Table 4 Example of the iterative process of adapting and amending a recommendation statement based on the feedback received from the Delphi expert group.

Delphi Statement #3: Are co-occurring traumatic brain injuries a major contributor to cognitive impairment in SCI?

Recommendation revision #1: Co-occurring traumatic brain injuries (TBI) are considered a major contributor to cognitive impairment in persons with SCI

Comments from expert group (Round 1):

 • “…as most cognitive impairment in people with an SCI is not caused by a TBI, we risk missing deficits and problems in people if we focus on those with TBIs.”

 • “Although it is an important contributor, there are still up to 80% of SCI shown to have cognitive deficits that cannot be explained through TBI. Either TBI is often missed or there are other major contributors as not having a TBI can still lead to significant deficits.”

Revision #1: A number of factors are believed to contribute to cognitive impairment following a SCI, including co-occurring brain injuries, advancing age, psychological or somatic comorbidities, decentralised cardiovascular control, and sleep apnoea.

Comments from expert group (Round 2):

 • “Contribution to impairment is multifaceted and statement is now saying so”

 • “… have greater acknowledgment of the broad range of causes of impairment (beyond what is listed here) for example “including but not limited to…” or “which may include”.

Recommendation revision #2: A number of factors are believed to contribute to cognitive impairment following a SCI, including but not limited to co-occurring traumatic brain injuries, advancing age, psychological or somatic comorbidities, decentralized cardiovascular control, sleep apnoea, polypharmacy, and other possible contributor (e.g., inflammation to central nervous system, personal factors).

Final recommendation: It is recommended that healthcare providers understand and thoroughly assess all possible contributors to cognitive impairment in people with SCI.