Validation Of the Corticospinal Activation Protocol for Spinal Cord Injury Rehabilitation - A Delphi Consensus Study

Validation Of the Corticospinal Activation Protocol for Spinal Cord Injury Rehabilitation - A Delphi Consensus Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Validation Of the Corticospinal Activation Protocol for Spinal Cord Injury Rehabilitation - A Delphi Consensus Study SHARANJEET KAUR, Narkeesh Arumugam, Harvinder Chhabra This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8384097/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Spinal cord injury (SCI) rehabilitation is often delivered through heterogeneous activity-based therapy and conventional physiotherapy, which rarely provide a standardized, neurophysiologically driven framework targeting corticospinal activation and related systems. A Corticospinal Activation Protocol (CAP) was therefore developed to offer a multidomain, mechanism-based approach tailored to individuals with incomplete SCI. Objective To formulate a novel CAP for incomplete SCI and evaluate its content, face, construct, and criterion (concurrent and preliminary predictive) validity through expert consensus and pilot clinical testing. Methods CAP was formulated via a comprehensive literature review, development of a multidomain conceptual framework (motor, sensory, autonomic, cognitive, vocational), and stakeholder consultation with individuals with SCI and clinicians. Content and face validity were established using a Delphi consensus process with a multidisciplinary expert panel rating item relevance, clarity, and essentiality and providing qualitative feedback. Construct validity was examined by correlating CAP domain scores with established neurophysiological and clinical measures (e.g. motor and somatosensory evoked potentials, autonomic function scales, ASIA lower-limb scores, WISCI-II, SCIM-III). Criterion validity was explored in a pilot study including two small groups of individuals with traumatic, incomplete thoracolumbar SCI, comparing CAP with activity-based therapy plus conventional physiotherapy over a 30-day intervention. Results Experts demonstrated near-perfect agreement on CAP item relevance and essentiality, indicating strong content validity, and qualitatively endorsed the protocol as relevant, comprehensive, and aligned with neuroplasticity-driven, functional rehabilitation. CAP domain scores showed moderate-to-strong convergent correlations with corresponding neurophysiological and functional reference measures, supporting construct validity. In the pilot study, participants receiving CAP exhibited greater improvements across electrophysiological indices, locomotor capacity, functional independence, and autonomic function than those receiving standard therapy, providing preliminary evidence of concurrent and predictive criterion validity. Conclusion The Corticospinal Activation Protocol is a theoretically grounded, stakeholder-informed, and psychometrically supported framework for rehabilitation in incomplete SCI. CAP addresses important limitations of non-standardized activity-based and conventional physiotherapy and offers a structured platform for standardized clinical implementation and future multicentre trials. Health sciences/Medical research/Clinical trial design/Clinical trials Health sciences/Neurology/Neurological disorders/Spinal cord diseases SCI: Spinal Cord Injury CAP: Corticospinal Activation Protocol RTA: Road Traffic Accident ASIA: American Spinal Injury Association WISCI-II: Walking Index for Spinal Cord Injury II SCIM-III: Spinal Cord Independence Measure III Figures Figure 1 Figure 2 BACKGROUND Spinal cord injury (SCI) rehabilitation faces significant challenges due to the heterogeneity of injury presentations and the lack of standardized, evidence-based protocols tailored specifically for this population (Han et al., 2024). The epidemiology of spinal cord injury (SCI) reveals a significant and growing global burden. Recent data indicate that over 15 million people worldwide are living with SCI, with annual new cases estimated between 700,000 and 1.2 million globally. The incidence rate is approximately 23.77 per million people, with traumatic SCI at 26.48 per million and non-traumatic SCI at 17.93 per million. In India, it is estimated that around 1.5 million individuals live with SCI, with approximately 20,000 new cases each year (Liu et al., 2025). SCI predominantly affects males and is most commonly caused by trauma, such as falls and road traffic accidents, with high cervical and incomplete injuries increasing in recent years. The global burden is particularly high in populous countries like China, India, and the USA, which together account for a substantial proportion of both incidence and disability-adjusted life years (YLDs) due to SCI (Liu et al., 2025). The prevalence of SCI is projected to exceed 14.5 million by 2050, emphasizing the need for improved prevention, rehabilitation, and healthcare access. Despite advances in acute care, SCI continues to result in long-term disability, significant morbidity, and mortality, especially in low-resource settings where access to specialized rehabilitation services is limited. The persistent rise in SCI cases, coupled with demographic shifts and population aging, underscores the urgent need for targeted interventions and standardized, evidence-based rehabilitation protocols tailored to the unique needs of SCI patients (Ponzano et al., 2025). Current approaches, such as activity-based therapy (ABT), have demonstrated some efficacy in promoting motor recovery; however, they are often limited by their broad, non-specific nature and lack of targeted neuromodulatory strategies to address corticospinal pathway dysfunction . ABT protocols typically focus on repetitive task-specific training and functional electrical stimulation, but do not consistently address the underlying neurophysiological deficits in corticospinal excitability that are central to SCI-related motor impairment (Jervis-Rademeyer et al., 2024). Moreover, there is a notable absence of validated, protocol-driven interventions specifically designed for SCI rehabilitation, leading to considerable variability in clinical practice and suboptimal outcomes. The lack of a standardized, evidence-based protocol hinders reproducibility, limits comparative research, and impedes the translation of advances in neurophysiology into clinical care. This gap underscores the critical need for the development and validation of targeted, neuromodulatory protocols—such as the Corticospinal Activation Protocol (CAP)—that are specifically tailored to the unique pathophysiology of SCI and capable of enhancing corticospinal tract integrity and functional recovery. AIM AND OBJECTIVE OF THE STUDY To comprehensively evaluate the face, content, construct, concurrent, and ecological validity of CAP using expert consensus and clinical testing via a pilot study. NATURE OF THE STUDY The present study was Comprehensive Study including Delphi study and pilot study. The study formulated an exercise program i.e. Corticospinal Activation Protocol. The domains and items were generated by extensive search and in-depth direct interviews which included experts in the field of Physiotherapy and rehabilitation CONSENT AND ETHICAL CONSIDERATIONS The International Ethical consideration has been strictly used in the study. Prior to the commencement of the study, the proposed study applied for ethical approval to conduct the research from Institutional Ethical Committee, Punjabi University [ Ref Number: 28/55/IEC/PUP/2022), Dated 08/11/2022 ] . The Clinical Trail Registry India registration has been done as per the norms of the standards of good clinical practice [ Reg. No. CTRI/2023/02/049536] STUDY POPULATION AND SELECTION CRITERIA The study population will consist of ten physiotherapists including university professors related to SCI Neuro-rehabilitation and community health. The members of the expert panel should have at least 05 years of working experience in the field of neurological rehabilitation specific to SCI rehabilitation. The 11 th member of the research team will be an expert in statistics and research methodology to ensure the correct methodological procedure of the Delphi study. A pilot study to check the effectiveness of the protocol was done with 10 individuals who had survived traumatic incomplete thoracolumbar SCI with ASIA GRADE B, C, D with MMSE <24. SAMPLING METHOD The samples will be recruited through Interview Method (face to face method) for delphi study and purposive sampling method was used for pilot study METHODOLOGY TABLE I: PHASES OF STUDY Phase Description Phase 1 (Formulation) The CAP protocol was developed through a comprehensive review of current literature, integration of neurophysiological frameworks, and cognitive debriefing interviews conducted with patients and clinicians to ensure relevance and scientific rigor. Phase 2 (Expert Validation) Ten experts in neurorehabilitation and physiotherapy participated in a structured three-round Delphi process to establish both face and content validity of the protocol. Item-level Content Validity Index (I-CVI) and modified Kappa statistics were systematically calculated for each CAP component. Phase 3 (Pilot Study) A pilot study was conducted with ten individuals with incomplete spinal cord injury (ASIA C/D classification), randomized to either the CAP intervention group or a control group receiving activity-based therapy (ABT) and conventional physiotherapy over a four-week period. Key outcome measures included ASIA motor and sensory scores, the Walking Index for Spinal Cord Injury-II (WISCI-II), Spinal Cord Independence Measure-III (SCIM-III), general autonomic and sacral-autonomic assessments, as well as Motor and Somatosensory Evoked Potentials (recorded on days 0 and 30). Table 2: Stages of Formulation of Corticospinal Activation Protocol S.No. Stages Description 1 Literature Review Conducted comprehensive review of scientific literature relevant to the topic. 2 Conceptual Framework Integrated neurophysiological or theoretical frameworks to support the protocol design. 3 Stakeholder Consultation Conducted cognitive debriefing interviews with 5 patients with SCI and 5 clinicians working in SCI settings for real-world input. 4 Protocol Drafting Synthesized all data and formulate a preliminary draft of the study protocol. PHASE 1: FORMULATION OF CORTICOSPINAL ACTIVATION PROTOCOL The development of the study protocol was carried out in four sequential stages. In the first stage, a comprehensive literature review was conducted to identify existing evidence, gaps, and best practices related to spinal cord injury rehabilitation and corticospinal activation–based interventions. This stage ensured that the protocol was grounded in current scientific knowledge and aligned with contemporary rehabilitation paradigms. A systematic review titled "Exercise Based Approaches to Activate Central Pattern Generator in Spinal Cord Injury Survivors," published in the International Journal of Neurologic Physical Therapy, was included as a key reference to inform the evidence base for corticospinal and central pattern generator activation strategies in SCI rehabilitation (Kaur & Arumugam, 2024). This review provided a comprehensive synthesis of exercise-based interventions targeting CPG activation, offering critical insights into effective techniques, dosing parameters, and outcomes, which were instrumental in shaping the rationale and content of the Corticospinal Activation Protocol. In the second stage, a conceptual framework was formulated by integrating relevant neurophysiological and theoretical models to underpin the design of the protocol. This framework provided a structured rationale for the selection of components, dosing parameters, and outcome domains, ensuring that each element of the protocol was theoretically justified and mechanistically informed. The third stage involved stakeholder consultation through cognitive debriefing interviews with key end-users. A total of five individuals with spinal cord injury and five clinicians working in SCI rehabilitation settings were interviewed to obtain real-world perspectives on feasibility, clarity, acceptability, and perceived relevance of the proposed protocol. Their feedback was used to refine the content, language, and practical aspects of the protocol to enhance its clinical utility and patient-centeredness. Patients highlighted the importance of clear instructions, manageable exercise intensity, and practicality within their daily routines, emphasizing that interventions should be adaptable to varying levels of impairment and fatigue. One patient noted, " The exercises need to be simple and not too exhausting, so we can do them regularly without feeling discouraged." Clinicians stressed the need for standardized protocols that are easy to implement, monitor, and document, with one clinician stating, " A protocol that is well-structured and evidence-based will help us deliver consistent, high-quality care. " Both groups appreciated the inclusion of functional, task-specific activities and suggested integrating regular feedback mechanisms to track progress and adjust the protocol as needed. These insights were instrumental in refining the protocol to ensure it is both clinically effective and patient-centered In the fourth stage, all data from the literature review, conceptual framework, and stakeholder consultations were synthesized to draft the preliminary version of the study protocol. This iterative drafting process focused on integrating empirical evidence and stakeholder insights into a coherent, operational document that could subsequently be subjected to expert validation through the Delphi consensus process. PHASE II: EXPERT VALIDATION OF CORTICOSPINAL ACTIVATION PROTOCOL TABLE 3: DIFFERENT TYPES OF VALIDITY TESTING TO CHECK THE FEASIBILITY OF CAP IN CLINICAL SETTINGS Type of Validity Definition Application to CAP Content validity CAP covers all critical aspects of corticospinal and CPG activation Delphi consensus with experts Face validity CAP appears appropriate and logical to experts/clinicians Qualitative expert and clinician feedback Construct validity CAP targets its theoretical constructs (neuroplasticity, CPG) Neurophysiological & functional outcome correlations Criterion validity CAP outcomes correlate with external standards Comparison with standard locomotor training; predictive analysis Ecological validity CAP is feasible and relevant in real clinical contexts Pilot testing in clinical settings RESULTS AND FINDINGS CONTENT VALIDITY TABLE 4: Table showing the the kappa statistics for cap are reported to be near 1, it indicates almost perfect agreement among raters or experts. This means the components of cap have very high reliability and consensus, with minimal chance disagreement. Domain Item Experts Agreed I-CVI Pc k* Cognitive Training Non-invasive cortical stimulation (rTMS) 9 0.9 0.0098 0.899 tDCS application 10 1 0.001 1 Attention-focused tasks 9 0.9 0.0098 0.899 Memory-focused tasks 9 0.9 0.0098 0.899 Executive function tasks 10 1 0.001 1 Visuospatial training 9 0.9 0.0098 0.899 ANS Activation Trans-spinal stimulation 10 1 0.001 1 Pudendal nerve stimulation 9 0.9 0.0098 0.899 Aerobic training 9 0.9 0.0098 0.899 Multisite surface spinal stimulation 10 1 0.001 1 Thermal therapy 9 0.9 0.0098 0.899 Intermittent pneumatic compression 10 1 0.001 1 CPG Activation BWSTT 10 1 0.001 1 Rhythmic cycling 9 0.9 0.0098 0.899 High-frequency repetitive exercise 10 1 0.001 1 Overground gait training 10 1 0.001 1 Hip-knee-ankle coordination drills 9 0.9 0.0098 0.899 Trunk & Limb Control Supine → sitting training 10 1 0.001 1 Sitting → quadruped 9 0.9 0.0098 0.899 Kneeling tasks 10 1 0.001 1 Standing balance tasks 10 1 0.001 1 Functional strengthening 9 0.9 0.0098 0.899 Sensorimotor Training Tactile cueing 9 0.9 0.0098 0.899 Variable surface training 10 1 0.001 1 Load shifting tasks 9 0.9 0.0098 0.899 Proprioceptive stimulation 9 0.9 0.0098 0.899 Ambulation & Locomotion Robotic-assisted gait 10 1 0.001 1 Orthoses use 9 0.9 0.0098 0.899 Body weight support treadmill training 10 1 0.001 1 Functional walking tasks 9 0.9 0.0098 0.899 Mobility aid training 9 0.9 0.0098 0.899 Vocational & Skill Training Simulated work tasks 9 0.9 0.0098 0.899 ADL practice 9 0.9 0.0098 0.899 Computer-assisted vocational training 10 1 0.001 1 Community reintegration tasks 9 0.9 0.0098 0.899 Thus, it suggested that the delphi validation process yielded highly reliable and consensual results among experts, strengthening the protocol's validity. Content validity of the Corticospinal Activation Protocol (CAP) was systematically evaluated using a Delphi consensus approach, with expert raters assessing the relevance, clarity, and comprehensiveness of each protocol component. The kappa statistics, approaching unity, reflect almost perfect inter-rater agreement, indicating that the protocol’s elements are consistently perceived as essential and well-defined across expert perspectives. This high level of consensus substantiates the protocol’s content validity, confirming that its components are not only theoretically justified but also pragmatically relevant to the neurorehabilitation of spinal cord injury (SCI). 2. FACE VALIDITY TABLE 5: Face Validity of CAP Theme Description Illustrative Quotes Perceived relevance CAP aligns with neuroplasticity and functional goals “Clearly targets both neural and functional recovery.” Comprehensiveness Covers motor, sensory, cognitive, autonomic, vocational “Holistic approach that mirrors real-world needs.” Plausibility Logical developmental sequencing “Proximal to distal control is textbook yet often missing in protocols.” Evidence alignment Reflects task specificity, repetition, sensory feedback “Built on sound scientific foundation.” Recommendations Clarify progression, adjust cognitive tasks, add vocational outcome measures “Define progression criteria and measurable outcomes.” The face validity of the Corticospinal Activation Protocol (CAP) was strongly endorsed by the expert panel across several conceptually distinct domains. Perceived relevance was high, with experts indicating that the protocol is well aligned with contemporary principles of neuroplasticity and functional, goal-directed rehabilitation, and explicitly targets both neural recovery and functional performance. The CAP was also judged to be comprehensive, as it integrates motor, sensory, cognitive, autonomic, and vocational components, which experts perceived as reflecting the multidimensional demands and real-world needs of individuals living with spinal cord injury. Plausibility was supported by the logical developmental sequencing of activities, including the progression from proximal to distal control, which experts recognized as consistent with established neuromotor control frameworks yet often underrepresented in existing protocols. In addition, the protocol was viewed as closely aligned with the current evidence base, incorporating key principles such as task specificity, high-repetition practice, and enriched sensory feedback, and was therefore regarded as grounded in a robust scientific rationale. While experts suggested targeted refinements—such as clearer progression criteria, adjustment of cognitive tasks, and incorporation of vocationally oriented outcome measures—these recommendations were framed as optimization rather than fundamental critique. Collectively, these findings indicate strong face validity of the CAP, with experts perceiving it as theoretically sound, clinically meaningful, and feasible for implementation in spinal cord injury rehabilitation practice. Finally, the recommendations provided—focusing on clarifying progression criteria, refining cognitive tasks, and incorporating vocational outcome measures—indicate that while experts recognized minor areas for refinement, they endorsed the overall structure and content of the CAP as face valid and suitable for clinical application. 3. CONSTRUCT VALIDITY TABLE 6: Construct Validity of CAP Domain Comparator Tool / Scale Method (Convergent/Discriminant) Key Statistic Interpretation Cognitive Monitoring and Training Neuropsychological tests (MEPs, SSEPs) Convergent (Pearson r) r = 0.68 Adequate construct validity CPG Activation and Training CPG activation (MEPs, SSEPs, WISCI-II) Convergent (Pearson r, ICC) r = 0.60 Good protocol-specific validity ANS Activation and Training GAF & SAF Convergent (Pearson r) r = 0.63 Strong physiological construct validity Task Trunk Control in Developmental Sequencing ASIA-LOWER LIMB, SCIM-III Convergent (Pearson r) r = 0.65 Adequate construct validity Sensorimotor Training ASIA-SCALE Convergent (Pearson r) r = 0.67 Good convergence with standardized tests Ambulation and Locomotion Training WISCI-II Convergent (Pearson r) r = 0.69 Strong functional validity Vocational and Skill Enhancement Training SCIM-III Convergent (Pearson r) r = 0.61 Satisfactory occupational validity Construct validity of the Corticospinal Activation Protocol (CAP) was examined by testing the association between each CAP domain and established reference measures that assess similar underlying constructs in individuals with spinal cord injury. Across domains, convergent validity was supported by moderate to strong Pearson correlation coefficients (r ranging from 0.60 to 0.69), indicating that higher CAP performance was systematically related to better scores on standardized neurophysiological, functional, and participation scales. Cognitive Monitoring and Training showed adequate construct validity (r = 0.68) when correlated with neuropsychological and neurophysiological tests (MEPs, SSEPs), suggesting that the CAP items in this domain capture higher-order cognitive and monitoring functions relevant to SCI. CPG Activation and Training demonstrated good protocol‑specific validity (r = 0.60) against combined CPG activation measures (MEPs, SSEPs) and WISCI‑II, indicating that this domain reflects central pattern generator–related locomotor capacity.image.jpg Autonomic Nervous System (ANS) Activation and Training revealed strong physiological construct validity (r = 0.63) with GAF and SAF scores, supporting that CAP elements in this domain are sensitive to autonomic functioning. Task Trunk Control in Developmental Sequencing correlated adequately with ASIA lower limb scores and SCIM‑III (r = 0.65), confirming that the developmental, proximal‑to‑distal structure of this domain maps onto standardized measures of trunk and lower‑limb function. Sensorimotor Training showed good convergence with the ASIA scale (r = 0.67), indicating that graded sensorimotor tasks in the CAP reflect neurological impairment levels captured by routine clinical examination. Ambulation and Locomotion Training displayed strong functional validity (r = 0.69) relative to WISCI‑II, underscoring that this domain is closely aligned with real‑world walking capacity. Finally, Vocational and Skill Enhancement Training demonstrated satisfactory occupational validity (r = 0.61) against SCIM‑III, supporting its relevance to activity and participation outcomes. Statistically, convergent construct validity was assessed primarily using Pearson correlation coefficients (r) between CAP domain scores and comparator tools, with higher coefficients interpreted as stronger evidence that both instruments measure related constructs. In some domains (e.g., CPG Activation and Training), intraclass correlation coefficients (ICC) were additionally considered to capture agreement and consistency where repeated or multi‑item measures were involved. Establishing construct validity is essential for confirming that the CAP is not merely a collection of exercises, but a theoretically coherent and psychometrically sound protocol that targets specific neurophysiological and functional constructs relevant to the SCI population. These findings strengthen the scientific foundation of the CAP and support its use as a structured, measurable, and clinically meaningful framework for corticospinal and systems‑level rehabilitation in spinal cord injury. PHASE III: A PILOT TESTING TO ESTABLISH THE CRITERION VALIDITY 4. CRITERION VALIDITY TABLE 7: Table showing the criterion validity testing methodology Aspect Description Application in CAP (Interventional Protocol) Criterion Validity How well the CAP intervention effects correlate with a valid criterion or gold standard outcome measure. Correlation of CAP-induced neural and functional improvements with established scales Types of Criterion Validity Concurrent validity : Improvement in CAP group aligns with benchmark measures during intervention period Predictive validity : CAP outcomes predict long-term recovery success Concurren t: CAP effects vs immediate corticospinal excitability changes Predictive : CAP rehabilitation gains vs future motor independence Criterion (Gold Standard) Validated clinical or neurophysiological measures used to evaluate CAP outcomes Spinal Cord Independence Measure (SCIM-III), Motor Evoked Potentials (MEPs) via TMS Assessment Method Statistical analysis of CAP effects in comparison to control or criterion outcomes Comparison of pre-post CAP intervention scores and correlation with gold standard tests The pilot study was designed to examine the criterion validity of the Corticospinal Activation Protocol (CAP) by comparing its effects with those of activity‑based therapy (ABT) plus conventional physiotherapy in individuals with traumatic, incomplete thoracolumbar spinal cord injury (D11–L2). In this context, criterion validity was operationalized as concurrent and predictive validity, using established neurophysiological and clinical outcome measures as external criteria. The concurrent aspect was addressed by assessing whether patients who received CAP demonstrated superior or at least comparable performance on sacral autonomic function, motor evoked potentials (MEP) of tibialis anterior, MEP/SEP amplitudes, and SSEP latencies, as well as ASIA lower‑limb scores, WISCI‑II, SCIM‑III, and autonomic function indices at the end of the 30‑day intervention, relative to those who received ABT and conventional physiotherapy. Table 8 : Baseline demographical data of Experimental group (Group A) Code Age (years) Sex Type of SCI Level of injury Duration of injury E1 42 Female Traumatic (fall from stairs) Thoracic (D11–D12) 3 years (30-05-2021) E2 35 Male Traumatic (fall) thoracic (D4–D6) 2 weeks (01/2024) E3 36 Male Traumatic (fall) Thoracic (D11–D12) 6 months old E4 18 Male Traumatic (RTA) Lumbar (L3–L4) 2 months (01-12-2024) E5 39 Male Traumatic (fall) Lumbar (L4–L5) 4 months old Table 9 : Baseline Demographical data of Control Group (Group B) Code Age (years) Sex Type of SCI Level of injury Duration of injury C1 44 Female Traumatic (RTA) Thoracic (D11–D12) 9 years back C2 30 Male Traumatic (fall from tree) Thoracic (D11–D12) 8 months back C3 36 Male Traumatic (fall) Thoracic (D11–D12) 7 years old (2017) C4 55 Female Traumatic (fall) Thoracic (D8–D12) 2 years old (08-03-2023) C5 55 Male Traumatic (RTA) Thoraco-lumbar (D12–L1) 3 years old (28-03-2024) Visual inspection of the group means indicates that the CAP group showed larger improvements across multiple neurophysiological markers (e.g., increased MEP and SEP amplitudes, reduced SSEP latency) and functional scales (ASIA motor scores, WISCI‑II, SCIM‑III, autonomic outcomes) compared with the control group over the same time period. These findings suggested that higher engagement with CAP is associated with better performance on validated criterion measures that reflect corticospinal excitability, sensory pathway integrity, locomotor capacity, and autonomic regulation, thereby supporting concurrent validity of the protocol. From a criterion‑based perspective, the fact that CAP‑driven changes track in the expected direction and magnitude with established gold‑standard measures implies that the protocol is accurately capturing the constructs it is intended to influence in this population (Hachem et al., 2017). Although the small sample size (n = 5 per group) precludes definitive statistical inference, the consistent pattern of greater improvement in the CAP group across independent domains provides preliminary evidence of predictive validity as well. Patients exposed to CAP not only achieved better end‑point scores but also demonstrated changes that are clinically meaningful on widely used functional and neurophysiological scales, indicating that early application of CAP may predict more favorable recovery trajectories when benchmarked against recognized outcome criteria. Thus, this pilot work supports the criterion (concurrent and preliminary predictive) validity of the CAP and justifies larger, adequately powered trials to confirm these relationships and further establish CAP as a valid, criterion‑referenced protocol for individuals with thoracolumbar spinal cord injury. DISCUSSION Formulation The formulation of the Corticospinal Activation Protocol (CAP) directly responds to key limitations of activity‑based therapy (ABT) and conventional physiotherapy for spinal cord injury (SCI). Existing approaches are often heterogeneous, therapist‑dependent, and primarily focused on strengthening and compensatory task practice, with limited explicit targeting of corticospinal pathways, central pattern generators, or autonomic regulation (Ahuja & Fehlings, 2016). They typically lack a unified conceptual framework, clear progression criteria, and systematic inclusion of higher‑order domains such as cognition and vocational reintegration, which restricts standardization, multi‑centre reproducibility, and rigorous evaluation in clinical trials (Gee & Todd, 2025). In contrast, CAP was formulated as a mechanism‑based, multidomain protocol that integrates motor, sensory, autonomic, cognitive, and vocational components within a coherent neurophysiological framework. By operationalizing specific corticospinal activation strategies and linking each domain to defined neurophysiological and functional targets, CAP addresses unmet needs in SCI rehabilitation that are insufficiently covered by ABT and conventional physiotherapy. Expert Validation The expert validation phase further underscored the necessity and added value of CAP relative to existing rehabilitation practices. Specialists highlighted that current ABT and conventional protocols often omit logical developmental sequencing (e.g., proximal‑to‑distal control), provide limited guidance on intensity and progression, and rarely integrate autonomic and vocational goals in a structured manner. In evaluating CAP, experts judged its domains to be highly relevant to neuroplasticity and functional recovery, with near‑perfect agreement on the essentiality and clarity of its components, indicating strong content validity. Thematic feedback emphasized that CAP offers a more comprehensive and scientifically grounded framework than typical ABT programs, aligning closely with contemporary evidence on task specificity, repetition, and sensory‑rich training. This consensus supports the view that a validated, structured protocol such as CAP is needed to move SCI rehabilitation beyond fragmented, experience‑driven practice toward standardized, mechanism‑informed care. Pilot Testing Pilot testing provided preliminary empirical support for CAP and highlighted its potential advantages over ABT plus conventional physiotherapy, thereby reinforcing its clinical importance. In individuals with incomplete thoracolumbar SCI, the CAP group demonstrated greater improvements in neurophysiological markers (e.g., motor and somatosensory evoked responses, sacral and general autonomic function) and functional outcomes (ASIA lower‑limb scores, WISCI‑II, SCIM‑III) than the comparison group. This pattern suggests that a targeted corticospinal activation strategy may be more effective in driving meaningful neurological and functional change than non‑standardized ABT and routine physiotherapy alone. Although the pilot sample was small, the consistency and multidimensional nature of the observed gains support the concurrent and preliminary predictive validity of CAP, indicating that it captures and promotes clinically relevant recovery processes. These findings argue for the importance of implementing validated, criterion‑referenced protocols such as CAP to overcome the inherent variability and mechanistic limitations of traditional ABT and conventional physiotherapy in SCI rehabilitation. CONCLUSION The present work resulted in the formulation, expert validation, and preliminary testing of a novel Corticospinal Activation Protocol (CAP) specifically designed for individuals with incomplete spinal cord injury. The protocol was developed from a strong neurophysiological and rehabilitative framework, systematically incorporating motor, sensory, autonomic, cognitive, and vocational domains into a structured, progression-oriented program. Through a rigorous Delphi process, experts demonstrated almost perfect agreement regarding the relevance, clarity, and essentiality of CAP components, confirming robust content and face validity and highlighting its superiority over non-standardized activity-based therapy and conventional physiotherapy in terms of theoretical coherence and clinical completeness. Construct validity analyses showed moderate-to-strong convergence between CAP domains and established neurophysiological and functional outcome measures, indicating that the protocol accurately targets the intended rehabilitation constructs. Additionally, pilot criterion-validity testing in individuals with thoracolumbar incomplete injury suggested that CAP may confer greater gains in electrophysiological indices, locomotor performance, functional independence, and autonomic function than standard care. Although larger, adequately powered trials are required, these findings collectively support CAP as a feasible, mechanism-based, and psychometrically sound protocol that can standardize corticospinal-focused rehabilitation in spinal cord injury and provide a platforms for future clinical research and guideline development. Declarations Ethics Approval and Consent to Participate This study was approved by the Institutional Ethics Committee of Punjabi University, Patiala. All participants provided written informed consent prior to participation. [Ref Number: 28/55/IEC/PUP/2022), Dated 08/11/2022] . The Clinical Trail Registry India registration has been done as per the norms of the standards of good clinical practice [ Reg. No. CTRI/2023/02/049536] Consent for Publication Written informed consent for publication was obtained from all participants. No identifiable images or data were used in this study. Data Availability Statement The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Author Contributions All authors contributed to the study design, data collection, analysis, and manuscript preparation . Funding This study was supported by INSPIRE-DST FELLOWSHIP. Declaration of Interests The authors declare that they have no competing interests or financial relationships that could influence the interpretation of the results. References Angeli, C., Rejc, E., Boakye, M., Herrity, A., Mesbah, S., Hubscher, C., Forrest, G., Harkema, S., 2023. Targeted Selection of Stimulation Parameters for Restoration of Motor and Autonomic Function in Individuals With Spinal Cord Injury. 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Shane James Timothy Balthazaar, by B., 2011. Balthazaar - CARDIAC CONSEQUENCES AND EFFECTS OF EXERCISE INTERVENTIONS FOLLOWING SPINAL CORD INJURY IN HUMANS. Shulga, A. et al. (2021) 'A novel paired associative stimulation protocol with a high‐frequency peripheral component: A review on results in spinal cord injury rehabilitation,' European Journal of Neuroscience , 53(9), pp. 3242–3257. https://doi.org/10.1111/ejn.15191. Vivodtzev, I., Taylor, J.A., 2021. Cardiac, Autonomic, and Cardiometabolic Impact of Exercise Training in Spinal Cord Injury: A QUALITATIVE REVIEW. J Cardiopulm Rehabil Prev. https://doi.org/10.1097/HCR.0000000000000564 Wulf, M.J. and Tom, V.J. (2023) 'Consequences of spinal cord injury on the sympathetic nervous system,' Frontiers in Cellular Neuroscience , 17. https://doi.org/10.3389/fncel.2023.999253. Yang, F.A., Chen, S.C., Chiu, J.F., Shih, Y.C., Liou, T.H., Escorpizo, R., Chen, H.C., 2022. Body weight-supported gait training for patients with spinal cord injury: a network meta-analysis of randomised controlled trials. Sci Rep 12. https://doi.org/10.1038/s41598-022-23873-8 Graphs Graphs 1 to 11 are available in the Supplementary Files section. Additional Declarations There is no duality of interest Supplementary Files graphs.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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2","display":"","copyAsset":false,"role":"figure","size":158365,"visible":true,"origin":"","legend":"\u003cp\u003eidentified domains of corticospinal activation protocol from literature review\u003cstrong\u003e, \u003c/strong\u003econceptual framework and\u003cstrong\u003e \u003c/strong\u003estakeholder consultation\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8384097/v1/9f5bbf68d3680a9428f6d0a9.png"},{"id":104782906,"identity":"df26951d-ef7c-4fe0-8b78-08da357259a1","added_by":"auto","created_at":"2026-03-17 07:57:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1800408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8384097/v1/7c97665c-4547-45b5-843c-c014ddbfb89c.pdf"},{"id":98627504,"identity":"83055313-8c33-4223-a492-adb447f1096c","added_by":"auto","created_at":"2025-12-19 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The epidemiology of spinal cord injury (SCI) reveals a significant and growing global burden. Recent data indicate that over 15 million people worldwide are living with SCI, with annual new cases estimated between 700,000 and 1.2 million globally. The incidence rate is approximately 23.77 per million people, with traumatic SCI at 26.48 per million and non-traumatic SCI at 17.93 per million. In India, it is estimated that around 1.5 million individuals live with SCI, with approximately 20,000 new cases each year\u0026nbsp;(Liu et al., 2025).\u003c/p\u003e\n\u003cp\u003eSCI predominantly affects males and is most commonly caused by trauma, such as falls and road traffic accidents, with high cervical and incomplete injuries increasing in recent years. The global burden is particularly high in populous countries like China, India, and the USA, which together account for a substantial proportion of both incidence and disability-adjusted life years (YLDs) due to SCI (Liu et al., 2025). The prevalence of SCI is projected to exceed 14.5 million by 2050, emphasizing the need for improved prevention, rehabilitation, and healthcare access. Despite advances in acute care, SCI continues to result in long-term disability, significant morbidity, and mortality, especially in low-resource settings where access to specialized rehabilitation services is limited. The persistent rise in SCI cases, coupled with demographic shifts and population aging, underscores the urgent need for targeted interventions and standardized, evidence-based rehabilitation protocols tailored to the unique needs of SCI patients (Ponzano et al., 2025). Current approaches, such as activity-based therapy (ABT), have demonstrated some efficacy in promoting motor recovery; however, they are often limited by their broad, non-specific nature and lack of targeted neuromodulatory strategies to address corticospinal pathway dysfunction . ABT protocols typically focus on repetitive task-specific training and functional electrical stimulation, but do not consistently address the underlying neurophysiological deficits in corticospinal excitability that are central to SCI-related motor impairment (Jervis-Rademeyer et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, there is a notable absence of validated, protocol-driven interventions specifically designed for SCI rehabilitation, leading to considerable variability in clinical practice and suboptimal outcomes. The lack of a standardized, evidence-based protocol hinders reproducibility, limits comparative research, and impedes the translation of advances in neurophysiology into clinical care. This gap underscores the critical need for the development and validation of targeted, neuromodulatory protocols\u0026mdash;such as the Corticospinal Activation Protocol (CAP)\u0026mdash;that are specifically tailored to the unique pathophysiology of SCI and capable of enhancing corticospinal tract integrity and functional recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAIM AND OBJECTIVE OF THE STUDY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo comprehensively evaluate the face, content, construct, concurrent, and ecological validity of CAP using expert consensus and clinical testing via a pilot study.\u003c/p\u003e"},{"header":"NATURE OF THE STUDY","content":"\u003cp\u003eThe present study was Comprehensive Study including Delphi study and pilot study. The study formulated an exercise program i.e. Corticospinal Activation Protocol. The domains and items were generated by extensive search and in-depth direct interviews which included experts in the field of Physiotherapy and rehabilitation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT AND ETHICAL CONSIDERATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe International Ethical consideration has been strictly used in the study. Prior to the commencement of the study, the proposed study applied for ethical approval to conduct the research from Institutional Ethical Committee, Punjabi University\u003cstrong\u003e\u0026nbsp;[\u003cem\u003eRef Number: 28/55/IEC/PUP/2022), Dated 08/11/2022\u003c/em\u003e]\u003c/strong\u003e. The Clinical Trail Registry India registration has been done as per the norms of the standards of good clinical practice\u003cem\u003e\u0026nbsp; [\u003cstrong\u003eReg. No. CTRI/2023/02/049536]\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSTUDY POPULATION AND SELECTION CRITERIA\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study population will consist of ten physiotherapists including university professors related to SCI Neuro-rehabilitation and community health. \u0026nbsp; The members of the expert panel should have at least 05 years of working experience in the field of neurological rehabilitation specific to SCI rehabilitation. The 11\u003csup\u003eth\u003c/sup\u003e member of the research team will be an expert in statistics and research methodology to ensure the correct methodological procedure of the Delphi study. A pilot study to check the effectiveness of the protocol was done with 10 individuals who had survived traumatic incomplete thoracolumbar SCI with ASIA GRADE B, C, D with MMSE \u0026lt;24.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSAMPLING METHOD\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe samples will be recruited through Interview Method (face to face method) \u0026nbsp; for delphi study and purposive sampling method was used for pilot study\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMETHODOLOGY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cstrong\u003eTABLE I: PHASES OF STUDY\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"627\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20.2552%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhase\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.7448%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20.2552%;\"\u003e\n \u003cp\u003ePhase 1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(Formulation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.7448%;\"\u003e\n \u003cp\u003eThe CAP protocol was developed through a comprehensive review of current literature, integration of neurophysiological frameworks, and cognitive debriefing interviews conducted with patients and clinicians to ensure relevance and scientific rigor.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20.2552%;\"\u003e\n \u003cp\u003ePhase 2\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Expert Validation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.7448%;\"\u003e\n \u003cp\u003eTen experts in neurorehabilitation and physiotherapy participated in a structured three-round Delphi process to establish both face and content validity of the protocol. Item-level Content Validity Index (I-CVI) and modified Kappa statistics were systematically calculated for each CAP component.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20.2552%;\"\u003e\n \u003cp\u003ePhase 3\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Pilot Study)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79.7448%;\"\u003e\n \u003cp\u003eA pilot study was conducted with ten individuals with incomplete spinal cord injury (ASIA C/D classification), randomized to either the CAP intervention group or a control group receiving activity-based therapy (ABT) and conventional physiotherapy over a four-week period. Key outcome measures included ASIA motor and sensory scores, the Walking Index for Spinal Cord Injury-II (WISCI-II), Spinal Cord Independence Measure-III (SCIM-III), general autonomic and sacral-autonomic assessments, as well as Motor and Somatosensory Evoked Potentials (recorded on days 0 and 30).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eTable 2: Stages of Formulation of Corticospinal Activation Protocol\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.8141%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS.No.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.4872%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6987%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.8141%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.4872%;\"\u003e\n \u003cp\u003eLiterature Review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6987%;\"\u003e\n \u003cp\u003eConducted comprehensive review of scientific literature relevant to the topic.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.8141%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.4872%;\"\u003e\n \u003cp\u003eConceptual Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6987%;\"\u003e\n \u003cp\u003eIntegrated neurophysiological or theoretical frameworks to support the protocol design.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.8141%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.4872%;\"\u003e\n \u003cp\u003eStakeholder Consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6987%;\"\u003e\n \u003cp\u003eConducted cognitive debriefing interviews with 5 patients with SCI and 5 clinicians working in SCI settings for real-world input.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.8141%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29.4872%;\"\u003e\n \u003cp\u003eProtocol Drafting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61.6987%;\"\u003e\n \u003cp\u003eSynthesized all data and formulate a preliminary draft of the study protocol.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePHASE 1: FORMULATION OF CORTICOSPINAL ACTIVATION PROTOCOL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe development of the study protocol was carried out in four sequential stages. In the first stage, a comprehensive literature review was conducted to identify existing evidence, gaps, and best practices related to spinal cord injury rehabilitation and corticospinal activation\u0026ndash;based interventions. This stage ensured that the protocol was grounded in current scientific knowledge and aligned with contemporary rehabilitation paradigms. A systematic review titled \u0026quot;Exercise Based Approaches to Activate Central Pattern Generator in Spinal Cord Injury Survivors,\u0026quot; published in the International Journal of Neurologic Physical Therapy, was included as a key reference to inform the evidence base for corticospinal and central pattern generator activation strategies in SCI rehabilitation (Kaur \u0026amp; Arumugam, 2024). This review provided a comprehensive synthesis of exercise-based interventions targeting CPG activation, offering critical insights into effective techniques, dosing parameters, and outcomes, which were instrumental in shaping the rationale and content of the Corticospinal Activation Protocol.\u003c/p\u003e\n\u003cp\u003eIn the second stage, a conceptual framework was formulated by integrating relevant neurophysiological and theoretical models to underpin the design of the protocol. This framework provided a structured rationale for the selection of components, dosing parameters, and outcome domains, ensuring that each element of the protocol was theoretically justified and mechanistically informed.\u003c/p\u003e\n\u003cp\u003eThe third stage involved stakeholder consultation through cognitive debriefing interviews with key end-users. A total of five individuals with spinal cord injury and five clinicians working in SCI rehabilitation settings were interviewed to obtain real-world perspectives on feasibility, clarity, acceptability, and perceived relevance of the proposed protocol. Their feedback was used to refine the content, language, and practical aspects of the protocol to enhance its clinical utility and patient-centeredness. Patients highlighted the importance of clear instructions, manageable exercise intensity, and practicality within their daily routines, emphasizing that interventions should be adaptable to varying levels of impairment and fatigue. One patient noted, \u0026quot;\u003cem\u003eThe exercises need to be simple and not too exhausting, so we can do them regularly without feeling discouraged.\u0026quot;\u003c/em\u003e Clinicians stressed the need for standardized protocols that are easy to implement, monitor, and document, with one clinician stating, \u0026quot;\u003cem\u003eA protocol that is well-structured and evidence-based will help us deliver consistent, high-quality care.\u003c/em\u003e\u0026quot; Both groups appreciated the inclusion of functional, task-specific activities and suggested integrating regular feedback mechanisms to track progress and adjust the protocol as needed. These insights were instrumental in refining the protocol to ensure it is both clinically effective and patient-centered\u003c/p\u003e\n\u003cp\u003eIn the fourth stage, all data from the literature review, conceptual framework, and stakeholder consultations were synthesized to draft the preliminary version of the study protocol. This iterative drafting process focused on integrating empirical evidence and stakeholder insights into a coherent, operational document that could subsequently be subjected to expert validation through the Delphi consensus process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHASE II: EXPERT VALIDATION OF CORTICOSPINAL ACTIVATION PROTOCOL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;TABLE 3: DIFFERENT TYPES OF VALIDITY TESTING TO CHECK THE FEASIBILITY OF CAP IN CLINICAL SETTINGS\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDefinition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApplication to CAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eCAP covers all critical aspects of corticospinal and CPG activation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eDelphi consensus with experts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFace validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eCAP appears appropriate and logical to experts/clinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eQualitative expert and clinician feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConstruct validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eCAP targets its theoretical constructs (neuroplasticity, CPG)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eNeurophysiological \u0026amp; functional outcome correlations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriterion validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eCAP outcomes correlate with external standards\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eComparison with standard locomotor training; predictive analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2263%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEcological validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003eCAP is feasible and relevant in real clinical contexts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3868%;\"\u003e\n \u003cp\u003ePilot testing in clinical settings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"RESULTS AND FINDINGS","content":"\u003col\u003e\n \u003cli\u003eCONTENT VALIDITY\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eTABLE 4: Table showing the the \u003cstrong\u003ekappa statistics for cap are reported to be near 1,\u003c/strong\u003e it indicates almost perfect agreement among raters or experts. \u003cstrong\u003eThis means the components of cap have very high reliability\u0026nbsp;\u003c/strong\u003eand consensus, with minimal chance disagreement.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"663\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperts Agreed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eI-CVI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePc\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ek*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eNon-invasive cortical stimulation (rTMS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003etDCS application\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eAttention-focused tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eMemory-focused tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eExecutive function tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eVisuospatial training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANS Activation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eTrans-spinal stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003ePudendal nerve stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eAerobic training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eMultisite surface spinal stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eThermal therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eIntermittent pneumatic compression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPG Activation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eBWSTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eRhythmic cycling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eHigh-frequency repetitive exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eOverground gait training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eHip-knee-ankle coordination drills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrunk \u0026amp; Limb Control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eSupine \u0026rarr; sitting training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eSitting \u0026rarr; quadruped\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eKneeling tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eStanding balance tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eFunctional strengthening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensorimotor Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eTactile cueing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eVariable surface training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eLoad shifting tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eProprioceptive stimulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmbulation \u0026amp; Locomotion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eRobotic-assisted gait\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eOrthoses use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eBody weight support treadmill training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eFunctional walking tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eMobility aid training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVocational \u0026amp; Skill Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eSimulated work tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eADL practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eComputer-assisted vocational training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17.1946%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 32.2775%;\"\u003e\n \u003cp\u003eCommunity reintegration tasks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.1222%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.0106%;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.5189%;\"\u003e\n \u003cp\u003e0.0098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8763%;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Thus, it suggested that \u003cstrong\u003ethe delphi validation process yielded highly reliable and consensual results among experts, strengthening the protocol\u0026apos;s validity.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContent validity of the Corticospinal Activation Protocol (CAP) was systematically evaluated using a Delphi consensus approach, with expert raters assessing the relevance, clarity, and comprehensiveness of each protocol component. The kappa statistics, approaching unity, reflect almost perfect inter-rater agreement, indicating that the protocol\u0026rsquo;s elements are consistently perceived as essential and well-defined across expert perspectives. This high level of consensus substantiates the protocol\u0026rsquo;s content validity, confirming that its components are not only theoretically justified but also pragmatically relevant to the neurorehabilitation of spinal cord injury (SCI).\u003c/p\u003e\n\u003cp\u003e2. FACE VALIDITY\u003c/p\u003e\n\u003cp\u003eTABLE 5: Face Validity of CAP\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived relevance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003eCAP aligns with neuroplasticity and functional goals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Clearly targets both neural and functional recovery.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComprehensiveness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003eCovers motor, sensory, cognitive, autonomic, vocational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Holistic approach that mirrors real-world needs.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlausibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003eLogical developmental sequencing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Proximal to distal control is textbook yet often missing in protocols.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEvidence alignment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003eReflects task specificity, repetition, sensory feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Built on sound scientific foundation.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19.8068%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 41.7069%;\"\u003e\n \u003cp\u003eClarify progression, adjust cognitive tasks, add vocational outcome measures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38.4863%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ldquo;Define progression criteria and measurable outcomes.\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe face validity of the Corticospinal Activation Protocol (CAP) was strongly endorsed by the expert panel across several conceptually distinct domains. Perceived relevance was high, with experts indicating that the protocol is well aligned with contemporary principles of neuroplasticity and functional, goal-directed rehabilitation, and explicitly targets both neural recovery and functional performance. The CAP was also judged to be comprehensive, as it integrates motor, sensory, cognitive, autonomic, and vocational components, which experts perceived as reflecting the multidimensional demands and real-world needs of individuals living with spinal cord injury.\u003c/p\u003e\n\u003cp\u003ePlausibility was supported by the logical developmental sequencing of activities, including the progression from proximal to distal control, which experts recognized as consistent with established neuromotor control frameworks yet often underrepresented in existing protocols. In addition, the protocol was viewed as closely aligned with the current evidence base, incorporating key principles such as task specificity, high-repetition practice, and enriched sensory feedback, and was therefore regarded as grounded in a robust scientific rationale. While experts suggested targeted refinements\u0026mdash;such as clearer progression criteria, adjustment of cognitive tasks, and incorporation of vocationally oriented outcome measures\u0026mdash;these recommendations were framed as optimization rather than fundamental critique. Collectively, these findings indicate strong face validity of the CAP, with experts perceiving it as theoretically sound, clinically meaningful, and feasible for implementation in spinal cord injury rehabilitation practice. \u0026nbsp;Finally, the recommendations provided\u0026mdash;focusing on clarifying progression criteria, refining cognitive tasks, and incorporating vocational outcome measures\u0026mdash;indicate that while experts recognized minor areas for refinement, they endorsed the overall structure and content of the CAP as face valid and suitable for clinical application.\u003c/p\u003e\n\u003cp\u003e3. CONSTRUCT VALIDITY\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 6: Construct Validity of CAP\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparator Tool / Scale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethod (Convergent/Discriminant)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Statistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterpretation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCognitive Monitoring and Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eNeuropsychological tests (MEPs, SSEPs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequate construct validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPG Activation and Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eCPG activation \u0026nbsp;(MEPs, SSEPs, WISCI-II)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r, ICC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood protocol-specific validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eANS Activation and Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eGAF \u0026amp; SAF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrong physiological construct validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTask Trunk Control in Developmental Sequencing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eASIA-LOWER LIMB, SCIM-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdequate construct validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensorimotor Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eASIA-SCALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGood convergence with standardized tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmbulation and Locomotion Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eWISCI-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrong functional validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 18.7399%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVocational and Skill Enhancement Training\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19.7092%;\"\u003e\n \u003cp\u003eSCIM-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.0097%;\"\u003e\n \u003cp\u003eConvergent (Pearson r)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9.36995%;\"\u003e\n \u003cp\u003er = 0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26.1712%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSatisfactory occupational validity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eConstruct validity of the Corticospinal Activation Protocol (CAP) was examined by testing the association between each CAP domain and established reference measures that assess similar underlying constructs in individuals with spinal cord injury. Across domains, convergent validity was supported by moderate to strong Pearson correlation coefficients (r ranging from 0.60 to 0.69), indicating that higher CAP performance was systematically related to better scores on standardized neurophysiological, functional, and participation scales. Cognitive Monitoring and Training showed adequate construct validity (r = 0.68) when correlated with neuropsychological and neurophysiological tests (MEPs, SSEPs), suggesting that the CAP items in this domain capture higher-order cognitive and monitoring functions relevant to SCI. CPG Activation and Training demonstrated good protocol‑specific validity (r = 0.60) against combined CPG activation measures (MEPs, SSEPs) and WISCI‑II, indicating that this domain reflects central pattern generator\u0026ndash;related locomotor capacity.image.jpg\u003c/p\u003e\n\u003cp\u003eAutonomic Nervous System (ANS) Activation and Training revealed strong physiological construct validity (r = 0.63) with GAF and SAF scores, supporting that CAP elements in this domain are sensitive to autonomic functioning. Task Trunk Control in Developmental Sequencing correlated adequately with ASIA lower limb scores and SCIM‑III (r = 0.65), confirming that the developmental, proximal‑to‑distal structure of this domain maps onto standardized measures of trunk and lower‑limb function. Sensorimotor Training showed good convergence with the ASIA scale (r = 0.67), indicating that graded sensorimotor tasks in the CAP reflect neurological impairment levels captured by routine clinical examination. Ambulation and Locomotion Training displayed strong functional validity (r = 0.69) relative to WISCI‑II, underscoring that this domain is closely aligned with real‑world walking capacity. Finally, Vocational and Skill Enhancement Training demonstrated satisfactory occupational validity (r = 0.61) against SCIM‑III, supporting its relevance to activity and participation outcomes.\u003c/p\u003e\n\u003cp\u003eStatistically, convergent construct validity was assessed primarily using Pearson correlation coefficients (r) between CAP domain scores and comparator tools, with higher coefficients interpreted as stronger evidence that both instruments measure related constructs. In some domains (e.g., CPG Activation and Training), intraclass correlation coefficients (ICC) were additionally considered to capture agreement and consistency where repeated or multi‑item measures were involved. Establishing construct validity is essential for confirming that the CAP is not merely a collection of exercises, but a theoretically coherent and psychometrically sound protocol that targets specific neurophysiological and functional constructs relevant to the SCI population. These findings strengthen the scientific foundation of the CAP and support its use as a structured, measurable, and clinically meaningful framework for corticospinal and systems‑level rehabilitation in spinal cord injury.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHASE III: A PILOT TESTING TO ESTABLISH THE CRITERION VALIDITY\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e4. CRITERION VALIDITY\u003c/p\u003e\n\u003cp\u003eTABLE 7: Table showing the criterion validity testing methodology\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"619\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAspect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eApplication in CAP (Interventional Protocol)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCriterion Validity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eHow well the CAP intervention effects correlate with a valid criterion or gold standard outcome measure.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCorrelation of CAP-induced neural and functional improvements with established scales\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eTypes of Criterion Validity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConcurrent validity\u003c/strong\u003e: Improvement in CAP group aligns with benchmark measures during intervention period\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u0026nbsp;Predictive validity\u003c/strong\u003e: CAP outcomes predict long-term recovery success\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcurren\u003c/strong\u003et: CAP effects vs immediate corticospinal excitability changes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePredictive\u003c/strong\u003e: CAP rehabilitation gains vs future motor independence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eCriterion (Gold Standard)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eValidated clinical or neurophysiological measures used to evaluate CAP outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eSpinal Cord Independence Measure (SCIM-III), Motor Evoked Potentials (MEPs) via TMS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eAssessment Method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eStatistical analysis of CAP effects in comparison to control or criterion outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 33.3333%;\"\u003e\n \u003cp\u003eComparison of pre-post CAP intervention scores and correlation with gold standard tests\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe pilot study was designed to examine the criterion validity of the Corticospinal Activation Protocol (CAP) by comparing its effects with those of activity‑based therapy (ABT) plus conventional physiotherapy in individuals with traumatic, incomplete thoracolumbar spinal cord injury (D11\u0026ndash;L2). In this context, criterion validity was operationalized as concurrent and predictive validity, using established neurophysiological and clinical outcome measures as external criteria. The concurrent aspect was addressed by assessing whether patients who received CAP demonstrated superior or at least comparable performance on sacral autonomic function, motor evoked potentials (MEP) of tibialis anterior, MEP/SEP amplitudes, and SSEP latencies, as well as ASIA lower‑limb scores, WISCI‑II, SCIM‑III, and autonomic function indices at the end of the 30‑day intervention, relative to those who received ABT and conventional physiotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8 : Baseline demographical data of Experimental group (Group A)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eType of SCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall from stairs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D11\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 years (30-05-2021)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ethoracic (D4\u0026ndash;D6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 weeks (01/2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D11\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 months old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (RTA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLumbar (L3\u0026ndash;L4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 months (01-12-2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eE5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLumbar (L4\u0026ndash;L5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 months old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 9 : Baseline Demographical data of Control Group (Group B)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eType of SCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of injury\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (RTA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D11\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 years back\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall from tree)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D11\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 months back\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D11\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 years old (2017)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (fall)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic (D8\u0026ndash;D12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 years old (08-03-2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eC5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraumatic (RTA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eThoraco-lumbar (D12\u0026ndash;L1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 years old (28-03-2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eVisual inspection of the group means indicates that the CAP group showed larger improvements across multiple neurophysiological markers (e.g., increased MEP and SEP amplitudes, reduced SSEP latency) and functional scales (ASIA motor scores, WISCI‑II, SCIM‑III, autonomic outcomes) compared with the control group over the same time period. These findings suggested that higher engagement with CAP is associated with better performance on validated criterion measures that reflect corticospinal excitability, sensory pathway integrity, locomotor capacity, and autonomic regulation, thereby supporting concurrent validity of the protocol. From a criterion‑based perspective, the fact that CAP‑driven changes track in the expected direction and magnitude with established gold‑standard measures implies that the protocol is accurately capturing the constructs it is intended to influence in this population (Hachem et al., 2017).\u003c/p\u003e\n\u003cp\u003eAlthough the small sample size (n = 5 per group) precludes definitive statistical inference, the consistent pattern of greater improvement in the CAP group across independent domains provides preliminary evidence of predictive validity as well. Patients exposed to CAP not only achieved better end‑point scores but also demonstrated changes that are clinically meaningful on widely used functional and neurophysiological scales, indicating that early application of CAP may predict more favorable recovery trajectories when benchmarked against recognized outcome criteria. Thus, this pilot work supports the criterion (concurrent and preliminary predictive) validity of the CAP and justifies larger, adequately powered trials to confirm these relationships and further establish CAP as a valid, criterion‑referenced protocol for individuals with thoracolumbar spinal cord injury.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003eFormulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe formulation of the Corticospinal Activation Protocol (CAP) directly responds to key limitations of activity‑based therapy (ABT) and conventional physiotherapy for spinal cord injury (SCI). Existing approaches are often heterogeneous, therapist‑dependent, and primarily focused on strengthening and compensatory task practice, with limited explicit targeting of corticospinal pathways, central pattern generators, or autonomic regulation\u0026nbsp;(Ahuja \u0026amp; Fehlings, 2016). They typically lack a unified conceptual framework, clear progression criteria, and systematic inclusion of higher‑order domains such as cognition and vocational reintegration, which restricts standardization, multi‑centre reproducibility, and rigorous evaluation in clinical trials (Gee \u0026amp; Todd, 2025). In contrast, CAP was formulated as a mechanism‑based, multidomain protocol that integrates motor, sensory, autonomic, cognitive, and vocational components within a coherent neurophysiological framework. By operationalizing specific corticospinal activation strategies and linking each domain to defined neurophysiological and functional targets, CAP addresses unmet needs in SCI rehabilitation that are insufficiently covered by ABT and conventional physiotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExpert Validation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe expert validation phase further underscored the necessity and added value of CAP relative to existing rehabilitation practices. Specialists highlighted that current ABT and conventional protocols often omit logical developmental sequencing (e.g., proximal‑to‑distal control), provide limited guidance on intensity and progression, and rarely integrate autonomic and vocational goals in a structured manner. In evaluating CAP, experts judged its domains to be highly relevant to neuroplasticity and functional recovery, with near‑perfect agreement on the essentiality and clarity of its components, indicating strong content validity. Thematic feedback emphasized that CAP offers a more comprehensive and scientifically grounded framework than typical ABT programs, aligning closely with contemporary evidence on task specificity, repetition, and sensory‑rich training. This consensus supports the view that a validated, structured protocol such as CAP is needed to move SCI rehabilitation beyond fragmented, experience‑driven practice toward standardized, mechanism‑informed care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePilot Testing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePilot testing provided preliminary empirical support for CAP and highlighted its potential advantages over ABT plus conventional physiotherapy, thereby reinforcing its clinical importance. In individuals with incomplete thoracolumbar SCI, the CAP group demonstrated greater improvements in neurophysiological markers (e.g., motor and somatosensory evoked responses, sacral and general autonomic function) and functional outcomes (ASIA lower‑limb scores, WISCI‑II, SCIM‑III) than the comparison group. This pattern suggests that a targeted corticospinal activation strategy may be more effective in driving meaningful neurological and functional change than non‑standardized ABT and routine physiotherapy alone. Although the pilot sample was small, the consistency and multidimensional nature of the observed gains support the concurrent and preliminary predictive validity of CAP, indicating that it captures and promotes clinically relevant recovery processes. These findings argue for the importance of implementing validated, criterion‑referenced protocols such as CAP to overcome the inherent variability and mechanistic limitations of traditional ABT and conventional physiotherapy in SCI rehabilitation.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe present work resulted in the formulation, expert validation, and preliminary testing of a novel Corticospinal Activation Protocol (CAP) specifically designed for individuals with incomplete spinal cord injury. The protocol was developed from a strong neurophysiological and rehabilitative framework, systematically incorporating motor, sensory, autonomic, cognitive, and vocational domains into a structured, progression-oriented program. Through a rigorous Delphi process, experts demonstrated almost perfect agreement regarding the relevance, clarity, and essentiality of CAP components, confirming robust content and face validity and highlighting its superiority over non-standardized activity-based therapy and conventional physiotherapy in terms of theoretical coherence and clinical completeness.\u003c/p\u003e \u003cp\u003eConstruct validity analyses showed moderate-to-strong convergence between CAP domains and established neurophysiological and functional outcome measures, indicating that the protocol accurately targets the intended rehabilitation constructs. Additionally, pilot criterion-validity testing in individuals with thoracolumbar incomplete injury suggested that CAP may confer greater gains in electrophysiological indices, locomotor performance, functional independence, and autonomic function than standard care. Although larger, adequately powered trials are required, these findings collectively support CAP as a feasible, mechanism-based, and psychometrically sound protocol that can standardize corticospinal-focused rehabilitation in spinal cord injury and provide a platforms for future clinical research and guideline development.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee of Punjabi University, Patiala. All participants provided written informed consent prior to participation. \u003cstrong\u003e[Ref Number: 28/55/IEC/PUP/2022), Dated 08/11/2022]\u003c/strong\u003e. The Clinical Trail Registry India registration has been done as per the norms of the standards of good clinical practice \u0026nbsp;[\u003cstrong\u003eReg. No. CTRI/2023/02/049536]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all participants. No identifiable images or data were used in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study design, data collection, analysis, and manuscript preparation\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by INSPIRE-DST FELLOWSHIP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests or financial relationships that could influence the interpretation of the results.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAngeli, C., Rejc, E., Boakye, M., Herrity, A., Mesbah, S., Hubscher, C., Forrest, G., Harkema, S., 2023. 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E. (2024). Implementing Activity-Based Therapy for Spinal Cord Injury Rehabilitation in Canada: Challenges and Proposed Solutions. In \u003cem\u003eHealthcare (Switzerland)\u003c/em\u003e (Vol. 12, Issue 7). Multidisciplinary Digital Publishing Institute (MDPI). https://doi.org/10.3390/healthcare12070703 \u003c/li\u003e\n\u003cli\u003eJones, M.L., Evans, N., Tefertiller, C., Backus, D., Sweatman, M., Tansey, K. and Morrison, S. (2014). Activity-Based Therapy for Recovery of Walking in Individuals with Chronic Spinal Cord Injury: Results From a Randomized Clinical Trial. \u003cem\u003eArchives of Physical Medicine and Rehabilitation\u003c/em\u003e, [online] 95(12), pp.2239-2246.e2. doi: https://doi.org/10.1016/j.apmr.2014.07.400\u003c/li\u003e\n\u003cli\u003eLiu, W., Xu, Q., Wang, X., Wang, S., Gao, Z., Gu, R., Wu, H., \u0026amp; Zhu, Y. (2025). 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(2023) \u0026apos;Consequences of spinal cord injury on the sympathetic nervous system,\u0026apos; \u003cem\u003eFrontiers in Cellular Neuroscience\u003c/em\u003e, 17. https://doi.org/10.3389/fncel.2023.999253.\u003c/li\u003e\n\u003cli\u003eYang, F.A., Chen, S.C., Chiu, J.F., Shih, Y.C., Liou, T.H., Escorpizo, R., Chen, H.C., 2022. Body weight-supported gait training for patients with spinal cord injury: a network meta-analysis of randomised controlled trials. Sci Rep 12. https://doi.org/10.1038/s41598-022-23873-8\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Graphs","content":"\u003cp\u003eGraphs 1 to 11 are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"SCI: Spinal Cord Injury, CAP: Corticospinal Activation Protocol, RTA: Road Traffic Accident, ASIA: American Spinal Injury Association, WISCI-II: Walking Index for Spinal Cord Injury II, SCIM-III: Spinal Cord Independence Measure III","lastPublishedDoi":"10.21203/rs.3.rs-8384097/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8384097/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSpinal cord injury (SCI) rehabilitation is often delivered through heterogeneous activity-based therapy and conventional physiotherapy, which rarely provide a standardized, neurophysiologically driven framework targeting corticospinal activation and related systems. A Corticospinal Activation Protocol (CAP) was therefore developed to offer a multidomain, mechanism-based approach tailored to individuals with incomplete SCI.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo formulate a novel CAP for incomplete SCI and evaluate its content, face, construct, and criterion (concurrent and preliminary predictive) validity through expert consensus and pilot clinical testing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCAP was formulated via a comprehensive literature review, development of a multidomain conceptual framework (motor, sensory, autonomic, cognitive, vocational), and stakeholder consultation with individuals with SCI and clinicians. Content and face validity were established using a Delphi consensus process with a multidisciplinary expert panel rating item relevance, clarity, and essentiality and providing qualitative feedback. Construct validity was examined by correlating CAP domain scores with established neurophysiological and clinical measures (e.g. motor and somatosensory evoked potentials, autonomic function scales, ASIA lower-limb scores, WISCI-II, SCIM-III). Criterion validity was explored in a pilot study including two small groups of individuals with traumatic, incomplete thoracolumbar SCI, comparing CAP with activity-based therapy plus conventional physiotherapy over a 30-day intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eExperts demonstrated near-perfect agreement on CAP item relevance and essentiality, indicating strong content validity, and qualitatively endorsed the protocol as relevant, comprehensive, and aligned with neuroplasticity-driven, functional rehabilitation. CAP domain scores showed moderate-to-strong convergent correlations with corresponding neurophysiological and functional reference measures, supporting construct validity. In the pilot study, participants receiving CAP exhibited greater improvements across electrophysiological indices, locomotor capacity, functional independence, and autonomic function than those receiving standard therapy, providing preliminary evidence of concurrent and predictive criterion validity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe Corticospinal Activation Protocol is a theoretically grounded, stakeholder-informed, and psychometrically supported framework for rehabilitation in incomplete SCI. CAP addresses important limitations of non-standardized activity-based and conventional physiotherapy and offers a structured platform for standardized clinical implementation and future multicentre trials.\u003c/p\u003e","manuscriptTitle":"Validation Of the Corticospinal Activation Protocol for Spinal Cord Injury Rehabilitation - A Delphi Consensus Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-19 07:28:51","doi":"10.21203/rs.3.rs-8384097/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d514ae1-2a5c-4876-b820-0838cfc59258","owner":[],"postedDate":"December 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59930604,"name":"Health sciences/Medical research/Clinical trial design/Clinical trials"},{"id":59930605,"name":"Health sciences/Neurology/Neurological disorders/Spinal cord diseases"}],"tags":[],"updatedAt":"2026-03-16T16:16:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-19 07:28:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8384097","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8384097","identity":"rs-8384097","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}