Training to achieve over ground walking after spinal cord injury: A review of who, what, when, and how

Abstract

Objectives

(1) To provide clinicians with the best evidence for effective retraining of walking after spinal cord injury (SCI) to achieve over ground walking. (2) To identify gaps in our knowledge to guide future research.

Methods

Articles that addressed the retraining of walking in adults with SCI and reported outcome measures of over ground walking ability were identified through a non-systematic search of the PubMed, Scopus, and CINAHL databases. No restriction was applied to the method of training. Selected articles were appraised using the Physiotherapy Evidence Database scale. Information was synthesized to answer who best responds to what type of treatment, how that treatment should be delivered, and at what stage after injury.

Results

Individuals with motor incomplete SCI (American Spinal Injury Association (ASIA) Impairment scale (AIS) C and D) are most likely to regain walking over ground. The effective methods of training all involved a substantial component of walking in the training, and if assistance was provided, partial assistance was more effective than total assistance. Walking training resulted in a change in over ground walking speed of 0.06–0.77 m/s, and 6 minute walk distance of 24–357 m. The effective training schedules ranged from 10 to 130 sessions, with a density of sessions ranging from 2 per week to 5 per week. Earlier training led to superior results both in the subacute (<6 months) and chronic phases (>6 months) after injury, but even individuals with chronic injuries of long duration can improve.

Conclusions

Frequent, early treatment for individuals with motor incomplete SCI using walking as the active ingredient whether on the treadmill or over ground, generally leads to improved walking over ground. Much work remains for the future, including better quantification of treatment intensity, better outcome measures to quantify a broader range of walking skills, and better ways to retrain individuals with more severe lesions (AIS A and B).

Keywords:

• Rehabilitation
• Spinal cord injuries
• Locomotion
• Physical therapy
• Ambulation
• Body-weight supported therapy
• Robotic-assisted therapy
• Exoskeleton
• Lokomat
• Paraplegia

Acknowledgements

This article is based on a keynote presention at the fifth National Spinal Cord Injury Conference held in Toronto, Ontario, Canada in 2012. The authors thank the following individuals for their thoughtful comments: Elizabeth Ardolin, PT, PhD, Andrea Behrman, PT, PhD, Susan Harkema, PhD, Jennifer Keller, PT, Donna Livingstone, PT, Jay Nair, PT, Martina Spiess, PT. J. Yang's work on spinal cord injury has been supported by the Christopher and Dana Reeve Foundation, the Alberta Paraplegic Foundation, the Rick Hansen Foundation, and the Canadian Institutes of Health Research (CIHR). K. Musselman's fellowship is supported by the CIHR.