IJMS
Vol 36, No 4, December 2011

Review Article

Evidence-Based Evaluation of Physiological
Effects of Standing and Walking in Individuals
with Spinal Cord Injury
Mohammad Taghi Karimi

Abstract

Spinal Cord Injury (SCI) is damage to spinal cord, which is categorized according to the extent of functional loss, sensation
loss and inability of the subjects to stand and walk. The patientsuse two transportation systems including orthosis and wheelchair. It was claimed that standing and walking bring some benefits such as decreasing bone osteoporosis, prevention of pressure sores, and improvement of the function of the digestivesystem for SCI patients. Nevertheless, the question of wether or
not there is enough evidence to support the effect of walking
with orthosis on the health status of the subjects with SCI remains unanswered. In order to answer this question a review of
the relevant literature was carried out. The review of the literature showed that evidence reported in the literature regarding
the effectiveness of orthoses for improving the health conditionof SCI patients was controversial. Many investigators had onlyused the comments of the users of orthoses. The benefits mentioned in various research studies regarding the use of orthosis
included decreasing bone osteoprosis, preventing joint deformity, improving bowl and bladder function, improving digestive system function, decreasing muscle spasm, improving
independent living, and improving respiratory and cardiovascular systems function. The findings of the studies reviewed also showed that improving the independent living
and physiological health of the subjects were the only two
benefits, which were supported by strong evidence. The review of the literature suggests that most published studies arein fact surveys, which collected questionnaire-based information from the users of orthosis.
Iran J Med Sci 2011; 36(4): 242-253.
Department of Orthotics and Prosthetics,
Faculty of Rehabilitation, andMusculoskeletal Research Centre,
Isfahan University of Medical sciences,
Isfahan, Iran.
Correspondence:
Mohammad Taghi Karimi PhD,
Department of Orthotics and Prosthetics
Faculty of Rehabilitation Isfahan Universityof Medical sciences, Isfahan, Iran.
Tel: +98 311 7770553
Fax: +98 311 6687270
Email: mohammad.karimi.bioengineering@gmail.com
Received: 2 December 2010
Revised: 10 April 2011
Accepted: 24 April 2011

Keywords ● Spinal cord injury ● bone mineral density·orthosis · bone density
Introduction
Spinal Cord Injury (SCI) is a damage to the spinal cord that
results in the loss of mobility and sensation below the level of
injury. The disorder is characterized according to the amount offunctional loss, sensational loss, and inability to stand and1-3
walk. The incidence of SCI varies amongst countries. For example there are 12.7 and 59 new cases per million in France
and the United States of America, respectively.4,5 It may be theresult of trauma, especially motor vehicle accident, penetrating
injuries, or diseases. As a result of this type of disability, mostindividuals with SCI rely on a wheelchair for their mobility.

242 Iran J Med Sci December 2011; Vol 36 No 4

Standing and walking in individuals with spinal cord injury

They can transport themselves from one place
to another using a manual wheelchair with aspeed and energy expenditure similar to normal
subjects.6,7
Although, the use wheelchair provides mobility to such patients, it is not without problems.
The main problems are the restriction to mobility
from architectural features in the landscape,and a number of health issues due to prolonged
sitting. Decubitus ulcers, osteoporosis, joint deformities, especially hip joint adduction contracture, can result from prolonged wheelchair use.8
Individuals with SCI often undergo various rehabilitation programmes for walking and exercises. It has been suggested that by decreasing
urinary tract infections, improving cardiovascularand digestive systems functions and psychological health walking is a good exercise forparaplegics in order to maintain good health.8
In contrast, most patients prefer not to usean orthosis, or use it occasionally. They havementioned some problem associated with useof orthoses. The main problem with orthosis use
is the high energy demands it places on theusers during ambulation. In contrast to mobility
speed with a wheelchair, the mobility speed of a
SCI patient with an orthosis is significantly lessthan that of normal walking.9-13
Donning and doffing of the orthosis is another important problem associated with the useof an orthosis.14 The high amount of the force
applied on the upper limb musculature is another issue, which affects the use of an orthosis.
Depending on the style of walking, between
30% and 55% of body weight is applied on the
crutch during walking.15-17 The high extent of theforce, which is transmitted to the upper limb
joints, increases the incidence of some diseases as well as shoulder pain.18,19 Fear to fall,especially during hand function performances,is another problem of using an orthosis.
Although standing with an orthosis may havesome benefits for the patients, it has a number ofproblems. Therefore, the main question that remains is wether or not walking and standing withan orthosis can fulfil the afore-mentioned benefits. Unfortunately, the information mentioned insome textbooks regarding the benefits of using
an orthosis for SCI individuals are based on thesurvey studies. So, the aim of the present review
was to find some evidence regarding the effect ofusing orthoses on physiological improvement ofsubjects with SCI. Moreover, it was aimed to findthe performance of paraplegic subjects during
walking with orthoses and the problems associated with the use of orthoses.
Methods
An electronic search was done via the Pubmed, Embase and ISI web of knowledge databases from 1960 to 2010. The abstracts andtitle of each individual study was assessed by
the author. The selection of papers for review
was accomplished in two steps. In the firststep, relevant articles were selected based onwhether the title/abstract addressed the research questions of interest based on some
key words such as, Spinal Cord injury,
Physiological benefits, Walking, Standing andOrthosis. In the second step papers whose
language of publication was English, addressing the adults and children with paraplegia
and/or quadriplegia, and those in which subjects used orthoses or frame to improve someparameters such as, Bone Mineral Density(BMD), respiratory system function, cardiovascular system function, and joints range of mo-

Figure 1: The algorithm of search and selection of papers to include in the review.

Iran J Med Sci December 2011; Vol 36 No 4 243

M.T. Karimi

tion were selected. The algorithm of searchand selection of papers is shown in figure 1.
Findings
From an initial list of 100 articles, 40 articles
were fully retrieved and reviewed, based on
key words and parameters included. The re-sults of the research articles were fully reviewed
and categorized based on the mentioned
benefits. The results of the various researchstudies regarding the performance of the orthoses were categorized based on energy
consumption, and gait and stability analysis.
The results of reviewing the articles are shownin the following tables 1-13.

Table 1: The findings of various studies regarding the effects of standing and walking on bone mineral density
Reference
MethodResults[20]
Eight SCI subjects with complete lesion at levels C7- The BMD remained unchanged in lumber spine, but
L1participated in the study. The bone mineral density decreased to 50 % and 70% of normal value at prox(BMD) was measured at proximal tibia, lumber spine imal tibia and neckof femur, respectively.
and at tibia shaft 41 months after injury.
[21]
Ten SCI subjects with lesions at levels C6-T4 partici- The BMD remained unchanged in lumber spine, butpated in the study. The BMD was measured at proxi- increased by 10% in the proximal tibia.
mal tibia, lumber spine. The subjects were asked to
be upright and do cycling 30 minutes per day, threedays per week and for 12 months.
[21]
Ten SCI subjects with lesions at levels C6-T4 partici- The BMD remained unchanged in lumbar spine andpated in this study. The BMD was measured at prox- proximal tibia.
imal tibia, lumber spine. The subjects were asked to
be upright and do cycling 30 minutes per day, one
day per week and for six months.
[22]
Subjects with SCI (n=26) with complete lesion were The BMD of the femoral neck and shaft decreased
recruited. The BMD at lumber spine, femoral neck by 25%. For proximal tibia it decreased by more thanand shaft, proximal tibia was measured 2-25years 50%. Using Knee ankle foot orthosis (KAFO) did not
after injury.
influence BMD.
[23]
Subjects with SCI (n=54) participated in the research Leg BMD reduced by 19.62% in the standing groupstudy. No information regarding the level of lesion or and 24% in none standing group.
age of the subjects was given. The subjects wereasked to stand one hour per day and not less than
five days per week for a period varied between 12
and 24 months.
[24, 25]
Subjects with SCI (n=46) with complete and incom- The BMD was not significantly influenced by theplete lesion were recruited for the study. The BMD of levels of lesion and ambulatory status.
lumbar spine, proximal and distal parts of femur was Every effort should be expended to prevent turning
measured between one and 26 years after injury.
an incomplete into complete lesion. The rehabilitation should be life long.
[8]
Subjects with SCI (n=133) with complete and incomplete lesion participated in the study.
[26]
Six SCI individuals participated in this study. No in- Standing did not modify the bone density in any site.
formation regarding the level of lesion was given. The
BMD of long bones was measured 19 years after
injury. The standing time was 144 hours over a meanof 135 days.
[27]
Subjects with SCI (n=53) were recruited in this re- The use of long leg brace had significant effects on
search study. No information was given regarding the BMD at the proximal femur. The results of this relevel of lesion). The BMD of femur was measured one search showed that passive mechanical loading
year after walking with long leg brace and using could have a beneficial effect on preservation ofwheelchairbone mass.
[28]
Eighty individuals with myelomeningocele lesion at Although ambulatory status and neurological status
T4-T5 were recruited in this research study. The BMD (muscle stress) were both important factors in boneat distal radius and tibia was measured.
density, this study suggested that the latter was amore important.

Table 2: The findings of various studies regarding the effects of standing and walking on skin integrity
Reference
MethodResults[29]
A 17-items self-report survey questionnaire was sent They mentioned some benefits such as skin integrityto 463 adult patients, and 152 adult subjects with SCI and well–being.
(n=152) returned the questionnaire and were includedin the study.
[30]
The study was an investigation through a national There was a favourite response on the effects ofsurvey of a sample of individuals with SCI.
standing devices on the number of bed sores insome individuals.
[31]
Thirty six spina bifida patients used wheelchair com- The patients, who walked early, had fewer fracturespared with another 36 patients walked with orthosis
and pressure sores, were more independent, andwere more able to transfer

244 Iran J Med Sci December 2011; Vol 36 No 4

Standing and walking in individuals with spinal cord injury

Table 3: The findings of various studies regarding the effects of standing and walking on improving bowel and bladder function and urinary tract infection
Reference
MethodResults[8]
No real research was performed in this paper. The use of orthoses has a positive effects on bowel
It discussed the benefit of doing research only
regularity, and decreased the number of urinary tract
infections[30]
This was an investigation through a national survey of There was a favourable response to the effects ofa sample of individuals with SCI (paraplegia and qua- standing devices on the number of urinary tract
driplegia)
infections and on bowel regularity in some individuals They reported that they were able to empty their
bladder more completely.
[32]
A group of paraplegic subjects used a particular There was a reduction in urinary tract infections, but
ambulatory orthosis for upright weight bearing and there was no corresponding reduction in the level ofwalking. The amount of urine bacteria was counted bacteria.
before and after using orthosis

Table 4: The findings of various studies regarding the effects of standing and walking on improving joint range of motion anddecreasing muscle spasticity
Reference
MethodResults[26]
Six paraplegic men with a mean age of 49 years used The results showed that there was no importantorthosis for 19 years. They were been asked to walk difference between initial and final scores for clinical
144 times per 135 days.
assessment and joint range of motion.
[33]
Twenty five SCI patients walking with orthosis partici- Maintained range of motion and prevention of joint
pated in this research.
deformity were the two most important outcomes
mentioned by the researchers.

Table 5: The findings of various studies regarding the stability of paraplegic subjects in a quiet standing position with various
orthoses
Reference Number Position ofType of
COP path
COP
COP sway
Force applied
lesionorthosislength (m/m)
sway MLAP (mm)on crutch (N)[34]
9T4-T12
ARGO------41.72
35.22
43.26
[34]
9
T4-T12
NRGO------34.53
37.94
59.3
[35]
2
T4-T12
KAFO
0.51-0.62----------------------[35]2T4-T12MLO
0.123-0.2------------------------[35]2T4-T12RGO
0.116-0.16----------------------------[36]9T4-T12
Linked KAFO
0.74
1.11
1.75
------------[36]9T4-T12
Unlinked KAFO
0.659
1.087
2.07
-----------ARGO=advance reciprocal gait orthosis, NRGO=advance reciprocal gait orthosis without cable, KAFO=knee ankle foot orthosis,
MLO=medial linkage orthosis, ML=mediolateral, AP=anteroposterior, COP=centre of pressure, N=Newton, m=meter,
mm=millimeter

Table 6: The findings of various studies regarding the stability of paraplegic subjects while undertaking various hand tasks
Reference Type of
COP sway in COP sway in Sway path Sway path
Time for
Crutch peakorthosisAP (mm)
ML (mm)in AP (m)in ML (m)transverse
force (N)motion (s)[36]Linked KA4.78
4.94
0.91
0.34
-------------------FO[36]
Unlinked
5.35
4.4
0.9
0.76
---------------------KAFO
[34]
ARGO
--------------------------------11.12
179.75[34]
NRGO----------------------------------11.54
198
Staking plates[36]
Linked KA5.6
3.74
1.03
1.94
--------------------FO[36]
Unlinked
5.8
3.24
1.07
0.74
--------------------KAFO
KAFO=knee ankle foot orthosis, ARGO=advance reciprocal gait orthosis, NRGO=advance reciprocal gait orthosis without cable,
ML=mediolateral, AP=anteroposterior, COP=centre of pressure, N=Newton, s=second, m=meter, mm=millimetre

Iran J Med Sci December 2011; Vol 36 No 4 245

M.T. Karimi
Table 7: The findings of various studies regarding the force applied on the foot and crutch during walking with various orthoses
Reference
NumberPosition
Foot force
CrutchFoot
CrutchType ofType ofof subjectsof lesion(N/BW)
force (N/BW) verticalverticalwalkingorthosis
impulseimpulse[17]
5
T1-T100.784-1.042 0.288-0.296
0.712-0.794
0.206Rec
HGO
0.288
[37]
5
L3-L4
-------0.447-0.451-----------------Rec
RGO
[37]
5
L3-L4
-------0.556-0.572-----------------Swi
HKAFO
[15]
1
L2
0.90-1.10
0.35--------------Rec
HGO
[38]
9
T4-T9
0.29- 0.98
0.40---------------Rec
HGO
[39]
1
T7
0.83
0.33
---------------Rec
RGO
[40]
10
C5-T12----------0.15-0.50------------Swi
No orthosis
withcrutch[40]
10
C5-T12----------0.39-0.74------------Swi
No orthosis
with walker[11]5
T4-T12-----------0.39---------0.59
Rec
ARGO
0.43
(1)
[11]
5
T4-T12-----------0.36----------0.57
Rec
ARGO
0.40
(2)
[11]
5
T4-T12------------0.36--------0.57
Rec
ARGO
0.41
(3)
[11]
5
T4-T12-----------0.33----------0.59
Rec
ARGO
0.40
(4)
[41]
2
T4-T8
----------0.225-----------306Rec
ARGO
0.36
522.2 N.s
[41]
2
T4-T8
-----------0.22------------310.2Rec
ARGO
0.385
529 N.s
hybridRec=reciprocal gait mechanism, Swi=swing through gait mechanism, HGO: hip guidance orthosis, RGO=reciprocal gait orthosis,
HKAFO=hip knee ankle Foot orthosis, ARGO=advanced reciprocal gait orthosis, ARGO (1)=ARGO orthosis aligned in 6
degrees of abduction, ARGO (2)=ARGO orthosis aligned in 0 degrees of abduction, ARGO (3)=ARGO orthosis aligned in 3
degrees of abduction, ARGO (4)=ARGO orthosis aligned in 6 degrees of adduction, N/BW=newtone/body weigh

Table 8: The findings of various studies regarding the gait parameters of the subjects in walking with various orthoses
Reference
NumberLevel of
Orthosis
Hip Ext
Hip
Hip
Hip
PelvisPelvislesion(degree)
Flex
Abd
Add
(sajittal)(frontal)
[42]
1
T5
LSU
33
15
3
8
16
16
RGO
[42]
1
T5
ARGO
35
12
0
10
17
17
[42]
1
T5
HGO
21
16
9
7
11
12
[43]
4
T8-T12WBC
44.73 (flexion---------------------------extension
excursion)
WBC=weight bearing control orthosis, Abd=abduction, Add=adduction, Flex=flexion, Ext=extension

Pelvis(transverse)
232633-------------

Table 9: The findings of various studies regarding some gait parameters during walking with various orthoses
Reference
NumberLevel of
Orthosis
Pattern of
Velocity
StrideCadenceStancelesionwalking(m/min)length(steps/min)
phase
(m)
percentage
[44]
1
T7
WBC
Reciprocal
21.2
1.1
38.4
-----------gait
[44]
1
T7
HGO
Reciprocal
8
0.66
24.2
------------gait
[45]
1
T12
ARGO with Reciprocal
12
0.84
28.8
--------------locked
gait
knee
[45]
1
T12
ARGO with Reciprocal
10.8
0.79
26.8
-------------controlled
gait
knee
[46]
2
T6
Orthosis
Reciprocal
7.2-8.4
0.65-0.8---------------------with flex
gait
knee
[46]
2
T6
Orthosis
Reciprocal
7.8-8.4
0.58-----------------------with flex
gait
0.82
knee andankle
WBC=weight bearing control orthosis, HGO=hip guidance orthosis, KAFO=knee ankle foot orthosis, ARGO=advance reciprocal
gait orthosis

246 Iran J Med Sci December 2011; Vol 36 No 4

Standing and walking in individuals with spinal cord injury
Table 10: The findings of various studies regarding the results of some gait parameters in walking with various orthoses
Reference
Number Level of
Orthosis
Pattern of
Velocity
StrideCadenceStancelesionwalking
lengthphase
percentage[40]
10
C5-T12
Crutches
Swing through 18-48
0.43-0.67
42-89.3
69/31-74/26
gait
[40]
10
C5-T12
WalkerSwing through 10-24
0.3
30
73/27-95/5
gait
[47]
9
No data
KAFO
Swing through 41.7-59.9
1.23-1.5
67-79
64.6-70.7
gait
[47]
9
No data
KAFO
Swing to gait
23.4
0.53
88
83.9
[37]
5
L3-L4
HKAFO
Swing through 35.4
0.86
75.43
63
gait
[37]
5
L3-L4
RGO
Reciprocal
23.4
0.66
67.12
66
gait
[42]
1
T5
RGO
Reciprocal
18
1.02
35
67
gait
[42]
1
T5
ARGO
Reciprocal
18.6
0.99
37
67
gait
[42]
1
T5
HGO
Reciprocal
18
0.98
37
67
gait
[48]
29
T2-L5
VRSO
Swing through 26---------------------------------gait[49]
8
C7-T12
Scot Craig
Swing through 8.8- 17.5--------------------------------KAFO
gait
[49]
8
C7-T12KAFO with
Swing through 6.3-15.3--------------------------------single Ankle gait
[50]
5
T4-T12
ARGO
Reciprocal
14.4
0.89
32
-----------gait[50]
5
T4-T12
NRGO
Reciprocal
13.8
0.83
31.6
-----------gait
[51]
21
RGO
Reciprocal
12.6
0.72
34.5
76.5
gait
[51]
21
RGO with
Reciprocal
12
0.72
33.61
77.22
FES
gait
[43]
4
T8-T12WBC
Reciprocal
19.88------------44-----------gait
KAFO=knee ankle foot orthosis, HKAFO=hip knee ankle Foot orthosis, RGO=reciprocal gait orthosis, HGO=hip guidance orthosis, VRSO=Vannini Rizzoli stabilizing orthosis, FES=functional electrical stimulation, ARGO=advance reciprocal gait orthosis,
NRGO=advance reciprocal gait orthosis without cable, WBC=weight bearing control orthosis

Table 11: The findings of various studies regarding some results of energy consumption tests
Research
NumberLevel ofType ofStyle of walking
Walkingoflesionorthosis
velocity
subjects[7]25
T1-T12
Double KAFO
Swing through gait
26±16
[52]

8

T4-T12

Resting

Swing through gait

[52]

8

T4-T12

Swing through gait

[53]

10

T4-T9

[54]

26

T12-L3,4

Craig-Scottorthosis
HGO
orthosis
RGO

[54]

26

T12-L3,4[6]

3

T11-L2[6]

11

T11-L2------

Reciprocal gait-------12.84

Reciprocal gait

16.2

HKAFO

Reciprocal gait

40.8

KAFO

Swing through gait

32.4

Energy cost
(J/kg/m)
15.278±10.25-----------

Energyconsumption(J/kg/min)
288.83±100.496--------------

76.5
234.12

16

186

16.92
±7.1
11.28
±2.51
20.69

239.1
±38.66441±64.372446.84Wheel-----------84.9
4.28
430.54
chair
[7]
100
-------Normal subject--------------------3.135
248.71wheelchair±0.418±48.07[7]
10
T1-T9
OrthosisSwing through gait--------15.46
303
SCI±10.45±89.87[7]55
T1-T9
Wheelchair------------------3.34
240.35SCI±0.627±64.79
KAFO=knee ankle foot orthosis, HKAFO=hip knee ankle Foot orthosis, HGO=hip guidance orthosis, RGO=reciprocal gait orthosis,
SCI=spinal cord injury

Iran J Med Sci December 2011; Vol 36 No 4 247

M.T. Karimi
Table 12: The findings of various studies regarding the energy consumption of paraplegic subjects during walking with various orthoses
Research Number ofLevel ofType of orthosis
Style of
Walking
Energy cost
Energysubjects
lesionwalking
velocity(J/kg/m)consumption(J/kg/min)[49]
8
C7-T12
Scot Craig KAFO
Swing through
17.5
63.95
------------with crutch
gait
[49]
8
C7-T12KAFO with Single
Swing through
15.3
73.15
----------stop ankle joint
gaitwith crutch[49]
8
C7-T12
Scot Craig KAFO
Swing through
8.8
26.38
----------with walker
gait
[49]
8
C7-T12KAFO with Single
Swing through
6.3
36.78
------------stop ankle joint
gaitwith walker[43]4
T8-T12WBC
Reciprocal
19
119.5----------gait[50]
6
T4-T12
ARGO
Reciprocal--------------------355.58
gait
[50]
6
T4-T12
NRGO
Reciprocal-----------------------376.1
gait
KAFO=knee ankle foot orthosis, WBC=weight bearing control orthosis, ARGO=advance reciprocal gait orthosis,
NRGO=advance reciprocal gait orthosis without cable
Table 13: The findings of various studies regarding the physiological cost index (PCI) of
paraplegic subjects during walking with various orthoses
Reference
Type of orthosis
PCI (beats/metre)[10]
HGO
0.95-1.65[10]Parawaker 89
0.8-1.26
[50]
ARGO
5.4
[50]
NRGO
5.8
[55]
Walk about
11.5
[55]
MMLO
11.5
[44]
WBC
1.9
[44]
HGO
3.6
HGO=hip guidance orthosis, ARGO=advance reciprocal gait orthosis, NRGO=advance reciprocal gait orthosis without cable,
MMLO=Moorong medial linkage orthosis, WBC=weight bearing control orthosis

Discussion
According to the results of the research undertaken by Biering et al.56 BMD of long bone,such as femur and tibia decreased significantly
after injury. It may be a result of decreasing thecompression loads applied on the long bones,
or may be related to the lack of muscles stress20
applied on the bones. Most of the researchdone regarding the effects of using orthosis on
BMD have shown that walking and standing
with orthoses do not influence the magnitude
22,27
of osteoporosis as much as expected.
The
preservation of BMD in lumber spine is morethan that in long bones.20 It may be due to themaintain of the loads on the spine while sitting
in a wheelchair.
There is only one study, which specificallymentioned that walking with orthosis brought a
lot of physiological benefits for the subjects
8
without presenting any evidence. Unfortunately many textbooks in this field refer to that
paper without considering the results of otherresearch studies.57-59

248 Iran J Med Sci December 2011; Vol 36 No 4

The other important parameters regarding
the influence of standing and walking on BMD
is the duration of using an orthosis. It was
shown that walking and standing with an orthosis must be life-long, and must be repeatedseveral times a week to have any effects onbone osteoporosis (at least five session aweek and one hour every cession). The use of
mechanical orthoses and the neurological status (muscles stress), to remain ambulatory are
two important parameters which influence
BMD. However the findings of various researchstudies have shown that the effect of the latter
is more important (table 1 and 2).28
It seems that the type of injury, wether or
not complete, influences the BMD. The patients with incomplete lesion have more BMD
than those with a complete one.24,25 Therefore,
every effort should be made to prevent turning
an incomplete SCI into a complete one (table 3).
Last but not least important point regarding theeffects of using orthosis on the BMD of SCI
patients is that some of the research studies,
which their outcome differs from SCI, have

Standing and walking in individuals with spinal cord injury

been carried out on patients with spina bifida
and myelomeningocele patients.8,31
The results of various studies regarding theeffects of using orthosis on spasticity are shownin table 4. As the table shows, the majority of
researches cited are survey-based. The investigators had sent questionnaires to individuals
with SCI. Unfortunately, most of the subjects did
not return the questionnaires. According to thefindings of different investigations undertaken
on SCI subjects, there was a favourable response to the use of orthosis on spasticity.26,33
There are a number of ways, which can be used
to measure spasticity clinically and biomechanically such as using Ashworth scale, counting
beats of clonus, Tardieu scale, muscle stretch
reflexes, and functional tests.60
It seems that standing and walking with an
orthosis extends the hip and knee joints, andstretches the surrounding muscles. So, applying body weight through leg reduces muscle
spasm more efficiency than stretching themuscles only in a supine position.8,57 However,there is no evidence to support this view.
It has been stated that in standing position,
the pelvic tends to tilts more anteriorly than insitting position. This increase lumber lordosis,
and finally stabilizes the spine in an extended
posture. In this posture, the force applied on
the internal organs decreases, and as a result
the performance of respiratory organs increases.8,57 Abdominal organs fall downward
and forward during standing, because there isno an abdominal muscle to increase the stability of the abdominal walls anteriorly. At theend, the force applied on diaphragm decreases, and respiratory function improves.8
However, it was shown by Ogilive that the useof orthosis and ambulation did not affect the
respiratory function of participants 24 months
after continued use of orthoses (table 5).32
Improvement of the function of the cardiovascular system is a further benefits mentioned
in the literature for ambulation with orthosis.8
However, there is no evidence in literature to
support this view. Douglas et al mentioned thatwalking with orthosis influenced the performance of the cardiovascular system in 133 patients with SCI. There was no clear descriptionof the method, which was used to monitor thefunction of cardiovascular system in the subjects participating in the study. It seems thatthe authors only presented the comments of
the orthotic users.8
The decrease of urinary tract infections andimprovement in the function of bowel andbladder are the other benefits mentioned to beachieved from orthosis ambulation. There are

only two research studies based on national
survey of samples of individuals with SCI possessing symptoms of paraplegia or quadriplegia (table 3).30,32 The subject participated inthese studies mentioned that walking with orthosis decreased the number of urinary tract
infections, and regulated the functions of bowel
and bladder. They reported that they were able
to empty their bladder more completely.32 Unfortunately, there is no clinical research, which
has evaluated the effect of using orthosis on
improving the performance of bowel and bladder function.
Another benefit, which was mentioned by
Douglas et al regarding the benefits of using
orthosis, is the prevention of joint deformity
and improvement of joint range of motion.
They claimed that during standing the bodyweight is applied vertically downward andsymmetrically upon both feet. In standing position the gravitational positioning of flexed joints
decreased, and as a result the risk of deformity oflower limb joint decreased as well.8 Moreover,
Middleton et al mention that maintaining range of
motion and preventing of joint deformity were thetwo most important outcomes presented by theparticipants. However, they did not show any
evidence to support their findings (table 4).33
According to the results of various researchstudies, the main problems associated with theuse of orthosis is the high energy demand it
places on the users during ambulation (tables
11, 12, 13).6,7,49,52-54,61 Moreover, the walking
speed in a SCI individuals with an orthoses issignificantly less than that of healthy individuals and also in contrast to mobility with awheelchair (tables 11, 12, 13). Although, thetype of orthosis and style of walking influence
the magnitude of energy consumption, there isa huge difference between the energy consumptions between walking with and without
orthosis.62 As is shown in tables 11, 12, 13
there is a big difference between the performances of the subjects in walking with various
types of orthoses. Some parameters such as
the type of orthosis, the position of lesion invertebral column, age of subjects, and the styleof walking influence the performance of thesubjects.6,7,49,52
The high magnitude of the force applied on
upper limb musculature is another issue that
affects the use of orthosis. Depend on the styleof walking, between 30% and 55% of bodyweight is applied on the crutch during walking
15,40,63,64(table 7).
The high magnitude of theforce, which is transmitted to upper limb joints,
increases the incidence of some diseases andthe pain of shoulder.

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M.T. Karimi

Donning and doffing of orthoses is anotherimportant problem associated with the use ofan orthosis. Herman and Biering found that
only three out of 45 patients continued using
their orthosis after 10 years. The reason thatthey mentioned for withdrawing from the use oforthoses was the considerable time that theyneeded to spend on putting on and taking off
the orthosis.14
Although the results of the afore-mentioned
investigations can not support the effects ofwalking and standing with orthosis on physiological health of the SCI individuals, it is difficult to ignore the positive influences of orthosis. It is recommended to undertake further
studies with a sufficient number of participants,
and follow the subjects for a long time. Moreover, the performance of the subjects in using
the orthoses as well as the impact of the orthoses on the health status of the subjects
must be measured according to the standard
methods discussed in this article.

orthoses after they obtain it. The patients reported some problems such as high demand forthe energy expenditure and mechanical work
during walking with orthoses, poor cosmesis of
the orthoses, especially the hip guidance orthosis, needing considerable time and sometimes
assistance for donning and doffing, and problems related to the fear of falling.
It is recommended that to have any influences on physiological health of the SCI subjects, orthosis must be used for a long time.
However, the patients have lots of problems withdonning and doffing the orthosis. Therefore, thedesign of the orthosis must allow easy donningand doffing of the orthosis regularly. It is recommended to design a new orthosis with attachable
components, which allow the subjects to wear it
independently. The use of some sources of external power in orthoses may improve the performance of the subjects during walking.

Conclusion

References

A number of publication have emphasized thatwalking with orthosis is associated some benefits for individuals with SCI, such as improving
BMD, improving the functions of cardiovascular,
digestive and respiratory systems, decreasing
muscles spasm, and joint contractions. However, the findings of various studies have shownthat the effects of using orthosis on physiological health are not as much as they are supposed to be. There is no any strong evidence
that the use of orthosis can decrease bone osteoporosis, muscle spasm, and improve general
health. Moreover, most of the studies in thisfield are survey-based. It can be concluded thatin order to have any influences on the healthstatus of SCI patients, the use the orthosis forstanding and walking must be long-life. Moreover, orthoses must be worn four to five sessions of at least one hour every week.
A variety of orthoses have been designed toenable SCI individuals to stand and walk. Theyuse different mechanisms to stabilize the paralyzed joints, and to move the limbs forward during walking. Different sources of power such as
pneumatic pumps, hydraulic pumps, muscularforce resulting from electrical stimulation, andelectrical motors have been attempted for walking. However, the results of different studies
have shown that the performance of SCI individuals during walking with the mechanical orthosis is very low, and the patients experience a
lot of problems in using the orthoses. Many of
the SCI individuals discontinue from using their

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Conflict of Interest: None declared

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