includes the sacral segments S4S5
Grade C
Motor function is preserved below the neurological level, and
more than half of key muscles below the neurological level
have a muscle grade of less than 3
Grade D
Motor function is preserved below the neurological level, and
at least half of key muscles below the neurological level have
a muscle grade of 3 or more
Grade E
Motor and sensory function are normal
Panel 2: Spinal Cord Independence Measure
item 12mobility indoors11,12
0: Requires total assistance
1: Needs electric wheelchair or partial assistance to operate
manual wheelchair
2: Moves independently in manual wheelchair
3: Requires supervision while walking (with or without
devices)
4: Walks with a walking frame or crutches (swing)
5: Walks with crutches or two canes (reciprocal walking)
6: Walks with one cane
7: Needs leg orthosis only
8: Walks without walking aids
We applied a cuto SCIM (Spinal Cord Independence Measure ) mobility score to
dierentiate between patients who are unable to walk or are dependent on assistance
while walking (scores 03) and those who are able to walk independently (scores 48).
scale (AIS) grades were computed automatically
according to the international standards (panel 1).7
Because the aim of this study was to introduce a simple
clinical prediction rule with minimum burden on
patients and maximum time eciency for physicians,
we did not include aggregated neurological scores
(eg, total lower extremity motor score10) in analyses.
Outcome assessment
The ability to walk independently 1 year after injury was
the primary functional outcome. The Spinal Cord
Independence Measure indoor mobility item (SCIM
item 12, ability to walk <10 m) was assessed and
analysed for this purpose.11,12 The SCIM indoor mobility
item ranges from total assistance, to wheelchair use, to
walking with aids, to walking without aids, and has
1005
 Articles

independently and those who could not, a cuto SCIM

Setting
Inclusion period
Adults with complete initial neurological
examination within the rst 2 weeks after
traumatic spinal cord injury*
Sex (male)
Mean age at injury in years (SD, range)
65 years
Mean timing of examination in days after
injury (SD, range)
Examination <72 h after injury
Severity of initial neurological decit
AIS grade A
AIS grade B
AIS grade C
AIS grade D
Patients with tetraplegia
Outcome measurements
1-year follow-up measure
Only 6-month follow-up measure
Individuals who can walk independently
Data are n (%) unless otherwise stated. AIS=American Spinal Injury Association/International Spinal Cord Society
neurological standard scale.7 *Number used to calculate proportions for other characteristics. % is proportion of
patients with available follow-up data.
Table 1: Baseline characteristics
1442 patients with
1282 adult patients with
148 without 6-month
or 12-month follow-up
measurements
Figure 1: Selection of patients
shown excellent reliability and construct validity in
patients with spinal cord injury.12 To distinguish
between individuals who could walk indoors
Derivation group Temporal validation group
(n=1282) (n=389) indoor mobility score was applied; scores 03 were
grouped and dened as unable to walk or dependent on
19 European SCI centres 13 European SCI Centres
assistance while walking and scores 48 were grouped
July, 2001, to June, 2008 July, 2008, to December,
2009 and dened as able to walk independently (panel 2).8 To
640 (50%) 214 (55%) gain insight into the prospects of a patient being able to
walk outdoors independently, we did an ancillary
correlation analysis between the SCIM indoor mobility
504 (79%) 169 (79%) outcomes and ambulation outcomes for moderate
44 (17, 1892) 47 (19, 1889) distance (10100 m; SCIM item 13) and outdoors
108 (17%) 49 (23%) (>100 m; SCIM item 14).11,12
77 (47, 015) 80 (46, 015) In spinal cord injury research, 1-year follow-up
measurements are generally thought to be representative
123 (19%) 34 (16%) for the assessment of long-term outcomes.13 For patients
without 1-year follow-up measurements, 6-month follow-
314 (49%) 85 (40%) up measurements were used, as previously validated.8
88 (14%) 26 (12%) Physicians, physiotherapists, and occupational therapists
96 (15%) 46 (21%) who assessed the SCIM measurements were not masked
142 (22%) 57 (27%) to the initial neurological examination results.
341 (53%) 114 (53%)
Statistical analysis
374 (59%) 54 (25%) A descriptive analysis of patients characteristics was
118 (18%) 45 (21%) done with absolute and relative frequencies for qualitative
200 (41%) 43 (43%) variables and means (SD) for quantitative variables.
Positive and negative predictive values were calculated
from contingency tables with 95% CIs with the binomial
exact method.
Because the neurological candidate predictors included
in analysis are highly correlated, several models with
almost equivalent performances can be constructed. We
applied an exhaustive model search in which all logistic
spinal cord injury regression models, with a maximum of seven predictor
56 aged <18 years
variables, were assessed. The Akaike information
104 non-traumatic spinal criterion was calculated for each model to assess the
cord injury goodness-of-t.14 The smaller the number, the more
accurate the model. We identied the most accurate
traumatic spinal cord injury models, including the model with the lowest Akaike
578 no neurological
examination within the information criterion and those with a maximum of four
rst 15 days after injury points more. 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. The relative weighting
of every variable included in the nal model was based
on each variables value in logistic regression analysis.
374 with 12-month 118 with 6-month follow-up
follow-up measurements measurements only
We calculated predicted probabilities on the basis of
these weighted values.
The performance of each prediction rule was quantied
by its discriminatory ability, which was dened as the
area under receiver-operating-characteristics curve
492 with available outcome
measures (AUC). This curve shows a models ability to discriminate
between patients who can walk independently after 1 year
and those who cannot.15 Calibration of predictions was
assessed graphically by plotting recorded frequencies
against predicted probabilities.
Several ancillary analyses were done. First, the potential
additional predictive value of PPS scores, the timing of
examination (24 h, <72 h, or <15 days after injury), and

1006 www.thelancet.com Vol 377 March 19, 2011

 Articles

the level of injury (tetraplegia or paraplegia) were examined

Range of Weighted Minimum Maximum
by the addition of these variables separately to the nal test scores coecient score score
model.3,1619 Second, the AUC of the newly derived prediction
Age 65 years 01 10 10 0
rule was compared with the AUC of the AIS grading
Motor score L3 05 2 0 10
system.7 Third, we calculated the agreement between
Motor score S1 05 2 0 10
dichotomous SCIM indoor mobility outcomes and
Light touch score L3 02 5 0 10
moderate distance and outdoor mobility outcomes with
Light touch score S1 02 5 0 10
the kappa statistic (). Finally, for temporal validation, 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, right or left)
included in the EM-SCI network between July, 2008, and should be applied for the prediction rule (see Methods).
December, 2009. No alteration in the prognostic score was Table 2: Clinical prediction rule variables
allowed after temporal validation began. Statistical analyses
were done with the SPSS software package version 16.0.02
and the R software package version 2.10.1. 100

Role of the funding source 90

The sponsor of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of 80
the report. The corresponding author had full access to all
the data in the study and had nal responsibility for the 70
Probability of walking independently (%)

decision to submit for publication.

60
Results
Between July, 2001, and June, 2008, 1442 patients with
50
spinal cord injury were admitted to one of 19 EM-SCI
centres. Of 1282 adult patients with traumatic injury in
the study population (table 1), 640 had completely 40
documented neurological examinations assessed within
the rst 15 days after injury and were included for analysis 30
(table 1; gure 1). The clinical characteristics of individuals
included in the analysis were much the same as those of 20
individuals excluded (webappendix p 1). Ambulation
outcome measures were available in 492 patients (77%, 10
gure 1). 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).
Figure 2: Probability of walking independently 1 year after injury based on the prediction rule score
After logistic regression analysis, 11 dierent models The shaded area around the curve is the 95% CI of the prediction rule based on the regression model. The dotted
consisting of age and four neurological predictors were lines are a visual aid to determine the probability of walking independently.
most signicantly related to ambulation outcomes
(webappendix pp 36 shows complete datasets of the The prediction rule distinguished well between those See Online for webappendix
best models). The nal 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 0956, 95% CI 09360976,
at 65 years) and four neurological predictors: quadriceps p<00001; webappendix p 8). To visualise the calibration
femoris muscle grade (L3), gastrocsoleus muscle grade of the prediction rule, the total sample was divided into
(S1), LTS at L3, and LTS at S1. We estimated the four groups that contained roughly the same number of
probability of an individual being able to walk patients (gure 3).
independently 1 year after traumatic spinal cord injury Ancillary analyses showed that neither level of injury
with the weighted coecients of the nal prediction rule (p=0659) nor timing of examination (p=0312) had a
(table 2), with a minimum total score of 10 and a signicant additional value with respect to prediction of
maximum total score of 40. To calculate the probability an individuals ability to walk independently. The addition
of being able to walk independently with this predic- of aggregated lumbosacral PPS scores to the nal model
tion rule score, we used the following equation: did not signicantly improve its t (p=0339). However,
e3273+0267score/1 + e3279+0267score. Figure 2 provides a graphical after applying a backward selection we noted one
representation of the equation. signicant additional eect for PPS at L5 (p=0017). The

www.thelancet.com Vol 377 March 19, 2011 1007

 Articles

A B
10
Probability of walking independently (%)

08

06

04

02

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. (B) Data from the 99 patients in the validation group. The size of each point corresponds to the number of
patients in the interval and the vertical bars are the 95% CIs. The vertical stripes at the lower horizontal border represent the prediction rule scores of patients who were
not able to walk independently. The vertical stripes at the upper horizontal border represent the prediction rule scores of patients who were able to walk independently.

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 (0959 [95% CI 09400978] vs (% [95% CI]) (% [95% CI])
0956). Table 3 shows the predictive values of the AIS AIS grade A 240 (49) 917 (874948) 83 (52126)
grading system. The accuracy of the prediction rule was AIS grade B 66 (13) 606 (478724) 394 (276522)
signicantly higher (change in AUC: 0058, p<00001, AIS grade C 76 (16) 382 (273500) 618 (500728)
95% CI 00300086) than was the accuracy of the AIS AIS grade D 110 (22) 27 (0678) 973 (922994)
grading system (AUC: 0898, 08670928, p<00001).
The prediction rule had a clear additional clinical value AIS=American Spinal Injury Association/International Spinal Cord Society
neurological standard scale.
for the prediction of an individuals ability to walk
independently in each of the AIS grades (webappendix p 9). Table 3: The predictive value of the AIS grading system to discriminate
We recorded highly signicant correlations of SCIM between the ability to walk independently or not 1 year after injury
item 12 with SCIM items 13 (=0962, p<00001) and 14
(=0862, p<00001; webappendix p 7).
Between July, 2008, and December, 2009, 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 (0964,
13 EM-SCI centres. 214 patients with completely 95% CI 09350994, p<00001) compared with the AUC
documented neurological examinations assessed within of the prediction rule alone.
the rst 15 days after injury were included in analysis
(table 1). Because analysis was done before some 1-year Discussion
follow-up measurements could be recorded, 1-year follow- 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). The discriminating ability of the prediction rule patients with traumatic spinal cord injury and their
in the validation group was excellent (AUC 0967, 95% CI families during the initial phase after injury. On the basis
09390995, p<00001; webappendix p 8). Figure 3 shows of age and four clinical neurological parameters, a
the calibration of the prediction rule with data from patients long-term probability of walking independently
patients in the validation group. Although, because of the after injury can be calculated more accurately than it can
smaller sample size, deviations from the predicted with the widely used AIS grading system. Studies10,20 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, combined with sensory tests) are better than AIS grades
the calibration was very good. The addition of PPS scores alone to predict the likelihood of independent walking

1008 www.thelancet.com Vol 377 March 19, 2011


after traumatic spinal cord injury. Our prediction rule not
only accords with these previous clinical data, but
provides a statistically reliable basis for prediction of
walking after such injury with an ecient and simple
clinical examination.
Many neurological variables have been assessed for their
predictive value of ambulation outcomes.7,8,2023 Several
studies have shown the prognostic value of the early
assessment of only one neurological predictor, such as
strength of the quadriceps femoris,24 strength of the hip
exors,25 or anal sensation,20,21 but, except for a clinical
trial20 and a European database,8 these studies have used
small samples. Use of multivariate prognostic models to
determine outcomes after neurotrauma (eg, traumatic
brain injury) that include large samples and apply external
validation have gained increased recognition,26 but such
models have not been applied to traumatic spinal cord
injury. Ours is an accurate and well validated prediction
rule for walking after traumatic spinal cord injury.
Although our prediction rule is more accurate and less
time consuming than the AIS grading system, to do
accurate and reliable assessments of the four neurological
tests, a physician must have experience in the physical
examination of patients with traumatic spinal cord
injury.27 Furthermore, for assessment of injury severity
and eectiveness of treatments, the international
standards for neurological classication of spinal cord
injury are the reference standard.27
Neurophysiological variables such as somatosensory
evoked potentials have been assessed for their prognostic
value on ambulation outcomes,22 but they are time
consuming to test and are therefore not suitable for
inclusion in a simple prediction rule. Nonetheless,
neurophysiological assessments can be of value in patients
who cannot participate in a reliable physical examination.
Variables that are highly correlated with others
contribute little independent information and can be
excluded before the development of a prognostic model.9
By contrast with earlier reports,21 a high-volume study8
from the EM-SCI consortium showed that sacral PPS
and LTS scores have a similar discriminative ability for
prediction of an individuals ability to walk after traumatic
spinal cord injury. Because we wanted the prediction
rule to be as simple as possible, we included only LTS
scores in the initial model. Although the addition of the
PPS at L5 to the prediction rule resulted in a slightly
higher AUC in the derivation group, its inclusion
resulted in a marginally lower AUC in the validation
group. This occurrence was probably because, with the
addition of PPS at L5, the model was overtted to the
dataset from which it was derived. Overall, we think that
the exclusion of PPS scores before development of a
model is a valid approach.
Because many of the EM-SCI centres are referral centres,
most (81%) of the neurological assessments had not been
done within 72 h after injury. There is no consensus about
the dierence between the prognostic value of immediate
www.thelancet.com Vol 377 March 19, 2011
Articles
(<24 h) versus subacute (<72 h) examinations.16 A post-hoc
analysis in our study population showed that the timing of
examination (<24 h, <72 h, or <15 days after injury) did not
have a pronounced eect on the accuracy of the prediction
rule. Furthermore, whereas Kirshblum and colleagues3
postulated that patients with incomplete tetraplegia are
less likely to be able to walk independently than are
patients with incomplete paraplegia, we noted no
dierence in outcome between patients with tetraplegia
and those with paraplegia.
A dichotomisation of SCIM item 12 was applied as the
primary functional outcome measure.8,11,12 The present
study accords with previous studies,28 showing that the
SCIM indoor mobility outcome is strongly correlated
with moderate and outdoor distance outcomes. Our
prediction rule, however, can be applied to predict the
ability to walk independently for indoor distances only.
Strengths of our study include the prospectively
collected data in a large European population, the
availability of validated and detailed information about
patients initial neurological impairments assessed by
trained and certied physicians, the use of a well validated
clinical outcome measure for ambulation (SCIM), and a
temporal validation of the derived clinical prediction rule.
Nonetheless, several potential limitations of our study
exist. Although the applied dichotomous outcome is easy
to use, it does not provide detailed information about a
patients quality of walking. Furthermore, because some
EM-SCI centres are specialised rehabilitation centres,
acute-phase measurements were absent for many
patients. Nonetheless, the clinical characteristics of
patients who were excluded were much the same as for
those who were included (webappendix p 1). Details of
patients lost to follow-up (eg, mortality) have not been
documented, which might have resulted in an
overoptimistic prediction model. Before application of
the prediction rule in clinical practice, an external
validation study is needed to assess its generalisability.29
Moreover, the clinical ecacy of the prediction rule also
needs to be established by investigation of whether its
use results in more ecient use of rehabilitation
resources and improved psychological wellbeing of
patients with spinal cord injury.3,30 Finally, although no
eective treatment that results in major neurological or
functional recovery is available, future eective treatment
strategies might necessitate a reassessment of the
prediction rules accuracy.31
Contributors
AJFH, AC, ACHG, and HVdM are all senior authors, managed the
project, and obtained funding. JJvM and ARTD did data analysis and the
preparation of the nal report. All authors contributed to the writing of
the paper and read and approved the nal version.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
This work was supported by a grant from the Internationale Stiftung fr
Forschung in Paraplegie (IFP), Zrich, Switzerland. All spinal cord injury
centres participating in the EM-SCI network contributed to the study.
1009
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