Brain Research Bulletin 78 (2009) 43–51 Contents lists available at ScienceDirect Brain Research Bulletin journal homepage: www.elsevier.com/locate/brainresbull Research report Prediction of walking recovery after spinal cord injury Giorgio Scivoletto * , Valentina Di Donna Spinal Cord Unit, IRCCS Fondazione S. Lucia, Via Ardeatina 306, 00179 Rome, Italy article info Article history: Received 19 December 2007 Received in revised form 28 May 2008 Accepted 4 June 2008 Available online 17 July 2008 Keywords: Spinal cord injury Walking recovery Prognostic factors abstract The recovery of walking function is considered of extreme relevance both by patients and physicians. Con- sequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Society is making demands for treatment before adequate trials have been conducted, but the scientific community has emphasized the need for rigorous guidelines and studies. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affect- ing the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones. The prognostic value of some instrumental examinations and of the more diffuse pharmacological and surgical interventions has also been reviewed. © 2008 Elsevier Inc. All rights reserved. 1. Introduction Walking recovery is one of the main goal of patients after SCI: walking is rated at first place by patients with incom- plete lesions [34]. Furthermore, epidemiological studies show an increase of the number of patients with incomplete lesions (e.g., with chances of walking recovery) [87]. Therefore, the recovery of ambulation has become the target of several pharmacological and rehabilitative approaches [85,116] and a precise evaluation of the natural recovery of walking and of the prognostic factors influencing this function has become mandatory [40,104]. Recent reports highlighted the importance not only of walking level, but also of walking performances, in particular, speed and distance [68]. In the present work we evaluated the effect of several clinical and demographic features on the prognosis for walking recovery. Furthermore, because one of the main problems of the acute phase of SCI is the lack of reliable examinations, we took into exam the prognostic value of neurophysiological and neuroimaging exam- inations. Finally, we briefly reviewed the effects of the principle pharmacological and surgical interventions during the acute phase of the spinal injury. * Corresponding author. Tel.: +39 06 51501604; fax: +39 06 51501679. E-mail address: g.scivoletto@hsantalucia.it (G. Scivoletto). 2. Clinical examination The most relevant prognostic factor for SCI patients is the neurological status at the moment of the first examination. The physical examination of these patients has been standardised by the American Spinal Injury Association [4]. The required elements of this examination determine the precise sensory, motor, and the neurologic levels of injury, as well as the severity of the lesion (impairment). Components also include a rectal examination for voluntary anal contraction and anal sensation (Figs. 1 and 2). The completeness of the lesion (AIS impairment A), according to the ASIA Impairment Scale, is defined as the absence of sen- sory or motor function at the lowest sacral segments, while the incomplete injury is defined as the preservation of motor function (voluntary external anal sphincter contraction) or sensation below the neurologic level of injury, that includes the lowest sacral seg- ments. Without sacral sparing (i.e., voluntary anal contraction, light touch or pinprick at the S4/S5 dermatome, or anal sensation), motor recovery is not significantly different between complete and incom- plete patients [4] (Fig. 2). The timing of examination has been a matter of debate, but right now there is a general agreement that the 72h examination may be more accurate than 48 h assessment as a prognostic predictor [54]. Another commonly used examination interval for predicting recovery is 1-month postinjury [109,111,120]. Historically, it tended to correspond more closely with the timing of admission to a reha- bilitation facility, but recently managed care and medical reform have led to shorter lengths of stay for acute hospitalization [39,43]. 0361-9230/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.brainresbull.2008.06.002