Dr Jeff Tubbs
4/16/14

James S. Krause, PhD, Holly Wise, PhD; PT, and
Elizabeth Walker, MPA have disclosed a research
grant with the National Institute of Disability and
Rehabilitation Research

The contents of this presentation were developed
with support from an educational grant from the
Department of Education, NIDRR grant number
H133B090005. However, those contents do not
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by the Federal Government.

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
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
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
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
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Identify factors associated with the ability to
ambulate after SCI
Discuss the prognosis of ambulation based on
injury level and functional impairments.
Identify methods for aiding ambulation and
gait training following SCI.

Ambulation is an important goal for many
with acute SCI
Combat osteoporosis
Reduced urinary calcinosis
Reduced spasticity/ROM
Improved digestion/bowel
function
 Prevent pressure ulcers
 Access items not accessible
at wheelchair level
 Psychological

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
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

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

High energy demand
Increased weight
bearing through UEs
Muscle atrophy
Ability to don orthosis
Fracture risk
May not be a priority in
acute Inpatient Rehab
setting
BENEFITS

Can help slow bone loss….






Standing alone not sufficient to reverse
bone loss after SCI
Potentially decreased
spasticity/contracture
Bowel/bladder
Improvement in orthostatic
hypotension
Improved self-concept/depression
Skin Health
(Kirshblum 2011)
CAUTIONS

Fracture risk

LE edema

No firm recommendations
regarding degree of bone loss at
which standing is contraindicated.
 Standing Frames
 Tilt Tables
 Orthotics


Non-ambulatory
Exercise
 Can stand and take few steps with orthotics
 Requires assistance (person, parallel bars…)

Household
 Ambulate I-Mod I in home
 Use WC for longer distances

Community
 Sitstand
 Don/doff orthotics
 Walk ≥ 150 ft

Requirements (Hussey, Stauffer 1973)
 Bilat hip flexor strength +
unilateral Knee Ext ≥ 3/5
 Maximum bracing =
▪ 1 long leg brace (KAFO) + 1
short leg brace (AFO)
 Proprioception
▪ At least hip and ankle









Spasticity
ROM
Proprioception
Vision
Cognitive status
Aerobic capacity
Upper body/trunk strength
Muscle Atrophy
Motivation
(Barbeau et al. 2006)

Depends on…
 Energy cost
 Level of independence
 Cosmesis
 Orthotic function/reliability
 Finances
▪ Orthosis, assistive devices, fitting, training,
maintanance

Ambulating at Rehab discharge
▪
▪
▪
▪
AIS A < 1%
AIS B = 1-15%
AIS C = 28-40%
AIS D = 67-75%
▪ Tetraplegia vs Paraplegia did not
significantly affect walking in AIS C-D
(Kay et al. 2007, Burns et al. 1997)


T12 and above (complete injury)
 Do not expect community or household ambulation
L2 and below
 Best prognosis for community ambulation

Community ambulation at 1 year
 Complete Paraplegia = 5%
 Incomplete tetraplegia = 46%
 Incomplete Paraplegia = 76%

20-50% AIS B recover ability to walk at 1 year
 Pinprick preservation more important prognostic ally
(Alekna et al. 2008, Stauffer et al. 1978, Oleson et al. 2005, Waters & Mulroy 1999)

Prognosis for community ambulation at 1 yr
based on exam 30 days post injury
(Waters et al. 1992, 1994,
1994,1998)
 Complete paraplegia
▪ LEMS = 0  < 1%
 Incomplete paraplegia
▪ LEMS = 0  33%
▪ LEMS >10  100%
 Incomplete tetraplegia
▪ LEMS = 0  0%
▪ LEMS = 10-19  63%
LEMS = 1-9  45%
LEMS = 1-9  70%
LEMS = 1-9  21%
LEMS > 20  100%

Based on LE motor scores

hip flexors, hip abductors, hip extensors,
knee extensors, knee flexors
 Each muscle graded 0-3 (max score = 30)
AMI = % of max
 Higher scores associated with…






Faster gait
Increased cadence
Decreased oxygen cost
Decreased force on UE assistive devices
AMI ≥ 60% required for community
ambulation

Correlated with maximum of 1 long leg
brace
(Waters et al. 1989)

Anyone who wants to…
 First, do no harm
 Keeping in mind co-morbidities
 Setting appropriate, clear goals

Thoracic, Complete injuries
 Focus on being independent at WC level first

Reciprocal (alternating)
 Requirements
▪ Hip flexion ≥ 3/5
▪ …or able to compensate
(lifting hip + post pelvic tilt to
advance leg)
 LEMS is the main
determinant of …
▪ Speed, cadence, oxygen
consumption

Swing-through (with crutches)
 Typically used by those with complete injuries
▪ Bilat KAFO
▪ Arm strength needed to lift/swing body
 Compared to normal ambulation…
Mulroy 1999)
▪ 64% slower
▪ 38% additional oxygen requirement
(Rosman & Spira 1974, Waters &

KAFO (long leg brace)
 Conventional
▪ Double metal upright AFO attached to shoes
▪ Knee joint
▪ Thigh uprights with thigh band
 Thermoplastic
▪ Lighter, better cosmesis, no shoe attachment
▪ More difficult to modify
▪ Potential for skin breakdown
▪ Not accommodating for edema, tone, decreased sensation

Swivel Walker
 Children
 Caudal to C6
 Allows ambulation w/out
walking aids
 Rocking to alternative
sides  foot lifted off
ground  brace swivels
due to gravity
 Ambulation is slow
 Only on level surface

Reciprocating Gait
Orthosis (RGO)
 Bowden cables
 Extension of 1 hip causes
flexion of the other
 Extension of trunk causes
extension of stance hip
 Gait is slow
 3-4x energy cost of normal
slow walking
 10-58% abandonment rate

Hip Guidance Orthosis (HGO) Orlau Parawalker
 Used in thoracic paraplegia
▪ Reciprical gait with crutches
 Rigid body brace connected to
bilat KAFO
 Hips resists adduction/abduction
 Uses gravity for swing phase

Parastep
 Transcutaneous FES
 Quads, common peroneal
(for hip flex reflex), glut
max/paraspinals
 Reciprocal gait
 Control switches on
walker
 Candidates
 Complete thoracic SCI
 Intact lumbo/sacral cord

“The Loco-Motion”
 1962 – Little Eva (#1)
 1974 – Grand Funk
Railroad (#1)
 1988 – Kylie Migonue
(#3)

Activity based training
 Repetitive stepping
overground/treadmill while
connected to body weight supported
system
 Variable loading of body weight
 Spinal cord can generate rhythmic
movements resulting in locomotion
w/out supraspinal input (Barbeau et al. 1998)

The basic neuronal circuitries responsible for
generating efficient stepping patterns are
embedded within the lumbosacral spinal cord.
General scheme of the normal control of locomotion.
Rossignol S Phil. Trans. R. Soc. B 2006;361:1647-1671
©2006 by The Royal Society

However, a CPGs alone
not sufficient for
overground walking
 Feedback from other
systems (touch,
proprioception, visual,
vestibular, cortical…)
 Modulation of muscle
activity based on the
environment

Plasticity of spinal neuronal circuits is largely task specific and usedependent

Spinal neuronal circuits learn the sensorimotor task that is
specifically practiced and trained
 Practice walking  better walking
 Practice standing  better standing
 Practice walking
(Hubli and Dietz, 2013)
≠ better standing

C00rdination lower limb muscles in stepping
is present in the human lumbosacral spinal
cord, however…
 Cats  full weight-bearing stepping with step
training
 Humans w/complete SCI at the thoracic level 
only partial weight-bearing steps
(Edgerton, Harkema and Roy, 2010)
 Motor complete and incomplete SCI
 coordinated leg muscle activation pattern in both legs can be induced
following partial unloading standing on a moving treadmill

Successive reloading might be an important stimulus for leg
extensor activation during locomotion in cats and humans

Afferent input is important for shaping locomotor output
(Hubli and Dietz, 2013)

May recognize the “gestalt” pattern of input
 Feed-forward control

State-Dependent Processing
 Complete SCI  activation of extensor muscles
increases as load bearing increases
(Edgerton, Harkema and Roy 2010)

Concept that spinal cord is not just
a relay center
 Experience dependent information
processing/decision making

All input may provide info to cord
in order to recognize temporal
events and anticipate what to do
next
 Muscle spindles, GTO, free nerve
endings in muscles/joints/skin
(Edgerton, Harkema and Roy 2010)

Implications for anything that reduces
afferent input to the spinal cord

Objectives
 Progressive loading of LES
 Timing
 Leg kinematics
 Step speed
 Strength

Types
 Body Weight Supported Suspension
▪ BWSTT – treadmill
 Combo with FES
 Robotic
▪ Exoskeleton

Parachute Harness or Pneumatic Harness
 Pneumatic closer to normal loading/unloading gait pattern

Over ground/treadmill
 LiteGait (2 point attachment)
 Biodex (1 point attachment)

Robomedica
 Pneumatic lift, elevated treadmill

Therastride
 Hardware-software interface for treadmill and BWS
control
LITEGAIT
BIODEX
ROBOMEDICA
THERASTRIDE
ADVANTAGES



Therapist can perceive
level of assistance
needed
Higher volume of
repetitions per
treatment period
compared to non-BWS
gait training
Therapist can guide the
support needed
 Prevent “bad habits”
DISADVANTAGES



Labor intensive, multiple
therapists
Non-ergonomic for
therapists
Difficult to control
trajectory of joints
consistently

Stimulation
 Quads
 Hamstrings
 Gluteal
 Peroneal N
▪ To get flexion withdrawl
response (hip/knee flex,
dorsiflex)

Treadmill
 Lokomat

Footplates
 Gait Trainer GT-1, HapticWalker, G-EO, LokoHelp

Exoskeleton
 ReWalk, Ekso, Indego,Tibion Bionic Leg
Active control hip and
knee position
 Passive control of ankles.
 Sensors track force
generated at each joint
 “guidance control”
feature can provide some
variability in walking


Goal = Consistent bilat
coordinated stepping
pattern with normal
kinetics

Limited to repetitive
walking on level
surface
FIGURE 3
Robotic-Assisted Gait Training and Restoration.
Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation.
91(11) Supplement 3:S217-S231, November 2012.
DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 3 . Photo of LokoHelp, courtesy of the
manufacturer.
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
4

Haptic Walker
 (commercially available as G-EO System)
 Unconstrained hip/knee joints
 “adaptive mode”  allows for some kinematic
variability during walking
FIGURE 4
Robotic-Assisted Gait Training and Restoration.
Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation.
91(11) Supplement 3:S217-S231, November 2012.
DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 4 . Photo of G-EO in use by a patient with a
stroke, courtesy of MossRehab.
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
5

Locomotor training trials
 Historically
▪ Largely nonrandomized
▪ No control group
▪ Various outcome measures
▪ Various training duration/intensity

Wirz et al. 2005, multisite trial
▪ N = 20, chronic (>2 yr) motor
▪
▪
▪
▪
incomplete
16 could ambulate overground
(>10m) @ baseline
Up to 45 min, 3-5x/week, x8
weeks
Improved overground walking
speed/endurance
No change in walking aids,
orthoses, physical assistance
FIELD-FOTE ET AL. 2005

Walking outcomes for chronic,
motor incomplete SCI (n = 27)

BSWTT with manual
assistance, BWSTT w/FES,
BWS overground w/FES,
Lokomat

0% became community
ambulators
Improvement in walking
speed in each group,
improved household
ambulation
No significant difference b/w
groups


FIELD-FOTE AND ROACH, 2011
Single-blind, randomized
N= 74 (64 completed training),
chronic motor incomplete SCI
 5x/week, 12 weeks
 Treadmill training with manual
assistance, treadmill/FES,
overground/FES, treadmill with
robotic assist


Walking speed improved with
overground and treadmillbased training
 Walking distance improved
more with overground training


Cochrane Review (Mehroholz et al. 2008)
 Insufficient evidence that any one LT strategy
improves walking recovery more than any other

Tefertiller et al. 2011
 Review of locomotor training after SCI, CVA, MS,
TBI, Parkinson
 Supported LT with robotic assistance for
improving walking function after SCI and CVA
 Gait speed/endurance not significantly different
b/w LT approaches in motor incomplete SCI

Additional potential benefits






Metabolism
Body composition
Attenuating bone loss
Cardiovascular
Bowel Care/reduced time
Pressure ulcer
▪ Increased muscle mass, increased peripheral blood flow,
less seating pressure
(Kirshblum 2011)

Full body unloading during robotic assisted
walking does not lead to significant leg
muscle activation
 Ground contact is key
Hubli and Dietz, 2013
FIGURE 5
Robotic-Assisted Gait Training and Restoration.
Esquenazi, Alberto; Packel, Andrew; PT, NCS
American Journal of Physical Medicine & Rehabilitation.
91(11) Supplement 3:S217-S231, November 2012.
DOI: 10.1097/PHM.0b013e31826bce18
FIGURE 5 . Photo of ReWalk in use by a patient with
complete spinal cord injury, courtesy of MossRehab.
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc.
6


Walking robot, Patient controlled
Intended for patients with motor complete paraplegia

Zeilig et al. 2012, pilot study for safety
 N=6
 Avg 13-14 training sessions  no adverse safety events

Esquenazi et al. 2012
 Study of safety and performance
 Motor complete SCI
 After training 100% (n = 11) , could transfer and walk atleast 50-100
m continuously over 5-10 min
 Self reported improvement in bowel function (n = 5/11), and
spasticity (n = 3/11)

Fineburg et al. 2013
 Chronic motor complete (n=6)
 1.5-14 yr post injury (5 AIS A, 1 AIS B)
▪ Able bodied controls (n=3) with their normal gait  no
exoskeleton
 Outcomes
▪ F-scan in shoe pressure monitoring system to measure ground
reactive force
 Results
▪ those in ReWalk who could ambulate w/out assistance had vGRF
that were similar to able bodied controls (no exoskeleton)
▪ If needed min A to ambulate, ~50% compared to able bodied
Parker-Hannifin design concept for the commercial
version of the exoskeleton. (Courtesy of Parker-Hannifin)

Esquenazi A, Packel A. Robotic-assisted gait training
and restoration. Am J Phys Med Rehabil. 2012 Nov;91(11
Suppl 3):S217-31. Good Review
 “seek to provide intensive, task-specific training with
high numbers of repititions.”
 Identify and address underlying components that are
interfering with walking
 Overground walking would be most “task-specific”
activity for household/community ambulation
▪ Consider robotic assisted gait training if cannot achieve the
desired intensity/volume overground

Still unanswered questions regarding
locomotor training in SCI:
 How early to start therapy?
 How intense should it be?
 Duration of training?

In general, locomotor training should be
challenging with only minimal support by
therapists/robot
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5.
Edgerton VR, Harkema SJ, Roy RR (2010). Retraining the Human Spinal Cord: Exercise Interventions to Enhance Recovery after a Spinal Cord Injury. In Lin VW (2nd Ed), Spinal Cord Medicine:
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6.
Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Rehabil. 2012 Nov;91(11 Suppl 3):S217-31.
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Esquenazi A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskelton to restore ambulatory function to individuals with thoracid-level motor-complete spinal cord injury. Am J Phys
Med Rehabil. 2012 Nov;91(11);911-21.
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Field-Fote EC, Roach KE. Influence of a locmotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial. Phys Ther. 2011
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Fineberg DB, Asselin P, Harel NY, et al. Vertical ground reaction force-based analysis of powered exoskeleton-assisted walking in persons with motor-complete paraplegia. J Spinal Cord Med
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Hubli M, Dietz, V. The physiological basis of neurorehabilitation – locomotor training after spinal cord injury. J Neuroeng Rehabil. 2013 Jan 21;10:5.
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Hussey RW, Stauffer ES. Spinal cord injury: requirements for ambulation. Arch Phys Med Rehabil 1973;54;54(12).
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Kay ED, Deutsch A, Wuermser LA. Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury. Arch Phys Med Rehabil 2007;88(6)745-750.
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Kirshblum S, Bloomgarden, McClure I, et al. Chapter 17, Rehabilitation of Spinal Cord Innury. In Kirshblum S, Campagnolo DI (Eds.) Spinal Cord Medicine, 2nd Ed. 2011. Philadelphia: Lippincott
Williams & Wilkins.
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Mehrohlz J, Kugler J, Pohl M. Locomotor training for walking after spinal cord injury. Cochrane Database Syst Rev 2008;2:CD006676. doi:10.1002/14651858. CD006676.
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