Study design: Construction of an international walking scale by a modi®ed Delphi technique. Objective: The purpose of the study was to develop a more precise walking scale for use in clinical trials of subjects with spinal cord injury (SCI) and to determine its validity and reliability. Setting: Eight SCI centers in Australia, Brazil, Canada (2), Korea, Italy, the UK and the US. Methods: Original items were constructed by experts at two SCI centers (Italy and the US) and blindly ranked in an hierarchical order (pilot data). These items were compared to the Functional Independence Measure (FIM) for concurrent validity. Subsequent independent blind rank ordering of items was completed at all eight centers (24 individuals and eight teams). Final consensus on rank ordering was reached during an international meeting (face validation). A videotape comprised of 40 clips of patients walking was forwarded to all eight centers and inter-rater reliability data collected. Results: Kendall coecient of concordance for the pilot data was signi®cant (W=0.843, P50.001) indicating agreement among the experts in rank ordering of original items. FIM comparison (Spearman's rank correlation coecient=0.765, P50.001) showed a theoretical relationship, however a practical dierence in what is measured by each scale. Kendall coecient of concordance for the international blind hierarchical ranking showed signi®cance (W=0.860, P50.001) indicating agreement in rank ordering across all eight centers. Group consensus meeting resulted in a 19 item hierarchical rank ordered`Walking Index for Spinal Cord Injury (WISCI)'. Inter-rater reliability scoring of the 40 video clips showed 100% agreement. Conclusions: This is the ®rst time a walking scale for SCI of this complexity has been developed and judged by an international group of experts. The WISCI showed good validity and reliability, but needs to be assessed in clinical settings for responsiveness. Spinal Cord (2000) 38, 234 ± 243

Study design: Cross-sectional and longitudinal direct observation of a constrained consensus-building process in nine consumer panels and three rehabilitation professional panels. Objectives: To illustrate differences among consumer and clinician preferences for the restoration of walking function based on severity of injury, time of injury and age of the individual. Setting: Regional Spinal Cord Center in Philadelphia, USA. Methods: Twelve panels (consumer and clinical) came to independent consensus using the featuresresource trade-off game. The procedure involves trading imagined levels of independence (resources) across different functional items (features) at different stages of recovery. Results: Walking is given priority early in the game by eight out of nine consumer panels and by two out of three professional panels. The exception consumer panel (ISCIo50) moved walking later in the game, whereas the exception professional panel (rehRx) moved wheelchair early but walking much delayed. Bowel and Bladder was given primary importance in all panels. Conclusions: Walking is a high priority for recovery among consumers with spinal cord injury irrespective of severity of injury, time of injury and age at time of injury. Among professional staff, walking is also of high priority except in rehabilitation professionals.

Study design: Retrospective examination. Objectives: To compare the Walking Index for Spinal Cord Injury (WISCI) and current scales for their sensitivity to walking changes in subjects with a spinal cord lesion (SCL) and further validate the WISCI for use in clinical trails. Setting: A large rehabilitation hospital in the center of Italy. Patients and methods: Retrospective review was performed on 284 patient records with an SCL. Measurements included neurological evaluation with Lower Extremity Motor Scores (LEMS) according to the American Spinal Injury Association (ASIA) and walking status assessed by Barthel Index (BI (0-15)), Rivermead Mobility Index (RMI (three levels)), Functional Independence Measure (FIM (1-7)), Spinal Cord Independence Measure (SCIM (0-8)), and WISCI (0-20). The WISCI is a 21-level hierarchical scale which incorporates gradations of physical assistance and devices required for walking. Improvement in walking is based on the change of scores from admission to discharge. Statistical analysis included Spearman rank correlation and w 2 test; Po0.05. Results: There was a significant positive correlation between WISCI and other scales (WISCI and BI r ¼ 0.67, Po0.001; WISCI and RMI r ¼ 0.67, Po0.001; WISCI and SCIM r ¼ 0.97, Po0.001; WISCI and FIM r ¼ 0.7, Po0.001). The initial ASIA grade was predictive of mobility outcome on the WISCI: of the 78 ASIA A patients, only five achieved independent walking versus 4/17 ASIA B (P ¼ 0.02), 56/109 ASIA C (Po0.001) and 39/44 ASIA D (Po0.001). The correlation of LEMS to the WISCI was 0.58 (Po0.001). At discharge, patients were distributed into 12 WISCI levels versus four FIM, three BI, two RMI and five SCIM levels. The most frequent WISCI levels at discharge were 13 (walker, no braces or assistance), 16 (two crutches, no braces or assistance) and 20 (no devices or assistance). Conclusions: Similar correlation between the WISCI and the other scales indicates that all these measures address the same concept, mobility, which is a measure of concurrent validity. The correlation is not 100% because of conceptual differences (the WISCI incorporates gradations of physical assistance and devices required for walking while most of the other scales focus on burden of care or mobility in the environment). The WISCI is more detailed and appears more sensitive to walking recovery than the other scales, as demonstrated by our patients' score distribution at discharge. Within each of the most frequent WISCI levels (13,16,20) LEMS and other walking features varied; therefore the scale would benefit from further refinement based on speed, distance and energy cost.

Study design: The present study was undertaken to focus the age-related characteristics of a population of traumatic and nontraumatic spinal cord patients. Objectives: to examine demographic, injury and outcome characteristics of older adults with spinal cord lesions as a result of trauma and nontrauma, and to compare these characteristics with those of younger patients in matched cohorts. Setting: Spinal Cord Unit, Fondazione Santa Lucia IRCCS, a large rehabilitation hospital of the centre-south of Italy. Methods: In total, 284 consecutive newly injured patients with traumatic and nontraumatic spinal cord lesions were retrospectively reviewed and divided according to age into two groups: under 50 years (group 1) and over 50 years (group 2). The following information was collected: onset of lesion to admission; injury variables: aetiology, level, associated injuries, medical complications and surgical intervention; length of stay; American Spinal Injury Association (ASIA) impairment and motor scores; Barthel Index (BI) and Rivermead Mobility Index (RMI) to assess independence in daily living; Walking Index for Spinal Cord Injury to assess ambulation; patients destination at discharge. In a subset of 130 subjects, a block design, matching procedure was used to control for the covariant effects of injury characteristics, time from lesion and aetiology on age effects. Results: In the entire group of 284 patients, older subjects had a higher probability of having incomplete tetraplegia of nontraumatic origin; they also showed a shorter length of stay and a higher rate of complications. In the matched cohorts, younger patients showed better neurologic recovery (intended as ASIA impairment grade improvement and motor scores increase), significantly higher Barthel Index and RMI at discharge, a higher level of independence in spontaneous bladder and bowel management and a higher frequency of independent walking. Conclusion: Older individuals with spinal cord injury and disease do well, but have a less favourable outcome in regard to walking, bladder and bowel independence than younger subjects and have more associated medical problems. Different rehabilitative strategies, therefore, are required for older subjects, which maximises the shorter length of stay and provides the necessary medical care and increased physical assistant resources following discharge.

Hemisphere specialization for mental rotation was investigated utilizing Shepard's (1971) paradigm. In each of two experiments, the procedure involved presenting pairs of novel non-verbal stimuli at various angles of disparity. Subjects were instructed to construct a mental image of one stimulus, rotate this image, and judge whether or not the image was a congruent match with its mate. Both response time and accuracy were measured. In Experiment 1, the testing of right-handed normals revealed a significant left visual field advantage for accuracy (p less than .0001) and response time (p less than .05). In Experiment 2, a comparison of right parietal lesioned patients with both left parietal lesioned patients and matched normal controls likewise revealed significant right lesion effects for accuracy (p greater than .0001) and response time (p greater than .01). Right hemisphere specialization for mental rotation was documented for both normals and brain damaged subjects.