Introduction to Gait Rehabilitation in Spinal Cord Injury

Original Editor -Ewa Jaraczewska based on the course by Maha Tayseer Mohammad

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction[edit | edit source]

Walking recovery for patients with spinal cord injury is a target of various rehabilitative approaches. Understanding prognostic factors influencing recovery is necessary when choosing the most appropriate therapeutic intervention.[1] This article discusses two approaches in gait rehabilitation and factors that help to predict ambulation recovery for patients with a spinal cord injury (SCI).

Plasticity-based Approach[edit | edit source]

The plasticity-based approach to gait rehabilitation in spinal cord injury arises from activity-dependent neural adaptation and training research. The afferent input influences the activity-dependent plasticity of the spinal cord, which affects the neurobiological control of walking.[2] Examples can be found in the studies by Sherrington[3], Grillner and Rossignol [4], who looked at the input of hip position and the effect of load on retraining walking after SCI. As a result of these studies, the rehabilitation strategies to regain the ability to ambulate a patient with a spinal cord injury focused on hip extension, load and other sensory elements to facilitate walking.

In a plasticity-based approach, a specific task, like locomotion, undergoes intensive practice in a specific training environment while an appropriate sensory input is provided. The training environment may include a treadmill with body-weight support (BWS), a lokomat, or an Exoskeleton. The sensory input can be offered through limb loading and unloading, trunk posture, hip extension, or limb kinematics.


Example: Locomotor training (Lokomat or treadmill with body-weight support system).[5]

  • The goal is to generate stepping in response to specific afferent input associated with the task of walking
  • The general guidelines focus on maximising loading of the lower limbs through body-weight support systems or overground walking with assistive devices

Compensatory-Based Approach[edit | edit source]

Compensation is "a rehabilitation strategy for non-remediable deficits of strength (force-generating capacity), voluntary motor control, sensation, and balance."[6] It is based on the principle that patients use their remaining abilities (compensate) to complete the task, or the task or environment is modified to achieve the established goal.[6]

In a compensatory-based approach, walking is accomplished using orthosis and assistive devices, and the outcome depends on the degree of motor and sensory loss.

Definitions of Walking Recovery in Spinal Cord Injury[edit | edit source]

General Definitions[edit | edit source]

Functional ambulation is “the ability to walk, with or without the aid of appropriate assistive devices (such as prostheses, orthoses, canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living.”[7]

Ambulatory capacity is "the highest level of walking function achieved within a standardised environment."[8]

Community ambulation is “independent mobility outside the home, which includes the ability to confidently negotiate uneven terrain, private venues, shopping centres, and other public venues.”[9]

Eight dimensions of community ambulation include the following:

  • Ability to manage distances
    • The walk distance is 16 to 677m, depending on the community destination.[10]
  • Temporal characteristics
    • Gait velocity, cadence, step length, and step time.
  • Speed
    • Crosswalk speed requirements range from .44 to 1.32m/s, vary by country and increase with increasing population size.[10]
  • Ambient conditions
    • Lighting, air temperature, weather condition
  • Terrain
    • Temporal spatial characteristics of ambulatory participants with SCI are affected by the surfaces they walk on.[11]
    • Compared to a hard surface, the average stride length, cadence, and walking speed of a patient with SCI are decreased while walking on artificial grass, soft, and pebble surfaces.[11]
  • Physical load
    • Poor roads condition, side-walks with cracks, pot-holes
  • Attentional demands
    • Gait alteration in response to obstacles within the path of travel
  • Postural transitions
    • Ability to maintain dynamic balance
  • Density
    • The number of people and objects in the immediate surroundings

Definitions of Ambulation in Spinal Cord Injury Research[edit | edit source]

There is no consistent definition of walking recovery after spinal cord injury. The following definitions are used in the publications that discuss predictors for functional outcome of walking:

  • 'Walking recovery is defined as having "regained ability to walk independently in the community, with or without the use of devices and braces."[1]
  • Functional ambulation is defined as:
    • "The capacity to walk reasonable distances in and out of home unassisted by another person."[12]
    • "Independent mobility outside the home to access goods and services in the community.” [13]

Four categories of functional ambulation in spinal cord injury and gait speed requirements:[14]

  1. Requires supervision to walk indoors and is wheelchair-dependent outdoors: a minimal speed requirement of 0.09 ± 0.01 m/s.
  2. Can walk indoors but is wheelchair-dependent outdoors: a minimal speed requirement of 0.15 ± 0.08 m/s.
  3. Requires a walking aid outdoors (“assisted walker”): a minimal speed requirement of 0.44 ± 0.14 m/s.
  4. Walks without aid: a minimal speed requirement of 0.70 ± 0.13 m/s.
  • Outdoor walking is " the self-reported ability to walk more than 100 m outside using one cane, leg orthosis only, or no assistive devices."[15]
    • Managing curbs is considered a critical task for independent community ambulation

Predictors for Functional Outcome of Walking[edit | edit source]

Motor and Sensory Loss[edit | edit source]

  • Moon et al. have found that hip flexor strength, followed by knee extensors, are the most important contributors to regaining independent walking in patients with incomplete SCI.[16]
  • A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury includes motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1. [17]
  • A score greater than 33 for the motor scores of the quadriceps (L3), big toe extensors (L5), and the light touch sensory score (S1) indicates the likelihood of the patient regaining outdoor walking ability one year after spinal cord injury.[15]
  • According to Cathomen and colleagues[18], the motor score of the myotomes L2 and L3 allow us to differentiate between walkers and non-walkers. The motor score of myotomes L4-S1 are considered prognostic factors for indoor versus outdoor walkers (with and without aids).

Level of Injury and Severity of the Spinal Cord Lesion[edit | edit source]

The first examination of the patient with the SCI is performed 72 hours after the lesion using The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). It allows us to determine the neurological level of injury and the severity of the lesion. The ASIA Impairment Scale (AIS) A through D defines the complete and incomplete lesions.

Severity of the Spinal Cord Lesion[edit | edit source]

Patients with the following severity of the spinal cord lesion may or may not recover their walking ability:

  • AIS A:[1]
    • Achieving functional walking is very limited.
    • 14% of patients who converted to incomplete injury recovered some walking function.
    • Patients with spinal cord injury at the thoracic or lumbar levels (T12-L3) who regain some walking abilities will need the support of braces and devices to walk.
    • Gait is characterised by slow average velocities and great energy expenditure, which may not be functional for the patient.
  • AIS B:[1]
    • About 33% of patients will recover the ability to ambulate.
    • Pinprick preservation is a positive factor in walking recovery compared to a light touch only (less extensive damage to the spinothalamic tracts and posterior column).
  • AIS C: [1]
    • About 75% of patients have a positive prognosis for walking recovery.
    • It affects patients converted to AIS D and patients with AIS C who achieve some walking function.
    • Walking recovery affects mostly patients with low thoracic or lumbar lesions.
    • Patients will be able to ambulate with braces and devices.
    • Age is a strong prognostic factor. 80-90% of patients younger than 50 can walk functionally. 30-40% of older patients can achieve the same.
  • AIS D: [1]
    • A very good ambulation prognosis at 1 year post-injury.
    • Regardless of age, most patients will likely be able to walk upon discharge from the rehabilitation facility.

Level of Injury[edit | edit source]

Patients with the following level of spinal cord injury may or may not recover their walking ability:[19]

  • T11-T12 levels
    • Can ambulate at home with lower extremity orthoses and a walker.
  • L1-L2 levels
    • They may be able to ambulate with KAFOs for short distances but need a wheelchair for a long distance.
  • L3-L4 levels
    • Can ambulate socially with elbow crutches and ankle foot orthoses.
  • L5 and lower
    • May be independent in all activities

Lower Extremities Range of Motion[edit | edit source]

Spasticity or contracture can prevent meeting the following joint range of motion requirements for walking recovery:

  • A full range of knee extensions is needed to use a knee-ankle-foot orthosis (KAFO) for ambulation.[20]
  • Adequate ankle dorsiflexion allows one to achieve foot clearance. [21]
  • A minimum zero degrees of hip extension range is necessary to allow the patient to lean backwards and move the centre of gravity of the trunk poste­rior to the hip joint to achieve standing when hip extensor muscles are absent.[22]
  • 110 degrees hip flexion allows the patient to transition to standing from sitting with locked KAFOs.[22]

Cardiovascular Endurance[edit | edit source]

"Walking requires increased energy demands on the body and the cardiovascular system, and walking with assistive devices will pose further increased demands."[20]---Maha Tayseer Mohammad

  • A swing-through crutch-assisted gait with bilateral knee-ankle-foot orthosis requires 43 per cent more of an average oxygen consumption rate than that of the patients who use a wheelchair. [23]
  • A swing-through crutch-assisted gait with bilateral knee-ankle-foot orthosis requires 38 per cent more of an average oxygen consumption rate than that of the patients who walk with a normal gait pattern. [23]
  • A reciprocal crutch-assisted gait with ankle-foot orthosis required 20 per cent more of an average oxygen consumption rate than that required for wheelchair use and 15 per cent greater than that required for normal walking.[23]

Age[edit | edit source]

Age is an important factor in predicting the ambulation outcome following SCI.[24]

  • Older individuals with an SCI demonstrate worse functional outcomes than younger individuals.
  • It is more difficult to predict walking abilities for older SCI patients as the outcomes are more variable.

Assistive Devices[edit | edit source]

The primary goals of gait rehabilitation of patients with SCI are to increase their independence and to improve their health status. A prolonged wheelchair use has disadvantages, including:[25]

  • restriction to mobility due to architectural barriers
  • decubitus ulcers
  • osteoporosis
  • joint deformities, including hip joint adduction contracture

However, the use of orthosis for ambulation in spinal cord injury comes with a list of problems that include:[25]

  • Donning and doffing the orthosis takes a significant amount of time.
  • Depending on the walking style, a high percentage of the force is applied to the upper limb musculature. Up to 55% of body weight can be applied on the crutch during walking, leading to shoulder pain.
  • High energy demand during ambulation with orthosis and slow walking speed of individuals with SCI with an orthosis.

Orthosis[edit | edit source]

"The performance of SCI patients and the efficiency of treatment approaches should be evaluated about all aspects of functions, such as activities of daily living and participation."[26]

The evaluation of the use of orthosis for a patient with spinal cord injury should be done by a multidisciplinary team and must include the patient in the decision making to participate in the following: [27]

  • Establish the orthotic and rehab goal.
  • Clarify the limitations of the orthosis.

The patient must receive early education on orthosis use, and a follow-up must be scheduled to ensure the patient's safety.

The most commonly used orthosis in gait rehabilitation in spinal cord injury are:

  • Hip-Knee-Ankle-Foot Orthosis (HKAFO)
  • Knee-Ankle-Foot Orthosis (KAFO)
  • Ankle-Foot Orthosis (AFO)
Hip-Knee-Ankle Foot Orthosis

Hip-Knee-Ankle-Foot Orthosis (HKAFO)[edit | edit source]

HKAFO is an orthosis that allows a reciprocal gait. It is designed with hybrid metal and plastic, drop lock knee joints, and plastic AFO at neutral. [27]

Patient example: T12, AIS A SCI presented with the following:

  • bilateral lower extremity paralysis
  • good trunk and arm control
  • absent sensation
  • mild lower extremities oedema
  • 1+ increased tone based on the Modified Ashworth Scale

Watch this video of a person who sustained a spinal cord injury after a traffic accident. He is walking with HKAFO.


Reciprocating gait orthosis (RGOs)[edit | edit source]

Reciprocating Gait Orthosis (RGO) consists of hip-knee-ankle-foot orthosis, which allows full control of hip extension and assists with reciprocal hip flexion during the swing phase of gait. The lower limbs and the trunk are stabilised in sagittal and frontal planes. The reciprocal gait is possible due to a double or a single cable built between hip joints.

Advantages of using RGOs:[29]

  • psychological benefit of assuming the upright position and talking to others at the same level
  • possibility to achieve a functional level of home ambulation with limitations

Disadvantages of using RGOs:[29]

  • high cost of orthosis
  • discomfort with wearing the orthosis
  • poor fitting
  • di􏰁difficulties with donning and doffing
  • slow walking as compared with wheelchair use
  • difficulty with getting in and out of the car, walking outside, and climbing the stairs.

Patient example: Patient with AIS A T1 spinal cord injury

  • no severe lower limb spasticity
  • no lower limb oedema
  • between 25 and 50 years old


Knee-Ankle-Foot Orthosis (KAFO)[edit | edit source]

KAFO can be metal, plastic, carbon, or hybrid with the following knee joint options:

  • Plastic KAFO
    Free knee
  • Drop lock
  • Bail lock
  • Trigger lock
  • Ratchet lock
  • Offset
  • Trick knee

The most common design for KAFO in spinal cord injury gait rehabilitation is plastic with drop lock.

There is a new generation of stances controlling KAFO. It locks the knee joint automatically in stance but allows flexion during swing. The video below demonstrates gait training with bilateral stance controlling KAFOs.


Watch this video where a patient with a T12 spinal cord injury demonstrates walking with crutches and stairs negotiation with one crutch and one rail.


Patients with a spinal cord injury who require KAFO bilaterally for swing-through crutch-assisted ambulation prefer to use a wheelchair. [23] They use a wheelchair as the primary means of mobilisation and discontinue walking after gait training due to:[23][25]

  • high energy demands during ambulation
  • slow walking speed in comparison with wheelchair propulsion or normal walking[23]
Plastic AFOs with different trimlines

Ankle-Foot Orthosis (AFO)[edit | edit source]

The AFO can be made of metal, plastic, carbon, or hybrid with anterior trim lines, mid-mall trim lines or posterior leaf springs. Plastic AFO with posterior leaf spring (PLS) is the most commonly used AFO in gait rehabilitation in spinal cord injury involving the lower lumbar spine. Thoracic or lumbar incomplete spinal cord injury may require AFO with anterior shell or anterior trim lines AFO. You can read more about different types of AFOs here.

Patient example: L4-5 spinal cord injury, AIS C presented with the following:

  • Flaccid footdrop
  • Mild sensory loss at the dorsum of the foot
  • No oedema
  • Bilateral posterior leaf AFOs

Watch the video below of a patient with an incomplete T7 spinal cord injury ambulating with bilateral AFOs with anterior shell:


Ambulatory Devices[edit | edit source]

The two most common ambulatory devices used by individuals with a spinal cord injury are walkers and crutches.

Walkers[edit | edit source]

A walker is a walking aid that provides a wide base of support. It usually has three sides, with the side closest to the patient being open. You can read more about walkers here.

Crutches[edit | edit source]

Crutches allow the person to ambulate with an increased base of support. They transfer weight from the legs to the upper body and are often used by individuals with spinal cord injuries who cannot use their legs to support their weight. You can read more about crutches here.

Footwear[edit | edit source]

When wearing orthotics, patients cannot "slip back" into their favourite pair of shoes.[34]

It is essential to emphasise the importance of appropriate footwear in promoting safe walking habits and minimising injury or falls. Remember to prioritise using suitable footwear to support the patient's rehabilitation journey.

  • Proper shoe assessment must be performed, and the following should be considered:
    • Presence of the lower extremities oedema
    • Pressure points after the shoes are removed. Complete a thorough assessment of the ankles, heels, and toes, as the patient may not be able to feel their feet and is at risk of developing a pressure sore.
  • Shoes recommended to wear with orthotics should include [35]
    • Enclosed heel and toe
    • Secure lace or velcro fastening
    • Removable insole
    • Heel height as recommended by the orthotist

Resources[edit | edit source]

References[edit | edit source]

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  2. Van de Crommert HW, Mulder T, Duysens J. Neural control of locomotion: sensory control of the central pattern generator and its relation to treadmill training. Gait Posture. 1998 May 1;7(3):251-263.
  3. Sherrington CS. Flexion-reflex of the limb, crossed extension-reflex, and reflex stepping and standing. J Physiol. 1910 Apr 26;40(1-2):28-121.
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  11. 11.0 11.1 Promkeaw D, Arrayawichanon P, Thaweewannakij T, Mato L, Amatachaya P, Amatachaya S. Various surfaces challenge gait characteristics of ambulatory patients with spinal cord injury. Spinal Cord 2019; 57: 805–813.
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