Gait Post Spinal Cord Injury

Original Editor - Prit Shah

Top Contributors - Prit Shah, Naomi O'Reilly and Kim Jackson  

Introduction[edit | edit source]

The recovery or improvement of ambulation after a Spinal Cord Injury (SCI) is an important goal because people who can walk independently are more likely to be able to participate in expected social roles and desired recreational activities, have a higher quality of life, and have improved health status.

The ability to walk after a Spinal cord injury (SCI) depends on many factors including:

  • Level of Injury
  • Severity of Injury
  • Level of Sensation
  • Time Since Injury
  • Age
  • Level of Fitness
  • Other Related Problems such as Spasticity and Joint Problems e.g. Contractures
  • Level of Pain [1]

Therefore, it is difficult to predict if a patient will regain walking ability and at what stage in the rehabilitation process. Some individuals take a few months, while for others it may take many years. 

Identifying the Level of Lesion[edit | edit source]

The designation of level of lesion in the spinal cord and the extent of motor and sensory function after injury has a large impact on the medical and rehabilitation needs of the individual.

ASIA Impairment Scale[edit | edit source]

The American Spinal Injury Association (ASIA) created the International Standards for Neurological Classification of Spinal cord injury (ISNCSCI) which provides a standardized examination method to determine the extent of motor and sensory function loss after a spinal cord injury (SCI) for establishing prognosis and is also an important tool for clinical research trials.[2]

The neurological level is defined as the most caudal level of the spinal cord with normal motor and sensory function on both the left and right sides of the body. Motor level is referred to as the most caudal segment of the spinal cord with normal motor function bilaterally. Sensory level is defined in the same way except in terms of sensory function. Sensory level is determined by testing the patient’s sensitivity to light touch and pinprick on the left and right side of the body at key dermatomes. Scoring of sensation is based on a 3-point ordinal scale where 0 = absent, 1 = impaired, and 2 = normal. Motor level is determined by testing the strength of a key muscle on the right and left side of the body at myotomes adjacent to the suspected level of impairment. Key muscle strength is scored using the 6-point ordinal scale commonly used for manual muscle testing.[3]

Grades Degree Of Impairment
A = Complete No sensory or motor function is preserved in the sacral segments S4-S5.
B = Sensory Incomplete Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5, AND no motor function is preserved more than three levels below the motor level on either side of the body.
C = Motor Incomplete Motor function is preserved below the neurological level**, and more than half of key muscle functions below the single neurological level of injury have a muscle grade less than 3 (Grades 0–2).
D = Motor Incomplete Motor function is preserved below the neurological level**, and at least half (half or more) of key muscle functions below the NLI have a muscle grade >3.
E = Normal If sensation and motor function as tested with the ISNCSCI are graded as normal in all segments, and the patient had prior deficits, then the AIS grade is E. Someone without a SCI does not receive an AIS grade.

**For an individual to receive a grade of C or D, i.e. motor incomplete status, they must have either voluntary anal sphincter contraction or sacral sensory sparing (at S4/5 or Deep Anal Pressure (DAP)) with sparing of motor function more than three levels below the motor level for that side of the body. The Standards at this time allows even non-key muscle function more than 3 levels below the motor level to be used in determining motor incomplete status (AIS B versus C).[1]

It is explained in detail right here - American Spinal Cord Injury Association (ASIA) Impairment Scale

Complete And Incomplete Injuries and Zones of Preservation[edit | edit source]

The International Standards for Neurological Classification of Spinal cord injury (ISNCSCI) defines a complete injury as having no sensory or motor function in the lowest sacral segments (S4 and S5). Sensory and motor function at S4 and S5 are determined by anal sensation and voluntary external anal sphincter contraction. An incomplete injury is classified as having motor and/or sensory function below the neurological level including sensory and/or motor function at S4 and S5. If an individual has motor and/or sensory function below the neurological level but does not have function at S4 and S5, then the areas of intact motor and/or sensory function below the neurological level are termed zones of partial preservation.[3]

Gait Analysis[edit | edit source]

A Spinal Cord Injury can result in decreased strength and spasticity, dependant on the level and type of lesion. It is known that individuals with an incomplete Spinal Cord Injury have more potential to regain ambulation in comparison to those with a complete Spinal Cord Injury, but gait training is often included in rehailitation for all types of spinal cord injury.[1]

In a study to find out the effects of injury level and spasticity on gait, it was found that those with thoracic injures demonstrated reduced cadence, forward velocity, and knee angular velocity, whereas those with lumbar injuries resulted in reduced stride length and ankle velocities. Gait in individuals with cervical injuries was not significantly different.[4]

A combination of studies showed that;

  • Individuals with Complete Spinal Cord Injury (ASIA A) are not likely to regain the functional lower extremity strength required to become independent ambulators.
  • Individuals with Incomplete Spinal Cord Injury (ASIA B, C, and D) the prognosis for recovery of walking ability is more complex.
  • For individuals with ASIA B (Sensory Incomplete) the preservation of pinprick sensation is an important prognostic indicator of the recovery of walking ability.
  • Most individuals with Incomplete Spinal Cord Injury (ASIA C and D) will regain some ability to walk.
  • Lower extremity ASIA Motor Scores, quadriceps strength in particular, can be a useful predictor of functional walking ability in people with Motor Incomplete Injuries.[5][6][7][8][9]

Preparation for Gait Training[edit | edit source]

Assessment[edit | edit source]

Initial assessment aims to determine strength, sensation, ability to stand up, transfers, bed mobility, balance while standing, spasticity or stiffness, and range of motion at your hips, knees, ankles, and trunk and accordingly plan out the training planner.

Assistive devices may be utilised to provide improved balance, joint protection, and ensure safety during gait training. Walking speed, endurance, and balance with these devices may also be determined in order to monitor and track progress during rehabilitation. [1]

The patient is made to understand the steps involved in the training, it’s potential benefits as well as the complications if not done right. For example, if an individual is using a wheelchair, trains to walk and eventually regains overground balance, coordination, the strength and does not risk falling in all environments (indoors and outdoors) completely, the use of wheelchair then should be slimmed to none or he will become dependent on it and the muscles will regress back into weakness and spasticity.

A study found that at the end of one year post-injury, individuals who were discharged from therapy trying to walk, but returned to using a wheelchair, had greater pain and more depression. [10]

Most individuals, those who are very old or are with complete SCI will rely on a wheelchair as their primary means of locomotion at home and in the community. Thus, it is important to assess patient’s wheelchair skills which can be done using the Wheelchair Skills Test (WST) [11][12][13]


Locomotor Training[edit | edit source]

Overview[edit | edit source]

It becomes necessary to assess and document the patient’s walking ability, function, ambulation speed, endurance, capacity and so on before beginning the training to compare from time to time so that his progression can be noted. The most commonly used tests are :-

  1. Walking Index for Spinal cord injury (WISCI) or (WISCI II) [14][15][16][17]
  2. 10 Metre Walk Test (10MWT) [16][17]
  3. 6 Minute Walk Test (6MWT) [16][17]
  4. Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) [18]

Locomotor Training for Incomplete Spinal Cord Injuries[edit | edit source]

Locomotor Training is done using Body Weight Support (BWS) And Treadmill System (TM). [19][20]

A body weight support (BWS) device lifts part of your weight through a harness you wear as you try to take some steps. Some of these devices roll on the ground and some are placed over a treadmill. This can be paired along with Parallel Bars to start with to train balance in standing and stepping. Therapist supervision and manual assistance will also be provided

The interventions are progressed as follows :-[1]

  1. Parallel Bars
  2. Overground (Indoors) - Individual walks with a BWS device with or without the TM but only indoors
  3. Overground Community (Outdoors) – Individual drops the BWS and TM and trains with Assistive Devices for safety. Constant manual assistance and supervision may be needed
  4. Then the individual may return to using BWS device and TM but this time, to improve balance, timing, coordination and increase walking speed.
  5. The individual finally transfers skills to different environments and outdoors for community ambulation. The individual may use Assistive Devices which best suits them, for safety and to decrease risk of falling. Transferring skills acquired in one environment to another is a crucial element and can be reinforced by a daily examination in the community and on the TM with BWS. [19]

The importance of the final step or Overground Locomotor Training (OLT) is very consequential since it also accelerates processes associated with oxygen delivery and utilization at the rest-to-work transition, and lowers oxygen extraction requirements of skeletal muscle during walking. [21]

Intensive Mobility Training (IMT) is another rehabilitative approach that uses intensive training through the incorporation of task-specific and massed practice. [22]

Locomotor Training (LT) for Complete Spinal Cord Injuries[edit | edit source]

Although the interventions followed for Complete SCIs is similar to that of Incomplete, the chances of the patient becoming functional ambulators are limited. Thus prior to the initiation of the training, the costs and potential benefits are cleared out. Standing alone may provide with other important benefits such as improved circulation, skin integrity, bowel and bladder function, sleep, and a sense of well-being. [23]

The orthotic prescription varies according to the lesion level. Ankle and/or knee control bracing is often necessary. Patients with complete thoracic lesions will require Knee-Ankle-Foot Orthoses (KAFOs) such as :-

  • Conventional KAFOs
  • Scott-Craig KAFO – used by individuals with paraplegia
  • Reciprocating Gait Orthoses (RGO) – composed of 2 plastic KAFOs

The training advancements involved are as follows (in this specific order) :-

  1. Donning and Doffing (Putting on and removing) of Orthoses
  2. Use of Forearm crutches since they are lightweight and used largely by patients with paraplegia
  3. Sit-To-Stand Activities
  4. Static Standing Balance
  5. Weight Shifting in Standing
  6. Push Ups
  7. Swing Through Gait Pattern while using the crutches
  8. Four Point Gait Pattern once the patient overcomes the swing through pattern. [2]

Assistive Devices[edit | edit source]

Assistive Devices may include :-

  • Walking Frames - Standard, Rollator, Reciprocal walkers
  • Canes
  • Tripods
  • Quadrupeds
  • Crutches - Axillary, Elbow, Gutter [2]

Braces[edit | edit source]

Braces may include :-

  • Ankle-Foot-Orthosis (AFO) – to support the ankle and foot
  • Knee-Ankle-Foot-Orthosis (KAFO) - worn up to the thigh to support the knee, ankle, and foot.
  • Hip-Knee-Ankle-Foot-Orthosis (HKAFO) - worn up to the hip to support the entire leg.
  • Trunk-Hip-Knee-Ankle-Foot-Orthosis (THKAFO) – extends till the trunk.[2]

Functional Electrical Stimulation (FES)[edit | edit source]

Functional Electrical Stimulation (FES) (also called neuroprosthesis) can be used instead of braces. It stimulates the muscles causing muscular contraction and generating joint movements helping the patient during walking. Pads acting as the electrodes are either attached to the skin or surgically implanted. For example, A cuff is attached to the lower leg and it’s stimulation helps pick up the foot as you take a step.[1]

Robotic Exoskeleton[edit | edit source]

These Robotic Exoskeletons called ReWalk Exoskeletons are worn by paraplegic patients and allows them to stand upright, walk and turn. It combines manual assistance with robotics to power hip and knee motions which enables the patients to walk. The drawbacks of these devices are that they are very expensive and can only be used by paraplegic patients. [24]  

Hybrid FES - Robotic Exoskeleton Device[edit | edit source]

The use of Functional Electrical Stimulation (FES) to generate joint movements in individuals with paraplegia is widely known for physiological and psychological benefits. However, early appearance of muscle fatigue due to repetitive muscle stimulation and difficulty in controlling joint trajectories are drawbacks commonly found in use as functional compensation of walking. Thus, there have been several attempts to improve gait performance and decrease energy expenditure by combining FES with passive or reciprocating orthoses but several have proved to be of no good. But, there have been some advancements in the Hybrid combination of FES with a Robotic control in an active or semi-active exoskeleton.

The study concludes there are a few disadvantages pertaining to the machine but the results do show that a control strategy for a hybrid machine delivers overground walking therapy along with fatigue management. The proposal being cooperative overcomes several disadvantages related to FES control of movement as well as shows improvements in the phases of the Gait Cycle to a certain extent. [25]

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.     Spinal Cord Injury and Gait Training. Available at -
  2. 2.0 2.1 2.2 2.3 O'sullivan, S.B, Schmitz , T.J, Fulk, G.D. Physical Rehabilitation. (6th ed.). Philadelphia: FA Davis Company; c2014.
  3. 3.0 3.1 Kirshblum SC, Biering-Sorensen F, Betz R, Burns S, Donovan W, Graves DE, Johansen M, Jones L, Mulcahey MJ, Rodriguez GM, Schmidt-Read M. International standards for neurological classification of spinal cord injury: cases with classification challenges. The journal of spinal cord medicine. 2014 Mar 1;37(2):120-7
  4. Krawetz P, Nance P. Gait analysis of spinal cord injured subjects: effects of injury level and spasticity. Archives of physical medicine and rehabilitation. 1996 Jul 1;77(7):635-8.
  5. Crozier KS, Graziani V, Ditunno JF, Herbison GJ. Spinal cord injury: prognosis for ambulation based on sensory examination in patients who are initially motor complete. Archives of physical medicine and rehabilitation. 1991 Feb 1;72(2):119-21.
  6. Burns SP, Golding DG, Rolle Jr WA, Graziani V, Ditunno Jr JF. Recovery of ambulation in motor-incomplete tetraplegia. Archives of physical medicine and rehabilitation. 1997 Nov 1;78(11):1169-72.
  7. Alander DH, Parker J, Stauffer ES. Intermediate-term outcome of cervical spinal cord-injured patients older than 50 years of age. Spine. 1997 Jun 1;22(11):1189-92.
  8. Crozier KS, Cheng LL, Graziani V, Zorn G, Herbison G, Ditunno JF. Spinal cord injury: prognosis for ambulation based on quadriceps recovery. Spinal Cord. 1992 Nov;30(11):762-7.
  9. Waters RL, Adkins R, Yakura J, Vigil D. Prediction of ambulatory performance based on motor scores derived from standards of the American Spinal Injury Association. Archives of physical medicine and rehabilitation. 1994 Jul 1;75(7):756-60.
  10. Riggins MS, Kankipati P, Oyster ML, Cooper RA, Boninger ML. The relationship between quality of life and change in mobility 1 year postinjury in individuals with spinal cord injury. Archives of physical medicine and rehabilitation. 2011 Jul 1;92(7):1027-33.
  11. Kirby RL, Dupuis DJ, MacPhee AH, Coolen AL, Smith C, Best KL, Newton AM, Mountain AD, MacLeod DA, Bonaparte JP. The wheelchair skills test (version 2.4): measurement properties. Archives of physical medicine and rehabilitation. 2004 May 1;85(5):794-804.
  12. Kirby RL, Swuste J, Dupuis DJ, MacLeod DA, Monroe R. The Wheelchair Skills Test: a pilot study of a new outcome measure. Archives of Physical Medicine and Rehabilitation. 2002 Jan 1;83(1):10-8.
  13. Lindquist NJ, Loudon PE, Magis TF, Rispin JE, Kirby RL, Manns PJ. Reliability of the performance and safety scores of the wheelchair skills test version 4.1 for manual wheelchair users. Archives of physical medicine and rehabilitation. 2010 Nov 1;91(11):1752-7.
  14. Ditunno JF, Ditunno PL, Graziani V, Scivoletto G, Bernardi M, Castellano V, Marchetti M, Barbeau H, Frankel HL, Greve JD, Ko HY. Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal cord. 2000 Apr;38(4):234-43.
  15. Ditunno JF, Scivoletto G, Patrick M, Biering-Sorensen F, Abel R, Marino R. Validation of the walking index for spinal cord injury in a US and European clinical population. Spinal Cord. 2008 Mar;46(3):181-8.
  16. 16.0 16.1 16.2 Jackson A, Carnel C, Ditunno J, Read MS, Boninger M, Schmeler M, Williams S, Donovan W. Outcome measures for gait and ambulation in the spinal cord injury population. The journal of spinal cord medicine. 2008 Jan 1;31(5):487-99.
  17. 17.0 17.1 17.2 van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Archives of physical medicine and rehabilitation. 2005 Feb 1;86(2):190-6.
  18. Field-Fote EC, Fluet GG, Schafer SD, Schneider EM, Smith R, Downey PA, Ruhl CD. The spinal cord injury functional ambulation inventory (SCI-FAI). Journal of rehabilitation medicine. 2001 Jul 1;33(4):177-81.
  19. 19.0 19.1 Behrman AL, Lawless-Dixon AR, Davis SB, Bowden MG, Nair P, Phadke C, Hannold EM, Plummer P, Harkema SJ. Locomotor training progression and outcomes after incomplete spinal cord injury. Physical therapy. 2005 Dec 1;85(12):1356-71.
  20. Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge D, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. 2006 Feb 28;66(4):484-93..
  21. Gollie JM, Guccione AA. Overground locomotor training in spinal cord injury: a performance-based framework. Topics in spinal cord injury rehabilitation. 2017;23(3):226-33.
  22. Fritz S, Merlo-Rains A, Rivers E, Brandenburg B, Sweet J, Donley J, Mathews H, Debode S, McClenaghan BA. Feasibility of intensive mobility training to improve gait, balance, and mobility in persons with chronic neurological conditions: a case series. Journal of Neurologic Physical Therapy. 2011 Sep 1;35(3):141-7.
  23. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G. Use of prolonged standing for individuals with spinal cord injuries. Physical therapy. 2001 Aug 1;81(8):1392-9.
  24. ReWalk Robotics – ReWalk Exoskeleton from ReWalk Robotics. Available from :
  25. Del-Ama AJ, Gil-Agudo Á, Pons JL, Moreno JC. Hybrid FES-robot cooperative control of ambulatory gait rehabilitation exoskeleton. Journal of neuroengineering and rehabilitation. 2014 Dec;11(1):1-5.