Study Design: Prospective, longitudinal cohort study. Objectives: To quantify the effect of formal training in the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) on the classification accuracy and to identify the most difficult ISNCSCI rules. Settings: European Multicenter Study on Human Spinal Cord Injury (EMSCI). Methods: EMSCI participants rated five challenging cases of full sensory, motor and anorectal examinations before (pre-test) and after (post-test) an ISNCSCI instructional course. Classification variables included sensory and motor levels (ML), completeness, ASIA Impairment Scale (AIS) and the zones of partial preservation. Results: 106 attendees were trained in 10 ISNCSCI workshops since 2006. The number of correct classifications increased significantly (Po0.00001) from 49.6% (2628 of 5300) in pre-testing to 91.5% (4849 of 5300) in post-testing. Every attendee improved, 12 (11.3%) achieved 100% correctness. Sensory levels (96.8%) and completeness (96.2%) are easiest to rate in posttesting, while ML (81.9%) and AIS (88.1%) are more difficult to determine. Most of the errors in ML determination arise from sensory levels in the high cervical region (C2 ÀC4), where by convention the ML is presumed to be the same as the sensory level. The most difficult step in AIS classification is the determination of motor incompleteness. Conclusion: ISNCSCI training significantly improves the classification skills regardless of the experience in spinal cord injury medicine. These findings need to be considered for the appropriate preparation and interpretation of clinical trials in spinal cord injury.

1. All giant interneurons (GIs) were ablated from the nerve cord of cockroaches by electrocautery, and escape behavior was analyzed with high-speed videography. Animals with ablations retained the ability to produce wind-triggered escape, although response latency was increased (Table 1, Fig. 4). Subsequent lesions suggested that these non-GI responses depended in part on receptors associated with the antennae.2. Antennal and cercal systems were compared by analyzing escape responses after amputating either cerci or antennae. With standard wind stimuli (high peak velocity) animals responded after either lesion. With lower intensity winds, animals lost their ability to respond after cercal removal (Fig. 6).3. Removal of antennae did not cause significant changes in behavioral latency, but in the absence of cerci, animals responded at longer latencies than normal (Fig. 7).4. The cercal-to-GI system can mediate short latency responses to high or low intensity winds, while the antennal system is responsive to high intensity winds only and operates at relatively longer latencies. These conclusions drawn from lesioned animals were confirmed in intact animals with restricted wind targeting the cerci or antennae only (Fig. 9).5. The antennae do not represent a primary wind-sensory system, but may have a direct mechanosensory role in escape.

Study design: This is a prospective observational cohort study. Objectives: The objectives of this study were to apply and adapt a rating scale based on locomotor stages (LSs) derived from cerebral palsy (CP) to spinal cord injury (SCI) and to quantify its inter-rater reliability and construct validity. Methods: The inter-rater reliability of LSs originally developed for children with CP was tested in a chronic SCI cohort. On the basis of the distribution of the LSs for CP, Locomotor Stages in Spinal Cord Injury (LOSSCI) were defined. Their validity was then tested with the Spinal Cord Independence Measure (SCIM) in another acute SCI cohort. Results: The 10-point LSs for CP were assessed by two raters in 65 chronic patients. Weighted Cohen's kappa (WCk) was 0.985 (Po0.0001). Only four mismatches were found, resulting in an accuracy of 93.4%. On the basis of the distribution of the LSs for CP in SCI, the five-point LOSSCI grading scale was developed. WCk of LOSSCI was 0.976 (Po0.0001). Only three mismatches between raters were found, resulting in an overall accuracy of 95.1%. The validity data sets consisted of 448 SCIM records from 161 patients obtained within the first year after injury. Spearman's correlation coefficients were the highest between LOSSCI and SCIM indoor mobility (room and toilet; R = 0.82) and the lowest between LOSSCI and SCIM respiration and sphincter management (R = 0.68). Conclusion: LOSSCI provides a reliable and valid clinical tool to assess locomotor function in SCI. LOSSCI not only reflects bipedal walking but also covers a wide range of key motor skills.