NEUROLOGICAL RECOVERY AND FUNCTIONAL OUTCOME OF COMPLETE TRAUMATIC SPINAL CORD INJURY PATIENTS: AN OBSERVATION FROM BANGLADESH

1,3 BOT, Centre for the Rehabilitation of the Paralysed, Bangladesh. 2 Consultant Neurosurgeon & Head of Medical Services Wing, Centre for the rehabilitation of the Paralysed (CRP). 5 MBBS, MBA, MPH, MD Resident, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University, Bangladesh. 4,6 BPT, Centre for the Rehabilitation of the Paralysed (CRP), Bangladesh. *7 MPH, Executive Officer, Bangladesh Physiotherapy Association (BPA).

and the extent of it cause upper and lower motor loss as well as sensory impairments, which are turn into complete or an incomplete lesion [5]. SCI mostly occurs in mid 20s and worldwide approximate annual incidence is 22 Spinal cord injury (SCI) is a sudden debilitating and devastating [1,2,3] event that causes longterm disability, increases morbidity and mortality [4]. SCI could be traumatic or non-traumatic per million of population [6]. Neurological recovery and functional outcome is the burning issue for the SCI patients. Most of the SCI patients after injury want to know when he/she can able to walk. Sometimes this is a prime goal of SCI patients throughout of his/ her course of the treatment [5,7]. But neurological recovery depends on the improvement of motor scores and American Spinal Injury Association (ASIA) impairment scale [8]. Less severe damaged cord which is known as incomplete and classified as American Spinal Injury Association Impairment Scale (AIS)-B, C, D has shown different extent of neurological and functional improvement. Whereas severely damaged cord which is classified as AIS-A, has rare possibility of having neurological improvement. Previously it was thought that a complete case will never become incomplete one. Fortunately now a day some of the studies showed the remarkable sensory-motor improvement even for the complete injured patients who never underwent surgery. An evident showed 12.1% of complete A converted to AIS grade B and 77.2% improved to AIS grade D whose Initial AIS was C approximately after 74 days [9]. Another study found that 2% to 3% complete SCI recovering to ASIA grade D status within 1 year after injury [10]. As functional outcome depends on neurological status or level of injury, neurological status or level of injury and natural recovery is very important for the measurement of prognosis and making management plan of a SCI patient [11]. Bangladeshis a developing country of South-Asia region, despite being burdened with 160 million populations has immense progress in health sector [1,2]. The aim of our study was to evaluate the amount of neurologic recovery and functional outcome in patients with complete traumatic spinal cord lesions. To the authors' best knowledge this is the first study to dealing with the neurological recovery and functional outcome of complete traumatic spinal cord injury patients in Bangladesh.

METHODOLOGY
Rehabilitation of the Paralysed (CRP), Savar, Bangladesh. And which was conducted in accordance with the Declaration of Helsinki. All information was kept in secure. Confidentiality of the person and the information was maintained and observed and unauthorized persons did not have any access to the collected data. Study Design: After clearance from Institutional Ethics Committee, we conducted a retrospective analysis of AIS grade, sensory level, SCIMS and demography related data. We included 437 SCI patients who were admitted to the Centre for the Rehabilitation of the Paralysed (CRP). Study shows that 72-hour to 1 -week examination most commonly used for long-term neurologic outcomes [12]. So During admission an initial neurologic deficit was assessed according to the ASIA standards [13] done by medical professionals with evaluation of right and left motor and sensory levels and ASIA impairment scale, and after completion of at least three months rehabilitation program during discharge time again ASIA done by well-trained medical professionals as because of compare of their Neurological extent as well as Functional outcome. Patient assessed according to ASIA impairment scale classes A, B, C and D [8]. After then motor score and Spinal Cord Independence Measure (SCIM) [14] changes were calculated based on the difference between admission and discharge during rehabilitation time. Since 1990 CRP provide three months rehabilitation program which was a complete predefined preplanned Rehabilitation program for SCI patients. This three month Rehabilitation program is performed by multi-disciplinary medical professionals, but some cases this time might be increase according to patient improvement and secondary complication. Site: CRP is a well-known not for profit organization in Bangladesh for Rehabilitation of the SCI patients. As a mother organization CRP receives referrals from different hospitals and from all over the Bangladesh for Rehabilitation of the SCI patients. CRP provides acute care for SCI patients and admits approximately 388 SCI patients in each year [15] which makes this NGO (Non-Government Organization) one of the largest acute spinal cord injury units in South East Asia.
Ethical consideration: The researchers were duly concern regarding the ethical aspects of the study, the study received ethical approval Participants Data were collected retrospectively from hospital records from June 2014 to June 2017. We include all AIS complete A, patients admitted to the CRP in the mentioned time. We exclude those participants who were below 15 years [11,9]    Most of the participants two hundred twenty four (51.3%) had fall from height and Road traffic accident was the second most common cause having the distribution of one hundred twenty six patients (28.8%). Sixty two patients (14.2%) gave history of fall of Heavy weight over neck or back. Among other causes (3.2%) diving into shallow water seven (1.6%), Scarf injury three (.7%) and Bull attack two (.5%) were interesting cause of spinal cord injury patients ( Figure 1). Abbreviations: AIS, American Spinal Injuries Association Impairment Scale; IQR, interquartile range. a The AIS classification was missing for one person who was wheelchair user at discharge.
The characteristics of the participants include from June 2014 to June 2017 are shown in Table  2. Three hundred and ninety-four (90.2%) participants were male with a median (IQR) age of 30 years (17). All the participants initial AIS was A, during discharge twenty six (5.9%) were shifted into B, thirty eight (8.7%) were shifted into C, twenty eight (6.4%) were shifted into D and unchanged were three hundred forty four (78.7%). Three hundred and thirty-eight (77.3%) participants were wheelchair-dependent and forty-nine (11.2%) were walking at the time of discharge. Most participants had traumatic paraplegia (278; 63.6%) or traumatic tetraplegia (159; 36.4%) ( Table 2).
Above T7 173 17 16 9 Distributions of AIS grades by Neurological level are listed in table 3. AIS grade A were disproportionately represented in the paraplegic group for the full sample about two hundred thirty three (53.31%) followed by AIS A one seventy three (39.58%) mentioning above T7 and sixty (13.72%) represented T1-6, whereas AIS B seventeen (3.89%) had above T7 and two (0.45%) had T1-6. Either way AIS A sixty nine (15.78%) found C1-4 and respectively four (0.91%) B, fourteen (3.20%) C and eight (1.83%) D (Table 3).  Patient with ASIA class B and C significantly increase initial SCIM during discharge (P=0.00).
There are no other significant relation ought to be seen. The relationship of initial and discharge SCIM with ASIA impairment is shown in (Tab. 4).

DISCUSSION
Patients admitted with spinal injuries at CRP from June 2014 to June 2017 were selected as the study population and age, gender, educational level, place of habitat, nature of work, and cause of injury were taking into consideration as demographic variables. Male predominance previously reported in both local [2,16,3] and global [11,10,9] studies were also found in this research where 90.2 % (n=394) were male and 9.8% (n=43) were female. Distribution of age in this study showed more people in their 2 nd decade and 3rd decade was vulnerable to spinal cord injury which was different from Scivoletto et al. where the mean age was 50.4 [5] and Marino et al. who found the mean age to be 41 [9]. Injury was evident from the fact that 69.6% of the respondents were from villages and it was also supported by Rahman et al. [2]. Majority of the participants of this study had traumatic paraplegia (63.6%) and the principle cause was fall from height (51.3%) and road traffic accident (28.8%) which was found to be consistent with other literatures [2,16,3,17]. Bull attack (.5%) and Diving into shallow water (1.6%) were the cause of fairly new and interesting phenomenon of spinal cord injury in this research which is recently reported Rahman et al [2,3]. Ability of walking is the most crucial question for the severely spinal cord injured patients [7].
In our study though the number is not big enough but in comparison of rarity during discharge home AIS A (2.92%), B (0.67%), C (2.25%), D (5.40%) are able to walk in a modifiable way and some are able to walk completely (table 2). The characteristics (table 2) of the participants (437) initial AIS was A and during discharge twenty six (5.9%) were shifted into B, thirty eight (8.7%) were shifted into C, twenty eight (6.4%) were shifted into D. Similar result found in other two studies [18,19] where 1-month baseline data reported 4% to 10% conversion rate from complete (AIS grade A) to incomplete injuries (AIS grades B, C, D) also a review [20] of the existing literature reported a conversion rate of 20% for persons with initial (3 rd -4 th ) week neurologic complete injuries (10% to AIS grade B, 10% to motor incomplete status). Another study [9] after completing rehabilitation and during discharge time approximately 74 days 78.3% remained AIS grade A at discharge from inpatient rehabilitation, whereas 12.1% shifted to AIS grade B and 9.6% converted to motor incomplete. Also participants who are initially classified as AIS grade C, 77.2% improved to AIS grade D, whereas 22% remained AIS grade C. (Table 3) AIS grade A were disproportionately represented in the paraplegic group for the full sample about two hundred thirty three (53.31%) followed by AIS A one seventy three (39.58%) mentioning above T7 and sixty (13.72%) represented T1-6. Similar result found in other study [5] where AIS grade A were represent the paraplegia group 53 (18.66%) and P=.001. We believe that Rehabilitation intervention played a positive role in changing the SCIM. In CRP patients are maximum time integrated with functional activities like self-care, mobility, daily activities, respiratory care and also outdoor sports. Strong interdisciplinary team approach played a vital role to fulfillment all these task. There is a high possibility of changing cortical plasticity due to structured and planned extensive therapeutic inventions which may subsequently effect to change SCIM. In (Table 4) during discharge where paraplegia shows AIS A 232 (53.08%) unchanged and B nineteen (4.34%). Traumatic tetraplegia shows A one hundred twelve (25.62%) unchanged and B seven (1.60%). Similar result found in other study [11] where A 74.4% unchanged in Paraplegia and 61.3% unchanged in Tetraplegia. In (Table 5) Patient with AIS class B significantly increase SCIM during discharge (P=0.00) and AIS class C significantly increase SCIM during discharge (P=0.00). CONCLUSION Though neurological recovery and functional outcome is very rare for the complete SCI, but there is a possibility in clinical situation. Sufficient structural integrity for proper signal conduction in the spinal cord after injury and compensatory plastic changes in the cortex, both may necessary for neurological and functional improvements. Proper physical and occupational therapeutic intervention may play a vital role in developing cortical plasticity. So, further large scale studies would be better to explore the variables and contributing factors that may help in neurological recovery and functional outcome of spinal cord injury patients.

ACKNOWLEDGEMENT
Authors thank medical services of CRP for their necessary help and cooperation Funding: It was a self-funded study.