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ORIGINAL RESEARCH|Articles in Press
A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After
Spinal Cord Injury
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A SINGLE DERMATOME CLINICAL PREDICTION RULE FOR INDEPENDENT WALKING 1 YEAR AFTER
SPINAL CORD INJURY
* Andrew C. Smith, PT, DPT, PhD
Andrew C. Smith
Correspondence
Corresponding author Andrew C. Smith, PT, DPT, PhD, Department of Physical
Medicine and Rehabilitation, University of Colorado School of Medicine,
Aurora, CO, USA.
Contact
Affiliations
Department of Physical Medicine and Rehabilitation, University of Colorado
School of Medicine, Aurora, CO
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* Christina Draganich, DO
Christina Draganich
Affiliations
Department of Physical Medicine and Rehabilitation, University of Colorado
School of Medicine, Aurora, CO
Craig Hospital, Englewood, CO
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* Wesley A. Thornton, PT, DPT
Wesley A. Thornton
Affiliations
Department of Physical Medicine and Rehabilitation, University of Colorado
School of Medicine, Aurora, CO
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* Jeffrey C. Berliner, DO
Jeffrey C. Berliner
Affiliations
Department of Physical Medicine and Rehabilitation, University of Colorado
School of Medicine, Aurora, CO
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* Peter J. Lennarson, MD
Peter J. Lennarson
Affiliations
Department of Neurosurgery, University of Colorado School of Medicine,
Aurora, CO
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* Enrico Rejc, PhD
Enrico Rejc
Affiliations
Department of Neurosurgery, University of Louisville School of Medicine,
Louisville, KY
Department of Medicine, University of Udine, Udine, Italy
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* Mitch Sevigny, MS
Mitch Sevigny
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Craig Hospital, Englewood, CO
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* Susan Charlifue, PhD
Susan Charlifue
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Craig Hospital, Englewood, CO
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Candace Tefertiller
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Craig Hospital, Englewood, CO
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Kenneth A. Weber II
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Open AccessPublished:July 04, 2023DOI:https://doi.org/10.1016/j.apmr.2023.06.015
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* Abstract
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ABSTRACT
OBJECTIVE
To derive and validate a simple, accurate CPR to predict future independent
walking ability after SCI at the bedside that does not rely on motor scores and
is predictive for those initially classified in the middle of the SCI severity
spectrum.
DESIGN
Retrospective cohort study. Binary variables were derived, indicating degrees of
sensation to evaluate predictive value of pinprick and light touch variables
across dermatomes. The optimal single sensory modality and dermatome was used to
derive our CPR, which was validated on an independent dataset.
SETTING
Analysis of SCI Model Systems dataset.
PARTICIPANTS
Individuals with traumatic SCI. The data of 3679 participants (N=3679) were
included with 623 participants comprising the derivation dataset and 3056
comprising the validation dataset.
INTERVENTIONS
Not applicable.
MAIN OUTCOME MEASURES
Self-reported ability to walk both indoors and outdoors.
RESULTS
Pinprick testing at S1 over lateral heels, within 31 days of SCI, accurately
identified future independent walkers 1 year after SCI. Normal pinprick in both
lateral heels provided good prognosis, any pinprick sensation in either lateral
heel provided fair prognosis, and no sensation provided poor prognosis. This CPR
performed satisfactorily in the middle SCI severity subgroup.
CONCLUSIONS
In this large multi-site study, we derived and validated a simple, accurate CPR
using only pinprick sensory testing at lateral heels that predicts future
independent walking after SCI.
KEYWORDS
* Clinical prediction rule
* Pinprick
* Rehabilitation
* Spinal cord injury
* Walking
LIST OF ABBREVIATIONS:
AIS (American Spinal Injury Association Impairment Scale), CI (confidence
interval), CPR (clinical prediction rule), ISNCSCI (International Standards for
Neurological Classification of Spinal Cord Injury), NPV (negative predictive
value), PPV (positive predictive value), SCI (spinal cord injury), SCIMS (Spinal
Cord Injury Model Systems)
The recovery of walking ability is a top priority early after traumatic spinal
cord injury (SCI).
1
* Ditunno PL
* Patrick M
* Stineman M
* Ditunno JF
Who wants to walk? Preferences for recovery after SCI: a longitudinal and
cross-sectional study.
Spinal Cord. 2008; 46: 500-506
* Crossref
* PubMed
* Scopus (215)
* Google Scholar
Because this patient group is so heterogeneous in nature, predicting future
independent walking ability is challenging.
2
* Pelletier-Roy R
* Richard-Denis A
* Jean S
* et al.
Clinical judgment is a cornerstone for validating and using clinical prediction
rules: a head-to-head study on ambulation outcomes for spinal cord injured
patients.
Spinal Cord. 2021; 59: 1104-1110
* Crossref
* PubMed
* Scopus (1)
* Google Scholar
Clinical prediction rules (CPRs) have been derived to aid in this task.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
,
4
* Hicks KE
* Zhao Y
* Fallah N
* et al.
A simplified clinical prediction rule for prognosticating independent walking
after spinal cord injury: a prospective study from a Canadian multicenter spinal
cord injury registry.
Spine J. 2017; 17: 1383-1392
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
,
5
* Jean S
* Mac-Thiong JM
* Jean MC
* Dionne A
* Bégin J
* Richard-Denis A
Early clinical prediction of independent outdoor functional walking capacity in
a prospective cohort of traumatic spinal cord injury patients.
Am J Phys Med Rehabil. 2021; 100: 1034-1041
* Crossref
* PubMed
* Scopus (1)
* Google Scholar
,
6
* Draganich C
* Weber KA
* Thornton WA
* et al.
Predicting outdoor walking 1 year after spinal cord injury: a retrospective,
multisite external validation study.
J Neurol Phys Ther. 2023; 47: 155-161
* Crossref
* PubMed
* Scopus (0)
* Google Scholar
However, problems with these CPRs include complex equations with multiple
predictor variables limiting true clinical utility as well as suboptimal
definitions of independent walking.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
,
7
* Wilson JR
* Grossman RG
* Frankowski RF
* et al.
A clinical prediction model for long-term functional outcome after traumatic
spinal cord injury based on acute clinical and imaging factors.
J Neurotrauma. 2012; 29: 2263-2271
* Crossref
* PubMed
* Scopus (131)
* Google Scholar
,
8
* Zörner B
* Blanckenhorn WU
* Dietz V
* Curt A
EM-SCI Study Group
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stratification after incomplete spinal cord injury.
J Neurotrauma. 2010; 27: 241-252
* Crossref
* PubMed
* Scopus (0)
* Google Scholar
As an example, van Middendorp et al's CPR uses 5 predictor variables (1 age, 2
motor, and 3 sensory) that are then weighted and summed to first calculate the
CPR score, the CPR score is then input into a logistical regression model (ie,
sigmoid function) to calculate the probability of walking.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
Hicks et al simplified this CPR to only 3 predictor variables (1 age, 1 motor,
and 1 sensory), but their CPR still requires calculating a weighted sum, which
is then input into a logistical regression model (also sigmoid function) to
calculate the probability of walking.
4
* Hicks KE
* Zhao Y
* Fallah N
* et al.
A simplified clinical prediction rule for prognosticating independent walking
after spinal cord injury: a prospective study from a Canadian multicenter spinal
cord injury registry.
Spine J. 2017; 17: 1383-1392
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
A recent study found that the van Middendorp CPR provided clinical utility for
only 45% of patients with traumatic SCI and also found that only 18% of
experienced clinicians found this CPR useful for established prognosis.
9
* Everhart J
* Somers M
* Hibbs R
* Worobey LA
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for ambulation prognosis following spinal cord injury.
J Spinal Cord Med. 2023; 46: 485-493
* Crossref
* PubMed
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* Google Scholar
There is a need for a more simplified CPR that offers better clinical
translation.
Using existing residual lower extremity motor function as a walking predictor
works for those on either end of the SCI severity spectrum (ie, no motor
recovery vs substantial motor recovery),
10
* Waters RL
* Adkins RH
* Yakura JS
* Sie I
Motor and sensory recovery following incomplete tetraplegia.
Arch Phys Med Rehabil. 1994; 75: 306-311
* Abstract
* Full Text PDF
* PubMed
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* Crossref
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but this is arguably a clinically-obvious prognosis. Indeed, motor-based CPRs do
not work as well for those initially classified in the middle of the SCI
severity spectrum where only minimal sensorimotor function is present.
12
* Phan P
* Budhram B
* Zhang Q
* et al.
Highlighting discrepancies in walking prediction accuracy for patients with
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a Canadian Multicenter Spinal Cord Injury Registry.
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* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
There is need for a clinical tool to predict future independent walking ability
after SCI that works for those in the middle of the SCI severity spectrum and
does not rely on motor scores.
The presence or absence of sensing pinprick below the level of SCI has
demonstrated promise to serve as a predictor variable for future walking
ability.
10
* Waters RL
* Adkins RH
* Yakura JS
* Sie I
Motor and sensory recovery following incomplete tetraplegia.
Arch Phys Med Rehabil. 1994; 75: 306-311
* Abstract
* Full Text PDF
* PubMed
* Scopus (197)
* Google Scholar
,
13
* Crozier KS
* Graziani V
* Ditunno JF
* Herbison GJ
Spinal cord injury: prognosis for ambulation based on sensory examination in
patients who are initially motor complete.
Arch Phys Med Rehabil. 1991; 72: 119-121
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* AS Burns
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* Geisler FH
* Coleman WP
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spinal cord injury.
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* Full Text
* Full Text PDF
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* Google Scholar
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* Ditunno JF
Influence of age alone, and age combined with pinprick, on recovery of walking
function in motor complete, sensory incomplete spinal cord injury.
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* Abstract
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Paraplegia. 1981; 19: 201-205
* Crossref
* PubMed
* Google Scholar
Per the American Spinal Injury Association Impairment Scale (AIS), people
classified with AIS B injuries (sensory sparing but motor complete) under 50
years old, having substantial pinprick sensation in the lower extremities was
associated with an increased likelihood of household ambulation 1 year after
SCI.
15
* v Oleson C
* RJ Marino
* Leiby BE
* Ditunno JF
Influence of age alone, and age combined with pinprick, on recovery of walking
function in motor complete, sensory incomplete spinal cord injury.
Arch Phys Med Rehabil. 2016; 97: 1635-1641
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (19)
* Google Scholar
Dermatomal testing of pinprick sensation is 1 part of the International
Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
examination,
18
ASIA and ISCoS International Standards Committee
The 2019 revision of the International Standards for Neurological Classification
of Spinal Cord Injury (ISNCSCI)-What's new?.
Spinal Cord. 2019; 57: 815-817
* Crossref
* PubMed
* Scopus (0)
* Google Scholar
which is the criterion standard SCI clinical exam. The full ISNCSCI exam may
take longer than 45 minutes to complete
19
* Kirshblum S
* Snider B
* Rupp R
* Read MS
International Standards Committee of ASIA and ISCoS
Updates of the International Standards for Neurologic Classification of Spinal
Cord Injury: 2015 and 2019.
Phys Med Rehabil Clin N Am. 2020; 31: 319-330
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (65)
* Google Scholar
and may not be feasible during the acute phase of SCI due to sedation or long
bone fracture. Thus, a CPR using more targeted sensory information may be
beneficial.
Light touch sensation may be another variable to consider for the prediction of
ambulation, as dermatomal testing of light touch is another part of the ISNCSCI
exam and also does not rely on motor scores.
18
ASIA and ISCoS International Standards Committee
The 2019 revision of the International Standards for Neurological Classification
of Spinal Cord Injury (ISNCSCI)-What's new?.
Spinal Cord. 2019; 57: 815-817
* Crossref
* PubMed
* Scopus (0)
* Google Scholar
Two established CPRs included S1 dermatome lower extremity light touch scores as
predictor variables for future walking.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
,
4
* Hicks KE
* Zhao Y
* Fallah N
* et al.
A simplified clinical prediction rule for prognosticating independent walking
after spinal cord injury: a prospective study from a Canadian multicenter spinal
cord injury registry.
Spine J. 2017; 17: 1383-1392
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
Questions remain as to what type of sensory testing may best predict independent
walking after SCI.
The objective of this study was to use a large, multisite SCI dataset to derive
and independently validate a simple and accurate CPR to predict future
independent walking ability after SCI at the bedside that does not rely on motor
scores and is predictive for those initially classified in the middle of the SCI
severity spectrum (AIS B and C injuries).
METHODS
This was a retrospective analysis of SCI Model Systems (SCIMS) data from 12
centers in the United States of America. This study was approved by the local
Institutional Review Board and complies with the Declaration of Helsinki
standards.
INCLUSION CRITERIA
To be included in the study, each participant's dataset required the following
variables to be available for analysis: diagnosis of traumatic SCI; cervical,
thoracic, or lumbar level of injury; lower extremity pinprick and light touch
sensory scores within 31 days after SCI; walking outcomes at 1 year after SCI;
and data available from the national SCIMS database from April 2004 to March
2021.
OUTCOME MEASURE AND INDEPENDENT VARIABLES
Similar to previous studies, 2 outcome variables collected 1 year after SCI with
yes/no answers were selected from the SCIMS Data Dictionary for the National SCI
Database Form II: “Are you able to walk (with or without mobility aid) for 150
feet in your home?”
20
* Smith AC
* Albin SR
* O'Dell DR
* et al.
Axial MRI biomarkers of spinal cord damage to predict future walking and motor
function: a retrospective study.
Spinal Cord. 2021; 59: 693-699
* Crossref
* PubMed
* Scopus (3)
* Google Scholar
and “Are you able to walk (with or without mobility aid) for one street block
outside?”
6
* Draganich C
* Weber KA
* Thornton WA
* et al.
Predicting outdoor walking 1 year after spinal cord injury: a retrospective,
multisite external validation study.
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Independent walking was defined based on a “yes” answer to both self-reported
ability to walk indoors 150 feet and outdoors 1 street block. Bilateral lower
extremity sharp/dull discrimination (pinprick) and light touch sensory scores
from the L3 through S4-5 dermatomes from the ISNCSCI examination, collected at
the time of rehabilitation admission (≤31 days from SCI), were used to predict
walking. Those who were not independent walkers were defined by a lack of an
answer “yes” to both walking outcome questions. Thus, the outcome being tested
was a binary variable, either independent walkers or not.
DERIVING AND VALIDATING THE CLINICAL PREDICTION RULE
Binary variables were derived for pinprick and light touch sensory scores at
each dermatome that indicated normal sensation bilaterally (both left and
right), normal sensation unilaterally (left or right), any sensation (normal or
altered) bilaterally (left and right), and any sensation unilaterally (left or
right). Next, a SCIMS center that had a large sample size and balanced number of
independent walkers and non-independent walkers was chosen to derive the CPR
(derivation dataset). Statistical analyses were conducted using Python
(version=3.7.11) Scikit-Learn (version=0.21.2), and Scipy (version=1.7.3)
libraries for machine-learning and scientific computing.
Positive and negative predictive values (PPV and NPV, respectively) are values
that can be used to appraise the success of a clinical test for predicting
whether a patient will truly have a desired outcome based on a positive or
negative test result.
22
* Monaghan TF
* Rahman SN
* Agudelo CW
* et al.
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specificity, positive predictive value, and negative predictive value.
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* Crossref
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* Google Scholar
Using true and false positive counts along with true and false negative counts,
the PPV assesses the probability of having the desired outcome based on a
positive test result (ie, “yes” response to predictor variable), while NPV
assesses the probability of not achieving the desired outcome based on a
negative test result (ie, “no” response to predictor variable).
22
* Monaghan TF
* Rahman SN
* Agudelo CW
* et al.
Foundational statistical principles in medical research: sensitivity,
specificity, positive predictive value, and negative predictive value.
Medicina (Kaunas). 2021; 57: 503
* Crossref
* PubMed
* Scopus (30)
* Google Scholar
For this study, PPVs and NPVs were calculated across the full derivation dataset
as well as the derivation subset including only those in the middle of the
recovery spectrum (AIS B and C). Across 10,000 bootstrapped samples, 95%
confidence intervals (CI) were calculated for each PPV and NPV of the binary
variables. Considering both the whole derivation dataset along with a subset
including only those in the middle of the recovery spectrum (AIS B and C), the
single sensory modality and dermatome that first maximized the PPV (primary
measure) and then the NPV (secondary measure) was identified. Pinprick and light
touch predictor variables across all dermatomes (L3 through S4-5) were
considered and assessed (see fig 1). The most optimal sensory modality (either
pinprick or light touch) at the most optimal dermatome was selected to be used
as the predictor variable. This single-sensory-modality-and-dermatome predictor
variable was then used to derive the CPR (see fig 1), which was then validated
on an independent dataset, using the patients from the other SCIMS centers
(validation dataset). Attempting to boost predictive performance in the AIS B
and C validation dataset subgroup, the CPR was applied to those under the age of
50 vs those 50 years and older. To investigate the possible influence of upper
vs lower motor neuron injury, the derived CPR was also tested separately on
participants within the validation dataset with only cervicothoracic neurologic
level injuries (n=2826) and only lumbar neurologic level injuries (n=185).
Finally, to study potential influence of the time of pinprick exam on predictive
performance, we performed a sub-analysis on the validation dataset for 3 time
windows of pinprick testing: within 0-3 days of SCI, within 4-7 days of SCI, or
within 8-31 days of SCI.
Fig 1Positive and negative predictive values of the candidate CPR variables
derived from the pinprick (A) and light touch sensory scores (B) in the
derivation dataset (n=623). For each dermatome and the pinprick and light touch
sensory scores, we derived binary variables that indicated normal sensation
bilaterally (both left and right), normal sensation unilaterally (left or
right), any sensation (normal or altered) bilaterally (left and right), and any
sensation (normal or altered) unilaterally (left or right). Mean PPVs and NPVs
are shown for each candidate variable (●). Error bars=bootstrapped 95% CIs.
★=Used in CPR.
* View Large Image
* Figure Viewer
* Download Hi-res image
* Download (PPT)
RESULTS
The derivation dataset consisted of 623 participants, with 261 independent
walkers and 362 non-walkers. See table 1 for a summary of both the derivation
and validation datasets. Pinprick at the L4 and S1 dermatomes yielded the
optimal PPV (primary measure, 89% and 89%, respectively) and NPV (secondary
measure, 82% and 81%, respectively) for predicting independent walking in the
whole derivation dataset (fig 1). When considering the AIS B and C subset of the
derivation dataset, pinprick at the S1 dermatome yielded the optimal PPVs
(primary measure, 69%) and NPVs (secondary measure, 68%) for predicting
independent walking (fig 2). Therefore, pinprick sensation at S1 was used to
derive the CPR. See table 2 for a breakdown of the CPR prediction statistics,
including true and false positives, true and false negatives, accuracy,
sensitivity, specificity, PPV, and NPV.
Table 1Demographic information
DatasetNAge (Years)% MenIndependent WalkersNon-Independent WalkersInitial AIS
AInitial AIS BInitial AIS CInitial AIS DDerivation (Full)62342.8±18.0
(1)79.826136224861118196Derivation (AIS B&C)17943.7±17.4
(0)79.9791000611180Validation (Full)305642.8±17.9
(22)79.1119118651161398636861Validation (AIS B&C)103444.0±17.5
(7)78.437565903986360Validation (Cervicothoracic)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
282643.3±18.0 (21)79.0104517811090350587799Validation (Lumbar)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
18536.4±16.1 (1)81.11295648434648
NOTE. Age displayed as mean ± 1 standard deviation with (#) indicating number of
participants with missing data.
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
* Open table in a new tab
Fig 2Positive and negative predictive values of the candidate CPR variables
derived from the pinprick sensory scores at the L4 and S1 dermatomes in the AIS
B and C derivation dataset subset (n=179). In the whole derivation dataset,
pinprick at the L4 and S1 dermatomes had similar predictive value (fig 1). When
considering the AIS B and C subset of the derivation dataset, pinprick at the S1
dermatome yielded the optimal PPV (primary measure) and NPV (secondary measure)
for predicting independent walking, so pinprick sensation at S1 was used to
derive the CPR. Mean PPVs and NPVs are shown for each candidate variable (●).
Error bars=bootstrapped 95% CIs. ★=Used in CPR.
* View Large Image
* Figure Viewer
* Download Hi-res image
* Download (PPT)
Table 2Clinical prediction rule prediction results
DatasetNPredictorTrue NegativeFalse PositiveFalse NegativeTrue
PositiveSensitivitySpecificityAccuracyPPVNPVDerivation (Full)623Normal left and
right S1 pinprick sensation351111758632.9 (27.4, 38.8)97.0 (95.1, 98.6)70.1
(66.5, 73.7)88.7 (81.9, 94.6)66.7 (62.6,70.8)Derivation (Full)623Any S1 pinprick
sensation left or right302606919273.6 (68.2,78.7)83.4 (79.5,87.1)79.3
(76.1,82.5)76.2 (70.7, 81.3)81.4 (77.3, 85.3)Derivation (AIS B and C)179Normal
left and right S1 pinprick sensation96470911.3 (4.9, 18.8)96.0 (91.7, 99.1)58.7
(51.4,65.9)69.2 (41.7, 92.9)57.8 (50.3, 65.3)Derivation (AIS B and C)179Any S1
pinprick sensation left or right6931334658.2 (47.4,69.0)69.0 (59.8,77.9)64.3
(57.5,70.9)59.7 (48.7, 70.5)67.7 (58.5, 76.5)Validation (Full)3056Normal left
and right S1 pinprick sensation18135287931226.2 (23.7,28.7)97.2 (96.4,97.9)69.5
(67.9,71.2)85.7 (82.0, 89.2)67.3 (65.6, 69.1)Validation (Full)3056Any S1
pinprick sensation left or right159527032386872.9 (70.3,75.4)85.5 (84,87.1)80.6
(79.2,82)76.3 (73.8, 78.8)83.2 (81.5, 84.8)Validation (AIS B and C)1034Normal
left and right S1 pinprick sensation636233294612.3 (9.0,15.7)96.5
(95.0,97.9)66.0 (63.1,68.9)66.7 (55.4, 77.6)65.9 (62.9, 68.9)Validation (AIS B
and C)1034Any S1 pinprick sensation left or right47918016021557.3
(52.2,62.3)72.7 (69.3,76.1)67.1 (64.2,70)54.4 (49.5, 59.3)75.0 (71.5,
78.3)Validation (AIS B and C under 50 years old)575Normal left and right S1
pinprick sensation34362012511.1 (7.2,15.2)98.3 (96.8,99.4)64.0 (60.0, 68.0)80.7
(65.6,93.8)63.1 (59.0,67.1)Validation (AIS B and C under 50 years old)575Any S1
pinprick sensation left or right271789613057.5 (50.9,64)77.7 (73.2,82.0)69.7
(65.9,73.4)62.5 (55.8,69.0)73.8 (69.2,78.3)Validation (AIS B and C, 50 years and
older)452Normal left and right S1 pinprick sensation288171272013.6
(8.2,19.3)94.4 (91.7,96.9)68.1 (63.7,72.3)53.9 (37.5,70.3)69.4
(64.9,73.7)Validation (AIS B and C, 50 years and older)452Any S1 pinprick
sensation left or right204101648356.4 (48.3,64.4)66.9 (61.5,72.2)63.5
(59.1,67.9)45.1 (37.8,52.4)76.1 (71.0.81.2)Validation (Cervicothoracic)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
2826Normal left and right S1 pinprick sensation17305176428126.9 (24.3,29.6)97.1
(96.3,97.9)71.2 (69.5,72.8)84.6 (80.6, 88.4)69.4 (67.6, 71.2)Validation
(Cervicothoracic)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
2826Any S1 pinprick sensation left or right152725426677974.6 (71.9,77.1)85.7
(84.1,87.3)81.6 (80.2,83.0)75.4 (72.8, 77.9)85.2 (83.5, 86.8)Validation (Lumbar)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
185Normal left and right S1 pinprick sensation5511022720.9 (14.1,28.1)98.2
(94.1,100)44.3 (37.3,51.4)96.4 (88.0, 100.0)35.1 (27.7, 42.8)Validation (Lumbar)
*
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
185Any S1 pinprick sensation left or right4115537658.9 (50.4,67.4)73.1
(61.0,84.4)63.2 (56.2,70.3)83.4 (75.5, 90.7)43.6 (33.7, 53.8)
NOTE. Data for Sensitivity, Specificity, Accuracy, PPV, and NPV are displayed as
mean (95% confidence intervals).
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis.
* Open table in a new tab
In the whole derivation dataset, normal pinprick sensation bilaterally at S1 had
a PPV of 89% (95% CI=82%-95%) for independent walking. Any pinprick sensation
unilaterally at S1 had a PPV of 76% (95% CI=71%-81%) for independent walking.
Any pinprick sensation unilaterally at S1 had an NPV of 81% (95% CI=77%-85%) for
independent walking. In the AIS B and C derivation subset (n=179, AIS B=61, AIS
C=118), normal pinprick sensation bilaterally at S1 had a PPV of 69% (95%
CI=42%-93%), any pinprick sensation unilaterally at S1 had a PPV of 60% (95%
CI=49%-71%) and any pinprick sensation unilaterally at S1 had an NPV of 68% (95%
CI=59%-77%). Two variables, normal pinprick sensation unilaterally at S1 and any
pinprick sensation bilaterally at S1, provided inferior PPVs and NPVs in
comparison with normal pinprick sensation bilaterally at S1 and any pinprick
sensation unilaterally at S1. Therefore, these 2 variables (normal pinprick
sensation unilaterally at S1 and any pinprick sensation bilaterally at S1) were
not considered for the CPR.
The validation dataset consisted of 3056 participants, with 1191 independent
walkers and 1865 non-walkers. In the whole validation dataset, normal pinprick
sensation bilaterally at S1 had a PPV of 86% (95% CI=82%-89%) for independent
walking. Any pinprick sensation unilaterally at S1 had a PPV of 76% (95%
CI=74%-79%) for independent walking. Any pinprick sensation unilaterally at S1
had an NPV of 83% (95% CI=82%-85%) for independent walking.
In the AIS B and C validation subset (N=1034; AIS B=398, AIS C=636), normal
pinprick sensation bilaterally at S1 had a PPV of 67% (95% CI=55%-78%). Any
pinprick sensation unilaterally at S1 had a PPV of 54% (95% CI=50%-59%). Any
pinprick sensation unilaterally at S1 had an NPV of 75% (95% CI=72%-78%).
In the AIS B and C validation subset of those age less than 50 (N=575), normal
pinprick sensation bilaterally at S1 had a PPV of 81% (95% CI=66%-94%). Any
pinprick sensation unilaterally at S1 had a PPV of 63% (95% CI=56%-69%). Any
pinprick sensation unilaterally at S1 had an NPV of 74% (95% CI=69%-78%).
In the AIS B and C validation subset of those age 50 years and older (N=452),
normal pinprick sensation bilaterally at S1 had a PPV of 54% (95% CI=38%-70%).
Any pinprick sensation unilaterally at S1 had a PPV of 45% (95% CI=38%-52%). Any
pinprick sensation unilaterally at S1 had an NPV of 76% (95% CI=71%-81%).
In the validation dataset, 45 participants had missing neurologic injury level
data and were excluded from the cervicothoracic and lumbar neurologic injury
level analysis. In the lumbar SCI validation subset (N=185), normal pinprick
sensation bilaterally at S1 had a PPV of 96% (95% CI=88%-100%). Any pinprick
sensation unilaterally at S1 had a PPV of 83% (95% CI=76%-91%). Any pinprick
sensation unilaterally at S1 had an NPV of 44% (95% CI=34%-54%). In the
cervicothoracic SCI validation subset (N=2826), normal pinprick sensation
bilaterally at S1 had a PPV of 85% (95% CI=81%-88%). Any pinprick sensation
unilaterally at S1 had a PPV of 75% (95% CI=73%-78%). Any pinprick sensation
unilaterally at S1 had an NPV of 85% (95% CI=84%-87%). See table 2 for a
breakdown of the CPR prediction statistics for the lumbar SCI and
cervicothoracic SCI validation subsets.
In the validation subset of those who received pinprick testing within 0-3 days
of SCI (N = 49), normal pinprick sensation bilaterally at S1 had a PPV of 87%
(95% CI=67%-100%). Any pinprick sensation unilaterally at S1 had a PPV of 93%
(95% CI=81%-100%). Any pinprick sensation unilaterally at S1 had an NPV of 59%
(95% CI=38%-79%). In the validation subset of those who received pinprick
testing within 4-7 days of SCI (N=599), normal pinprick sensation bilaterally at
S1 had a PPV of 93% (95% CI=88%-97%). Any pinprick sensation unilaterally at S1
had a PPV of 87% (95% CI=83%-91%). Any pinprick sensation unilaterally at S1 had
an NPV of 72% (95% CI=67%-77%). In the validation subset of those who received
pinprick testing within 8-31 days of SCI (N=2408), normal pinprick sensation
bilaterally at S1 had a PPV of 82% (95% CI=77%-87%). Any pinprick sensation
unilaterally at S1 had a PPV of 72% (95% CI=69%-75%). Any pinprick sensation
unilaterally at S1 had an NPV of 86% (95% CI=84%-87%). See table 3 for a
breakdown of the CPR prediction statistics by time window of pinprick testing.
See figure 3 depicting the CPR.
Table 3Clinical prediction rule results by time window of pinprick test
DatasetNPredictorTrue NegativeFalse PositiveFalse NegativeTrue
PositiveSensitivitySpecificityAccuracyPPVNPVValidation: pinprick assessed within
0-3 days of SCI49Normal left and right S1 pinprick sensation132211338.2 (22.2,
54.5)86.7 (68.4, 100)53.1 (38.8, 67.3)86.7 (66.7, 100)38.2 (22.2, 55)Validation:
pinprick assessed within 0-3 days of SCI49Any S1 pinprick sensation left or
right13292573.5 (57.9, 87.9)86.7 (68.4, 100)77.6 (65.3, 87.8)92.6 (81.0,
100)59.1 (38.1, 79.2)Validation: pinprick assessed within 4-7 days of
SCI599Normal left and right S1 pinprick sensation249823710530.7 (25.9, 35.7)96.9
(94.6, 98.8)59.1 (55.1, 62.9)92.9 (87.9, 97.3)51.2 (46.7, 55.6)Validation:
pinprick assessed within 4-7 days of SCI599Any S1 pinprick sensation left or
right219388525775.1 (70.5, 79.7)85.2 (80.8, 89.5)79.5 (76.3, 82.6)87.1 (83.2,
90.9)72.0 (67.0, 77.0)Validation: pinprick assessed within 8-31 days of
SCI2408Normal left and right S1 pinprick sensation15514262119423.8 (20.9,
26.7)97.4 (96.5, 98.1)72.5 (70.7, 74.3)82.2 (77.1, 87)71.4 (69.6,
73.3)Validation: pinprick assessed within 8-31 days of SCI2408Any S1 pinprick
sensation left or right136323022958671.9 (68.9, 75.0)85.6 (83.8, 87.3)80.9
(79.4, 82.5)71.8 (68.7, 74.9)85.6 (83.9, 87.3)
NOTE. Data for sensitivity, specificity, accuracy, PPV, and NPV are displayed as
mean (95% CI).
* Open table in a new tab
Fig 3The S1 lateral heel pinprick clinical prediction rule.
* View Large Image
* Figure Viewer
* Download Hi-res image
* Download (PPT)
DISCUSSION
In this large multi-site retrospective study, we derived and validated a CPR
using only pinprick sensory testing at the lateral heels (ie, S1 dermatomes)
within 31 days of SCI to accurately identify future independent walkers 1 year
after SCI. For our full validation dataset, ≈9 of 10 people with SCI and normal
pinprick sensation at both the left and right lateral heels endorsed independent
walking, and ≈8 of 10 people with any pinprick at either the left or right
lateral heels endorsed independent walking. In contrast, ≈8 of 10 people without
any pinprick sensation unilaterally (ie, no pinprick sensation at either the
left or right lateral heel) did not endorse independent walking. Importantly,
for people initially classified within the middle of the SCI severity spectrum
(ie, AIS B and C classification), who present the greatest challenge when
predicting clinical trajectory, ≈7 of 10 with normal pinprick sensation at both
the left and right lateral heels endorsed independent walking, while ≈8 of 10
people with no pinprick sensation at either the left or right lateral heel did
not endorse independent walking.
12
* Phan P
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* et al.
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* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
This CPR provides clinicians with a tool that has predictive value for people
across the recovery spectrum including those with AIS B and C injuries. Overall,
we demonstrate that pinprick sensory testing at the S1 dermatome(s) can be used
to accurately predict high level walking ability 1 year after SCI (both indoors
and outdoors). Limiting the CPR to only the S1 dermatome provides a simple and
accurate tool for predicting independent walking 1 year after SCI. Furthermore,
the variable for this CPR can easily be obtained by assessing pinprick sensation
at the lateral heels at bedside.
Our results are in alignment with previous studies that found pinprick sensation
to be important in the prediction of future functional recovery. Waters et al
found that 16% of people with motor complete SCI who had bilateral sacral
pinprick sensation eventually regained some voluntary movement in the lower
extremities.
10
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13
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We believe that our CPR is straightforward to implement at the bedside. After
SCI, if the individual can perceive pinprick sensation at the right and left
lateral heels and it feels normal, then there is a good prognosis for recovering
future independent walking ability. If the individual reports any pinprick
sensation in either lateral heel, even if it feels different than other
unimpaired skin areas (ie, face), then there is a fair prognosis for recovering
future independent walking ability. If the individual cannot feel pinprick
sensation at either lateral heel, then there is a poor prognosis for recovering
future independent walking ability. For these fair and poor prognosis cases,
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Regarding an optimal time window of pinprick exam to optimize predictive
performance, we found that the earlier time windows (within 0-3 days and 4-7
days of SCI) provided better PPV than the later time window (within 8-31 days of
SCI). However, the later time window provided better NPV. These data suggest
that our CPR may work best for ruling in future independent walkers when applied
within 0-7 days of SCI, yet may work best for ruling out future independent
walkers when applied later on.
The underlying reasons for the importance of pinprick sensation regarding future
motor recovery may be rooted in the anatomic locations of the human spinal
cord's ascending and descending tracts. The lateral corticospinal tracts,
responsible for volitional motor output, are in close proximity to the lateral
spinothalamic tracts which convey sharp pinprick sensation.
13
* Crozier KS
* Graziani V
* Ditunno JF
* Herbison GJ
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* Parrish TB
* Wasielewski M
* Elliott JM
Lateral corticospinal tract damage correlates with motor output in incomplete
spinal cord injury.
Arch Phys Med Rehabil. 2018; 99: 660-666
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (16)
* Google Scholar
,
31
* Smith AC
* O'Dell DR
* Albin SR
* et al.
Lateral corticospinal tract and dorsal column damage: predictive relationships
with motor and sensory scores at discharge from acute rehabilitation after
spinal cord injury.
Arch Phys Med Rehabil. 2022; 103: 62-68
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (0)
* Google Scholar
The main tracts that convey light touch sensation lie in the dorsal columns,
which are farther away from the motor pathways.
31
* Smith AC
* O'Dell DR
* Albin SR
* et al.
Lateral corticospinal tract and dorsal column damage: predictive relationships
with motor and sensory scores at discharge from acute rehabilitation after
spinal cord injury.
Arch Phys Med Rehabil. 2022; 103: 62-68
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (0)
* Google Scholar
Co-localization of the corticospinal and spinothalamic tracts may explain the
relation between residual pinprick sensation and independent walking—pinprick
sensation may act as a surrogate marker of corticospinal tract integrity.
In alignment with our findings, several past CPRs identified sensory function at
the S1 dermatome as an important predictor for future walking.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
,
4
* Hicks KE
* Zhao Y
* Fallah N
* et al.
A simplified clinical prediction rule for prognosticating independent walking
after spinal cord injury: a prospective study from a Canadian multicenter spinal
cord injury registry.
Spine J. 2017; 17: 1383-1392
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
,
5
* Jean S
* Mac-Thiong JM
* Jean MC
* Dionne A
* Bégin J
* Richard-Denis A
Early clinical prediction of independent outdoor functional walking capacity in
a prospective cohort of traumatic spinal cord injury patients.
Am J Phys Med Rehabil. 2021; 100: 1034-1041
* Crossref
* PubMed
* Scopus (1)
* Google Scholar
,
6
* Draganich C
* Weber KA
* Thornton WA
* et al.
Predicting outdoor walking 1 year after spinal cord injury: a retrospective,
multisite external validation study.
J Neurol Phys Ther. 2023; 47: 155-161
* Crossref
* PubMed
* Scopus (0)
* Google Scholar
From a clinical perspective, S1 is a distal spinal cord segment that provides
innervation to the lower extremity extensor muscle groups necessary for forward
propulsion during walking. On the other hand, for our CPR, S1 pinprick sensation
may be serving as a more global measure for spared sensation across the sacral
segments and especially the most caudally innervated at S4-5.
32
* Zariffa J
* Kramer JLK
* Jones LAT
* et al.
Sacral sparing in SCI: beyond the S4-S5 and anorectal examination.
Spine J. 2012; 12: 389-400
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (21)
* Google Scholar
In their 2020 study, Engel-Haber et al found improved CPR accuracy when using an
age cut-off of 50 years old.
33
* Engel-Haber E
* Zeilig G
* Haber S
* Worobey L
* Kirshblum S
The effect of age and injury severity on clinical prediction rules for
ambulation among individuals with spinal cord injury.
Spine J. 2020; 20: 1666-1675
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (5)
* Google Scholar
In alignment with these findings, when considering our AIS B and C validation
subset with age less than 50, we found that, while other predictive metrics were
not substantially improved, the PPV of having normal S1 bilateral pinprick
sensation improved from 67% to 81%. This suggests that our CPR may work even
better at ruling in future independent walkers if they are in the middle of the
SCI severity spectrum and younger than 50 years old.
When applying our CPR to the cervicothoracic SCI and lumbar SCI validation
subsets, the PPVs for normal bilateral pinprick sensation (85% and 96%,
respectively) and any pinprick sensation remained high (75% and 83%,
respectively). However, the NPV for no pinprick sensation in either the left and
right lateral heels was markedly lower for the lumbar SCI validation subset:
only 44% in comparison with 85% in the cervicothoracic SCI validation subset.
While we are unsure of the exact reasons underlying this finding, we hypothesize
that some of these participants with lumbar SCIs may be classified with lower
motor neuron injuries where function in key lower extremity muscles (ie,
quadriceps) may have remained at least partially intact. These individuals may
be able to walk independently using ankle-foot orthoses and/or other assistive
devices. Taken together, these data suggest a good prognosis for those with
lumbar neurologic level SCIs who have normal bilateral pinprick at the lateral
heels, but our CPR does not rule out future independent walking if pinprick at
the lateral heels is limited in this subgroup.
STUDY LIMITATIONS
Our intention was to create a simple CPR for those in the middle of the SCI
severity spectrum but admittedly, our CPR is less accurate in the AIS B and C
subgroup than the established van Middendorp and Hicks CPRs.
3
* van Middendorp JJ
* Hosman AJ
* Donders ART
* et al.
A clinical prediction rule for ambulation outcomes after traumatic spinal cord
injury: a longitudinal cohort study.
Lancet. 2011; 377: 1004-1010
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (183)
* Google Scholar
,
4
* Hicks KE
* Zhao Y
* Fallah N
* et al.
A simplified clinical prediction rule for prognosticating independent walking
after spinal cord injury: a prospective study from a Canadian multicenter spinal
cord injury registry.
Spine J. 2017; 17: 1383-1392
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
For their CPRs, overall accuracy is ≈74%,
12
* Phan P
* Budhram B
* Zhang Q
* et al.
Highlighting discrepancies in walking prediction accuracy for patients with
traumatic spinal cord injury: an evaluation of validated prediction models using
a Canadian Multicenter Spinal Cord Injury Registry.
Spine J. 2019; 19: 703-710
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Google Scholar
vs our overall accuracy of 67% for our AIS B and C validation subgroup. When
considering which CPR to use, simplicity and ease of clinical application
without reliance on motor scores should be considered for our CPR, but this
comes as a trade-off of reduced accuracy compared with the van Middendorp and
Hicks CPRs. Next, the use of self-reported outcome measures for the walking
outcome may not reflect actual walking performance, although past research found
good accuracy with self-reporting in a cohort of individuals with SCI compared
with physiatrist criterion standard.
34
* Harvey LA
* Weber G
* Heriseanu R
* Bowden JL
The diagnostic accuracy of self-report for determining S4-5 sensory and motor
function in people with spinal cord injury.
Spinal Cord. 2012; 50: 119-122
* Crossref
* PubMed
* Scopus (9)
* Google Scholar
STRENGTHS
We believe that a major strength of our CPR lies in its simplicity. Our CPR only
requires pinprick information at the right and left lateral heels (ie, S1
dermatomes) to predict walking 1 year after SCI. The lack of reliance on motor
scores is a strength of our CPR. Another strength is our definition of
independent walking, where each person had to endorse the ability to both walk
indoors as well as outdoors at least 1 street block. A third strength of our
study is the use of a multi-site dataset (12 sites) with a large and
geographically diverse sample. The large sample size allowed us to independently
derive (N=623) and validate (N=3056) the CPR, and the diversity in the sample
likely improves the generalizability of the CPR to the United States SCI
population.
35
* Ketchum JM
* Cuthbert JP
* Deutsch A
* et al.
Representativeness of the Spinal Cord Injury Model Systems National Database.
Spinal Cord. 2018; 56: 126-132
* Crossref
* PubMed
* Scopus (11)
* Google Scholar
FUTURE DIRECTIONS
A remaining research question is how to further improve the predictive value for
the AIS B and C subpopulation. Adding other clinical variables, such as
MRI-based measures of SCI,
20
* Smith AC
* Albin SR
* O'Dell DR
* et al.
Axial MRI biomarkers of spinal cord damage to predict future walking and motor
function: a retrospective study.
Spinal Cord. 2021; 59: 693-699
* Crossref
* PubMed
* Scopus (3)
* Google Scholar
,
21
* Berliner JC
* O'Dell DR
* Albin SR
* et al.
The influence of conventional T2 MRI indices in predicting who will walk outside
one year after spinal cord injury.
J Spinal Cord Med. 2023; 46: 501-507
* Crossref
* PubMed
* Scopus (5)
* Google Scholar
,
31
* Smith AC
* O'Dell DR
* Albin SR
* et al.
Lateral corticospinal tract and dorsal column damage: predictive relationships
with motor and sensory scores at discharge from acute rehabilitation after
spinal cord injury.
Arch Phys Med Rehabil. 2022; 103: 62-68
* Abstract
* Full Text
* Full Text PDF
* PubMed
* Scopus (0)
* Google Scholar
,
36
* Smith AC
* O'Dell DR
* Thornton WA
* et al.
Spinal cord tissue bridges validation study: predictive relationships with
sensory scores following cervical spinal cord injury.
Top Spinal Cord Inj Rehabil. 2022; 28: 111-115
* Crossref
* PubMed
* Scopus (1)
* Google Scholar
might bolster the prediction of walking in this subgroup. Also, future research
should consider external validation of our CPR in other cohorts and/or outside
the United States.
CONCLUSIONS
In this large, multi-site retrospective study, we derived and validated a simple
and accurate CPR that predicts future independent walking ability after SCI that
does not rely on motor scores and works for those in the middle of the recovery
spectrum. With pinprick sensory testing in a single dermatome, S1 at the lateral
heels, clinicians can use our CPR to predict—within 31 days after SCI—who is
likely to recover independent walking 1 year after traumatic SCI.
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Lateral corticospinal tract and dorsal column damage: predictive
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The effect of age and injury severity on clinical prediction rules for
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* Weber G
* Heriseanu R
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The diagnostic accuracy of self-report for determining S4-5 sensory and
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Spinal Cord. 2012; 50: 119-122
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* Scopus (9)
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* Crossref
* Google Scholar
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* Cuthbert JP
* Deutsch A
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Representativeness of the Spinal Cord Injury Model Systems National
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Spinal Cord. 2018; 56: 126-132
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* PubMed
* Crossref
* Google Scholar
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* O'Dell DR
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ARTICLE INFO
PUBLICATION HISTORY
Published online: July 04, 2023
Accepted: June 22, 2023
Received in revised form: April 24, 2023
Received: January 24, 2023
PUBLICATION STAGE
In Press Journal Pre-Proof
FOOTNOTES
This work was supported by the Craig Hospital Foundation. A.C.S. was supported
by Eunice Kennedy Shriver National Institute of Child Health and Human
Development of the National Institutes of Health—K01HD106928.
Disclosures: A.C.S. and W.A.T. were supported by the Boettcher Foundation's
Webb-Waring Biomedical Research Program. K.A.W. was supported by NIH National
Institute of Neurological Disorders and Stroke of the National Institutes of
Health—K23NS104211 and L30NS108301. The content is solely the responsibility of
the authors and does not necessarily represent the official views of the
National Institutes of Health.
IDENTIFICATION
DOI: https://doi.org/10.1016/j.apmr.2023.06.015
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SCIENCEDIRECT
Access this article on ScienceDirect
A Single Dermatome Clinical Prediction Rule for Independent Walking 1 Year After
Spinal Cord Injury
*
*
*
Hide CaptionDownloadSee figure in article
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* Fig. 1
* Fig. 2
* Fig. 3
* View Large Image
* Download Hi-res image
* Download .PPT
FIGURES
* Fig 1Positive and negative predictive values of the candidate CPR variables
derived from the pinprick (A) and light touch sensory scores (B) in the
derivation dataset (n=623). For each dermatome and the pinprick and light
touch sensory scores, we derived binary variables that indicated normal
sensation bilaterally (both left and right), normal sensation unilaterally
(left or right), any sensation (normal or altered) bilaterally (left and
right), and any sensation (normal or altered) unilaterally (left or right).
Mean PPVs and NPVs are shown for each candidate variable (●). Error
bars=bootstrapped 95% CIs. ★=Used in CPR.
* Fig 2Positive and negative predictive values of the candidate CPR variables
derived from the pinprick sensory scores at the L4 and S1 dermatomes in the
AIS B and C derivation dataset subset (n=179). In the whole derivation
dataset, pinprick at the L4 and S1 dermatomes had similar predictive value
(fig 1). When considering the AIS B and C subset of the derivation dataset,
pinprick at the S1 dermatome yielded the optimal PPV (primary measure) and
NPV (secondary measure) for predicting independent walking, so pinprick
sensation at S1 was used to derive the CPR. Mean PPVs and NPVs are shown for
each candidate variable (●). Error bars=bootstrapped 95% CIs. ★=Used in CPR.
* Fig 3The S1 lateral heel pinprick clinical prediction rule.
TABLES
* Table 1Demographic information
* Table 2Clinical prediction rule prediction results
* Table 3Clinical prediction rule results by time window of pinprick test
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