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Page 2 of 14 Zoghi et al. Neuroimmunol Neuroinflammation 2019;6:14 I http://dx.doi.org/10.20517/2347-8659.2019.03

INTRODUCTION
Spinal cord injury (SCI) is one of the most devastating disabilities which can affect a person’s life
significantly. Normal movement patterns are significantly impaired as a result of a spinal lesion, due to
decreased/loss of supraspinal influences over the spinal cord and impaired appreciation of peripheral
sensory inputs. One of the main aims of rehabilitation for patients with SCI is to assist them to become as
[1]
independent as possible in daily activities and facilitate normal movement patterns as much as possible.
For patients with complete SCI, however, therapists usually do not focus on promoting neurological
improvement in the paralysed extremities. For this group of patients, rehabilitation strategies are mainly
focused on teaching compensatory strategies including using a variety of assistive devices during
[1]
therapeutic sessions .

Many patients considered to have clinically complete SCI are neurophysiologically incomplete
[2-6]
(discomplete) . It has been argued that these connections are not detectable with clinical assessment;
however, they are able to modulate the excitability of spinal sensorimotor connections below the level of
[6-8]
injury . In addition, there has been a case where the function of muscles below the level of injury could
be improved by using functional electrical stimulation (FES) or locomotor training (LT) while body weight
is partially supported [9-11] .

Brain motor control assessment (BMCA) is a surface electromyography-based assessment that can add
[12]
resolution to clinical assessment in patients with SCI . In this assessment, motor outputs from the
[13]
nervous system are recorded through a variety of reflexes and voluntary motor tasks of the lower limbs
performed under strictly controlled conditions. Sub-clinical evidence of translesional motor connections
has been observed in patients considered to have a clinically complete lesion of the spinal cord using this
[2]
type of assessment . These subclinical responses can take various forms, for example repeatable responses
[14]
to reinforcement manoeuvres or strong vibration or the ability to volitionally suppress responses evoked
by plantar surface stimulation [15,16] .

This paper presents the results of the BMCA assessments conducted in patients at one site of a multi-centre,
[17]
assessor-blinded, randomised controlled trial (Spinal Cord Injury and Physical Activity Full-On) , which
investigated the effectiveness of an intensive activity-based therapy program for patients with clinically
[17]
complete and incomplete SCI. For full details of the protocol, please refer to Galea et al. . The trial was
registered on ClinicalTrials.gov (NCT01236976).

METHODS
Twelve neurologically intact participants (six female and six male) and 18 patients who were at least 6
months post-SCI participated in this study. The demographic information of patients with SCI including
neurological level (sensory and motor) and American Spinal Injury Association Impairment Scale (AIS)
[18]
classification are presented in Table 1 . These measurements were generated using the International
Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) [18,19] .

All participants gave their written informed consent before the BMCA assessments were carried out (in
addition to the consent for the clinical trial). All procedures used conformed with the Declaration of
Helsinki, and the protocol was approved by the Human Research Ethics Committees at The University of
Melbourne and Austin Health.

Neurologically intact participants were assessed using BMCA to generate prototype response vectors for
two bilateral voluntary tasks (hip/knee flexion-extension) and four unilateral voluntary tasks (hip/knee
flexion/extension and ankle dorsiflexion/plantar flexion). These values were used to calculate the similarity