Comparison of training methods to improve
walking in persons with chronic spinal cord
injury: a randomized clinical trial
Natalia Alexeeva1, Carol Sames2, Patrick L. Jacobs3, Lori Hobday4,
Marcello M. DiStasio5, Sarah A. Mitchell6, Blair Calancie1
1

Dept. of Neurosurgery, SUNY’s Upstate Medical University, Syracuse NY, 2College of Health Professions,
SUNY’s Upstate Medical University, Syracuse NY, 3Dept. of Exercise Science and Health Promotion, Florida
Atlantic University, Davie FL, 4Mauro-Bertolo Physical Therapy, Cicero NY, 5Dept. of Physiology and Pharmacology,
SUNY Downstate Medical Center, Brooklyn NY, 6Dept. of Urology, New York University, New York NY
Objective: To compare two forms of device-specific training – body-weight-supported (BWS) ambulation on a
fixed track (TRK) and BWS ambulation on a treadmill (TM) – to comprehensive physical therapy (PT) for
improving walking speed in persons with chronic, motor-incomplete spinal cord injury (SCI).
Methods: Thirty-five adult subjects with a history of chronic SCI (>1 year; AIS ‘C’ or ‘D’) participated in a 13-week(1 hour/day; 3 days per week) training program. Subjects were randomized into one of the three training groups.
Subjects in the two BWS groups trained without the benefit of additional input from a physical therapist or gait
expert. For each training session, performance values and heart rate were monitored. Pre- and post-training
maximal 10-m walking speed, balance, muscle strength, fitness, and quality of life were assessed in eachsubject.
Results: All three training groups showed significant improvement in maximal walking speed, muscle strength,
and psychological well-being. A significant improvement in balance was seen for PT and TRK groups but not for
subjects in the TM group. In all groups, post-training measures of fitness, functional independence, andperceived health and vitality were unchanged.
Conclusions: Our results demonstrate that persons with chronic, motor-incomplete SCI can improve walking
ability and psychological well-being following a concentrated period of ambulation therapy, regardless of
training method. Improvement in walking speed was associated with improved balance and muscle strength.
In spite of the fact that we withheld any formal input of a physical therapist or gait expert from subjects in thedevice-specific training groups, these subjects did just as well as subjects receiving comprehensive PT for
improving walking speed and strength. It is likely that further modest benefits would accrue to those subjects
receiving a combination of device-specific training with input from a physical therapist or gait expert to guidethat training.
Keywords: Spinal cord injuries, Ambulation training, Body weight support, Rehabilitation, Walking speed

Introduction
The majority of persons sustaining traumatic spinal cord
injury (SCI) ultimately recover some volitional lowerlimb motor function (i.e. they are ‘motor-incomplete’).1,2
A subset of these persons may benefit from rehabilitation
designed to improve their walking ability,3,4 consideredherein to be reflected by an increase in maximum
walking speed. However, the optimal ambulation
therapy approach remains an open question. Wernig
Correspondence to: Blair Calancie, Department of Neurosurgery, SUNY’s
Upstate Medical University, 750 E. Adams St., IHP #1213, Syracuse, NY
13210, USA. Email: calancib@upstate.edu

362© The Academy for Spinal Cord Injury Professionals, Inc. 2011
DOI 10.1179/2045772311Y.0000000018

and colleagues described substantial functional improvement in patients with SCI receiving treadmill (TM)based ambulation training while a portion of theirbody weight was supported in a harness,5,6 stating,‘The present results show that the novel (TM) therapy
can improve locomotive capabilities of the spinal cord
injured persons far beyond the outcome of conventional
rehabilitation’.6 The latter approach is known to enhancefunctional performance of SCI individuals by means of
exercising and compensation.7,8More recent studies utilizing body-weight support(BWS) and TM training have reported an improvement

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Alexeeva et al.

in overground walking ability at both sub-acute (i.e.
weeks to months post-injury)4 and chronic (i.e. morethan 1 year post-injury)3,9–12 stages following SCI.
Body-weight-supported training on a TM has become
more common in SCI rehabilitation, whereby thenear-constant speed of the TM belt helps to emphasize
the rhythmicity of voluntary movements.13–15
Unfortunately, most TMs preclude the use of assistive
ambulatory devices (e.g. walker, cane, Lofstrand
crutches), and they also minimize the ground reaction
forces that would normally come into play during overground walking. Systematic comparison of BWS training on a TM versus overground has not been reported
after SCI or other neurological disorders. Moreover,published studies utilizing BWS for gait-training inpersons with chronic SCI are few in number. Although
early initiation of physical activity after SCI could be
crucial,16 chronically injured individuals may still
benefit from a concentrated period of ambulation training.3,10,12,13,17,18 Based on animal studies, trainingmediated functional recovery after SCI appears to betask specific.16 Consequently, for human therapy one
might expect any intervention which influences and/or
incorporates the act of walking to be effective in promoting locomotor recovery. In the recent Spinal Cord Injury
Locomotor Trial (SCILT), comparison of conventional
physical therapy (PT) and BWS TM ambulation training did not reveal significant differences in improving
walking ability after acute SCI.4,19,20 However, theconclusion by Wernig and colleagues that use of a
training device (i.e. TM + BWS) is far superior to conventional PT for improving walking in persons withchronic SCI remains uncorroborated by an independent
laboratory.
In the present study, we compared three training
methods for improving walking speed in individuals
with chronic, motor-incomplete SCI. For two of thesetraining methods, we limited the amount of expert
advice made available to subjects, focusing on the role
played by the training device for mediating any improvements seen. One method utilized comprehensive PT; thiscan be considered as a study comparison group, in that
it is consistent with conventional rehabilitation methods.
The other two methods each used BWS, either over amoving TM, or over fixed ground using an overheadmonorail track and trolley apparatus (TRK). We
included the BWS + TM method as an example of a‘new’ rehabilitation approach for improving walking
after SCI, and in an attempt to replicate the findingsof Wernig and colleagues5,6 in a more stringent study
design. Finally, we included the third training approach(BWS + overground walking) as a still more novel, but

Ambulation training methods after SCI

also more realistic, method of rehabilitation after SCI
that – at the time this study was conceived – had notbeen previously described within a randomized clinical
trial.

Methods
The study was carried out at The Miami Project to Cure
Paralysis (‘TMP’) of the University of Miami School of
Medicine, and at the Department of Neurosurgery of
Upstate Medical University (‘Upstate’). All subjects
gave written informed consent to participate. The identical study protocol was approved by each institution’s
institutional review board.

Inclusion/exclusion criteria
The study included subjects who: (1) were 16–70 years
old; (2) had sustained injury to the spinal cord at or
rostral to the Tl0 (vertebral) level; (3) were injured atleast one year prior to enrollment; (4) had voluntary
movement in at least one leg; (5) were able to rise to
standing from a seated position with no more than moderate assistance, and independently advance at least one
leg; (6) agreed to maintain their current routine of medications and activity levels while training; and (7)received medical clearance from the study physician(assessment of general health and bilateral hip/knee
radiographs to rule out significant pathology, e.g. significant osteoarthritis; heterotopic ossification; joint
subluxation).
Exclusion criteria were: (1) degenerative myelopathy,
neoplasm, or congenital spinal cord anomalies; (2)prior gait training with BWS; (3) the need for bilateralknee-ankle-foot orthoses for standing; and (4) theability to jog or run.

Recruitment and randomization
Subjects were recruited regionally, nationally, andinternationally. If the subject resided regionally, he or
she visited the lab to demonstrate functional mobility.
If the subject was unable to visit, we asked them tohave their mobility videotaped and sent in forreview. In both cases, if appropriate subjects met theinclusion mobility criteria, candidates were eligible
for training assignment. In groups of three, subjects
were randomly assigned to the PT, TRK, or TM training group. Assignment was done by a staff member
not associated with the study, who drew printed
labels from a box.

Procedure
Subjects in the PT group received a structured program
delivered by a licensed physical therapist. Therapy was

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Ambulation training methods after SCI

individualized for each subject and typically involved
gait, balance, and functional activity modalities aswell as strengthening, stretching, and aerobic (e.g.
arm-crank) exercises. The physical therapist usedverbal and tactile cues to improve different aspects ofthe subject’s mobility. The therapist maintained adetailed log of activity and duration for each training
session, along with the average heart rate (see below).
The BWS training groups used 30% BWS provided bya parachute-type harness (Maine AntiGravity Systems,
Portland, ME, USA; Biodex Medical Systems, Shirley,
NY, USA), adjusted to be tight across the lower pelvis,
but loose about the thighs (thereby allowing for unrestricted hip flexion and extension). It was common for theharness to slip during a training session, requiring
adjustment. The amount of body weight being supported was determined using either load-cells attachedto the lifting bar (all TM and some TRK subjects) orforce plates along the walking path (remaining TRK
subjects). Load-cells provided a continual measure of
BWS. Force plate measures were updated once per lapof the monorail track. For track training, the harness
was supported directly under a six-wheel trolley
mounted on a 4′′ I-beam monorail supported by afree-standing series of 4′′ schedule-80 stainless-steel
pipes and fittings. The track length was ∼26 m, consisting of two 10-m straight sections connected on either
end with 3-m lengths curved to 180° (curve radius∼0.8 m). For TM training, suspension was accomplished by a ceiling-mounted pulley system powered byan electric winch. The support rails on either side of
the TM were removed to prevent subject unloading
through the arms, but grab-handles at the front of theTM (directly under the TM control panel) were left inplace; subjects were free to use these for stabilization
as desired. If subjects desired to use the TM grabhandles but lacked adequate grip-force to hold them,
their hands were fastened to the grab-handles withelastic wraps (i.e. ‘Ace’ bandages).
Subjects in the BWS groups were helped by an assistant who did not have any formal training in rehabilitation. This person provided encouragement to thesubjects during training sessions, but was told not tooffer any training-specific advice. Our intent throughthis restriction was to test the training modality (track
or TM) by itself in either of these groups against themore broad-ranging approach that the physical therapist
could adopt.
For all groups, training was delivered 3 days/week for
13 weeks (39 sessions). A period of 13 weeks was chosen
based on the time to plateau of overground walking
speed and distance for a study using functional electrical

364

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stimulation for ambulation in a population with thoracic-level SCI.21 Each session was restricted to a
maximum of 60 minutes of therapy, in order to mimica typical outpatient rehabilitation schedule. All subjects
walked at a self-selected pace. Within each session, they
were free to change their training pace, and to take as
many rests as they desired. The duration of training
was recorded for each session, as was the distancewalked (for subjects in the two BWS groups). Whensubjects in the TRK or TM groups needed manual
assistance to advance the leg during walking, this wasprovided and documented by the training assistant. In
all cases, assistance was provided at the subject’s foot/ankle; assistance at the knee or pelvis was never provided. Subjects in the PT and TRK groups were permitted to change the type of assistive ambulatorydevices they used during training sessions. For subjects
in the PT group, change in the use of assistive ambulatory devices was typically recommended by a therapist,
whereas for the TRK-based subjects, an assistive ambulatory device was added or changed only at that person’srequest. When training, all subjects wore a heart-ratemonitor (Polar Electro Oy, Finland) to record theheart rate (beats/minute). For each session, the total
number of heart beats, as an indirect measure of total
work performed,22 was calculated as the product of
average heart-rate X training time. Additional information obtained at each training session included thesubject’s weight, levels of activity outside of the lab
setting, changes in health status (e.g. pain; spasticity;
illness) and current medications. Subjects in all threegroups wore socks and runners. When an ankle-footorthosis was used, it was the molded type and wasworn inside the shoe.

Outcome measures
The maximum walking speed averaged over a 10-m distance served as the primary outcome measure for thisstudy. Secondary outcome measures included: (1)balance; (2) fitness ( peak oxygen uptake during armcrank); (3) muscle strength; (4) functional independence;and (5) quality of life. All measures – including
maximum walking speed – were conducted by persons
blinded to each subject’s training assignment. Tests
were carried out over a 2-day period, immediately
before training started, and following its conclusion.
For the walking test, subjects were asked to perform
three 2-minute walks at self-selected paces: (1) muchslower than normal; (2) normal; and (3) as quickly as
possible. Each trial was separated by a 3–5-minuteresting period during which the subject was seated,
and the heart rate was monitored for recovery. The

Alexeeva et al.

maximal walking speed in meters/second (m/second)
was calculated based upon the time needed to traverse
the first 10-m distance covered during the final 2minute walk. All subjects performed the same durationof walking at submaximal levels (effectively serving as a
warm-up) prior to walking at their maximal speed togenerate this study’s primary outcome measure(maximum walking speed). During this test, subjects
wore a BWS harness and walked underneath the monorail track, but they did not receive any BWS (i.e. theharness was used solely as a safety device). Subjects
were free to use whatever assistive device(s) they
desired for their initial walking test (e.g. AFO;
walker), with the caveat that they must use the samedevice(s) during the final evaluation.
On a different day, subjects performed an upper bodymaximal graded exercise test (GXT) in order to measurepeak work capacity and oxygen uptake. The arm ergometry protocol was performed in the upright position
with a starting resistance of 200 kg/m/minute (33 W)
increasing 50 kg/m/minute (8 W) every 3 minutes in athermoneutral laboratory. In Miami, testing was performed on a Monarch 881E (Varberg, Sweden) upper
body ergometer (UBE) and metabolic data were collected and analyzed with a Beckman MMC Horizon
system (Anaheim, CA, USA). In Syracuse, testing wasdone with a Scifit Pro 1000 UBE (Tulsa, OK, USA)and metabolic data were collected and analyzed usinga Cosmed Quark b2 system (Rome, Italy).
Testing at both sites involved calibration of both
UBEs to manufacturer specifications to ensure valid
and reliable workloads during testing. Seat positionand ergometer adjustments were made individually sothat the fulcrum was horizontal with the subject’s
shoulder, and elbow and shoulder were not fully
extended when the crank arm was in the away position.
In subjects who could not maintain an upright postureon the UBE, stabilizing straps were placed around thetrunk to secure the subject against the ergometer’s seatback. In subjects who could not grasp the crank handles,
Ace bandages were used to secure the hands to the ergometer’s crank handles.
Both the MMC Horizon and Cosmed Quark b2 metabolic cart systems were calibrated per manufacturer’s
guidelines prior to each test session using gases withthe same known concentrations (16% O2 and 5%
CO2). The turbine calculation for both systems wasmade with a 3-l syringe to ensure accurate volume
measurements of the turbine flowmeter. Peak VO2values (defined as the highest VO2 (averaged over thelast 10 s) attained during the test) obtained at bothsites fell within a common range for both the pre- andAmbulation training methods after SCI

post-testing, indicating consistency of instrumentationand methodology across both study sites.
Standard 12-lead electrocardiogram and cardiopulmonary responses were obtained during the 2-minuterest, 2-minute warm-up, exercise test, and 5-minuterecovery. Heart rate was continually recorded during
testing and recovery. The Borg 6–20 perceived exertion
scale was recorded during the last minute of each stage
and at peak exercise. In addition, blood pressure wasrecorded at rest (supine, sitting, and standing), peak
exercise, and recovery.
After the ergometer adjustments were made, thesubject was fitted with the facemask over the mouthand nose and told to sit quietly for 2 minutes to adjust
to the breathing pattern of the facemask. After rest,
the subject was instructed to crank the UBE at 60 rpm
at 0 kg/m/minute (0 W) for 2 minutes to acclimate to
the cranking rpm. After the 2-minute warm-up, theresistance was increased to 200 kg/m/minute (33 W).
Resistance was increased 50 kg/m/minute (8 W) every
3 minutes until volitional fatigue or failure to maintaina cadence of 60 rpm for 5 continuous seconds.
Smaller power output increases of 50 kg/m/minute(8 W) per 3-minute stage were utilized so that the targeted test duration was from 8 to 12 minutes, which ismore reflective of functional ability. In addition, thesmaller power outputs were selected because of the
known inability to stimulate the autonomic and cardiovascular systems to support aerobic metabolism that ispresent in persons with SCI at or rostral to the T6 neurologic segment.23 American College of Sports Medicine(ACSM) guidelines suggest smaller increments in
power output from 5 to 20 W per stage depending on
the functional level of SCI, muscular strength, and conditioning level of the subject.24
The Tinetti scale25 was used to assess balance. This test
measures movements of the trunk in the forwards, backwards, and sideways directions with eyes open versus
closed, and with arms relaxed versus being held in theair, in both standing and sitting positions. A value
ranging from 0 to 2 was assigned to each movement, andthe total score (maximum = 16) was calculated.
The ASIA International Standard (AIS) manualmuscle test (MMT) was used to assess muscle contraction strength.26 The upper and lower extremity motorscores (UEMS and LEMS, range 0–50 each) and thetotal MMT score (sum of UEMS and LEMS; range
0–100) were determined.
The motor domain component of the FIM measure
was used to quantify self-reported activities of dailyliving, including self-care, sphincter control and mobility. Of the 13 original motor items, 11 were included

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Ambulation training methods after SCI

for analysis. Subjects were asked about how much assistance they needed for eating, grooming, bathing, dressing, toileting, transfers, and management of bowel
and bladder.
The quality-of-life survey incorporated a subset ofitems from two existing questionnaires (Satisfaction
with Abilities and Well-Being Scale (SAWS) and the
SF-36 Short-Form Health Survey). Thirteen components from the SAWS scale27 were used to assess subjective well-being (Table 3-1). Subjects were also asked
to respond to each of four questions taken from the
SF-36 test,28 addressing general health at the present
time and one year ago (Table 3-2), a mental componentof health perception (Table 3-4), and vitality (energy andfatigue) over the past 4 weeks (Tables 3-3 and 3-5). In
addition to conducting this survey immediately before
and after training, this survey was also mailed to subjects for completion 1 month after finishing the training
protocol.
Balance, strength, functional independence, andquality of life were assessed by the same physical therapist, who was blinded to training assignment. In order tominimize investigator bias, this person was on-site only
for testing sessions; she did not take part in subject training, nor was she aware of the training assignment foreach subject. The same was true for testing of arm-ergometry and walking performance: investigators performing measurements did not know the training groups ofindividual subjects.

Figure 1366

Analysis
This study generally utilizes a mixed-factorial experimental design, with one independent measures factor
representing participant’s group and one repeatedmeasures factor representing the multiple observations
over time. We assessed each outcome separately;
however, in all cases we submitted participant’s repeatedoutcomes observations to a two-factor mixed-model
analysis of variance (ANOVA), setting two-tailedalpha to 0.05, with Bonferroni adjustments for multiple
comparisons. Prior to analysis, we examined the distributions of our data in order to assess whether data transformations would be necessary in order to meet theassumption of the ANOVA statistic that the data be normally distributed. Measures of speed were significantly
positively skewed and required a square root transformation for normalization.29 Spearman’s correlation wasused to investigate paired relationships (e.g. maximum
speed versus balance). Statistical analysis was donewith SPSS.

Results
Subjects
A total of 40 individuals with SCI consented to participate in the study and were randomized, as illustrated inFig. 1. Thirty-five subjects (5 female, 30 male) completed the training program and follow-up assessments.
Four of the five subjects who did not complete the study
had been randomized to the TM group; the remaining

CONSORT diagram summarizing numbers of subjects recruited and randomized to each of the three study arms.

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Alexeeva et al.

subject was randomized to the PT group. Demographic
characteristics of the study participants are listed inTable 1. There was no significant difference across training groups in subject age or gender, and each group was
dominated by persons in the AIS ‘D’ category.
Consistency across groups was lacking in the distribution by injury level, however, in that a high percentage of persons in the TM group had sustained
cervical injury (89%), whereas the incidence of cervicalinjury was considerably lower within the TRK (57%)
and PT (58%) training groups. Table 2 details the pretraining functional walking status of our subjects. All
study participants prior to training initiation were able
to ambulate at least 10 m overground, with the exception of subject #33. When visiting our laboratory fortesting and training, eight subjects chose to ambulate

Table 1

Demography

Subject

Group

Sex

Age

Years postinjury

SCI
level

1

PT

F

42

14

C6

2
3
4
5
6
7
8
9
10
11
12
13
14
15

PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
TRK
TRK
TRK

M
M
M
M
M
M
M
M
M
M
F
M
F
M

22
37
36
24
29
63
59
39
29
26
42
61
24
27

4
13
16
4
7
6
2
3
1.3
1.2
25
3
1.2
4

16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TM
TM
TM
TM

M
M
M
M
M
M
M
F
M
M
M
M
M
M
M

30
32
23
33
53
44
38
38
21
57
29
60
63
56
40

31
32
33
34
35

TM
TM
TM
TM
TM

M
M
F
M
M

31
56
35
30
19

Ambulation training methods after SCI

with assistive devices as their primary mode of mobility,
causing us to classify them as ‘wheelchair-independent’in Table 2. Each of these subjects did use a wheelchairwhen circumstances called for it. The remaining subjects
were dependent upon their wheelchair for their primary
mobility at all times.

Training data
Fig. 2 summarizes several training parameters fordifferent stages of the training protocol (averaged
across subjects for sessions 1, 13, 26, and 39). On
average, subjects in the TRK and TM groups tended
to increase their duration of training (Fig. 2A) throughout the first 26 training sessions, and then plateau
beyond this time. Actual durations for subjects in the

Etiology

AIS
score

Spasticity/
medication

Pain/medication

D+/Baclofen

+

T7
C7
C5
C4
T7
T7
C5
C5
T4
C5
T10
C3
T10
C6

Transverse
myelitis
TraumaTraumaTraumaTraumaVascular
VascularTraumaTraumaTraumaTraumaTraumaTraumaTraumaTrauma

D
C
D
D
D
D
D
D
C
D
D
D
C
C

−
+/Carbamazepine+−+−+/Gabapentin
+
+
−
+
−
+
+

5
14
1.4
12
37
16
5
6
1.0
2
1.1
6
2
1.5
1.0

C5
C6
T8
T3
C2
C3
C7
T4
T8
C3
T4
C4
C4
C5
C4

TraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTraumaTrauma

D
C
C
D
D
D
D
C
D
D
D
D
D
D
D

8
5
3
12
2

T8
C5
C3
C4
C5

TraumaTraumaTraumaTraumaTraumaD
DC
D
D+/Baclofen
+
+
+
+
+
+/Baclofen−+/Baclofen+/Baclofen+/Baclofen+/Clonidine++/Baclofen,
tizanidine+/Baclofen+/Baclofen+++/Baclofen+++/Baclofen++/Baclofen+/Baclofen+/Baclofen++/Baclofen+/Baclofen,
tizanidine++/Baclofen+/Baclofen+++/Amitriptyline−−+/Acetaminophen
−
+
+
+
−
+
−
+/Rofecoxib+/Acetaminophen−−++/Gabapentin++−

Abbreviations: PT: physical therapy; TRK: body-weight supported ambulation on a fixed track; TM: body-weight supported ambulation ona treadmill; M: male; F: female; AIS: ASIA International Standards.

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Table 2 Initial functional status
Subject

Group

Orthoses

Assistive device

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35

PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
PT
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TRK
TM
TM
TM
TM
TM
TM
TM
TM
TM

AFO
AFO
AFO
AFO

Walker(S)Walker(S)Walker(S)Walker(S)Walker(S)Cane
Lofstrands
Quad cane
Walker(S)Walker(R)Lofstrands–
Walker(R)Walker(S)Lofstrands
Walker(S)Walker(S)Walker(S)Lofstrands
Lofstrands
Lofstrands
Cane
Walker(S)Walker(R)CaneWalker(S)Walker(S)CaneWalker(S)Walker(S)Lofstrands
Quad cane
Walker(R)Walker(R)Lofstrands

AFO
2 AFOsAFO
2 AFOs

AFO, KAFO
AFO
KAFO
KAFO
2 AFOs

AFO
AFO
AFO
AFO
KAFO
2 AFOsAFO
KAFO
2 AFOs
AFO
AFO
KAFO
AFO

WISCI II
9
9
9
9
13
15
12
19
13
9
13
20
13
9
12
9
9
9
16
16
12
15
9
9
19
9
9
15
9
9
12
15
3
13
12

Community ambulation
W/D
W/D
W/D
W/D
W/D
Ind
W/D
Ind
W/D
W/D
W/D
Ind
W/D
W/D
W/D
W/D
W/D
W/D
Ind
W/D
Ind
W/D
W/D
W/D
Ind
W/D
W/D
Ind
W/D
W/D
Ind
W/D
W/D
W/D
W/D

Abbreviations: WISCI II: walking index for spinal cord injury; AFO: ankle-foot orthosis; KAFO: knee-ankle-foot orthosis; Walker(S):standard (4-point) walker, Walker(R): rolling walker; W/D: wheelchair dependent; Ind: wheelchair independent.

PT group are not illustrated, because sessions almost
always lasted a full 60 minutes.
At training session #39, there was an extremely wide
range of total distance walked (Fig. 2B) per session for
subjects in both the TRK (range = 20–3828 m) andTM (range = 4.2–3218 m) groups, yet the mean distances (888 m; 843 m) were remarkably similar for thetwo groups. Fig. 2B shows that – like walking duration –mean walking distance also increased in a steadymanner through training session #26, and thenappeared to plateau. No walking distances are plotted
for the PT group, since the walking route frequently
changed, and stairs were sometimes incorporated into
the walk-training portion of the PT sessions.
We measured heart rate to gain some sense of the metabolic demands imposed by the different training methods.
Each group showed increases in total heart beats throughtraining session #26 (Fig. 2C). Surprisingly, the total
heart beat value was higher in the PT group than in the
TM group. However, after correcting for training

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duration, subjects in the TRK group achieved thehighest average heart rate during training, whereas
those in the PT group had the lowest average heart rate
(Fig. 2D).
For subjects in the PT group, the average durations (inminutes) for key modalities were as follows: walking:15.5 ± 7.9; strengthening: 17.0 ± 7.1; stretching: 13.2 ±
4.0; cycling (arm-crank (mostly) and stationary bike):15.5 ± 6.3; balance training: 12.6 ± 5.9; and functional
activities (e.g. sit-to-stand; transfers): 5.1 ± 5.0
minutes. Note that the sum of these averaged totals
exceeds 60 minutes, because not all modalities were
included within each training session. In practice, individual PT training sessions were strictly limited to a
maximum of 60-minute duration.
We documented each subject’s requirement for assistance during gait, and the reliance on particular types ofassistive devices by subjects in all three groups. At the
beginning of training, two of the nine subjects in the TM
group needed manual assistance to advance their weaker

Alexeeva et al.

Ambulation training methods after SCI

Figure 2 Summary of training parameters and heart-rate data for training sessions #1, 13, 26 and 39 for subjects in the TRK (filledbars), TM (diagonal bars), and PT (open bars) groups. Values are the group averages (±SD) of the total duration of ambulation (A; in
minutes), total distance of ambulation (B; in meters), total number of heart beats while training (C), and average heart-rate (D) during
the time spent in training. Note that duration and distance measures are provided for the TRK and TM groups only, since subjects in
the PT group routinely trained for 1 hour each session, and walking distances within each PT training session were not tallied.

leg during stepping. By training session 24 (i.e. after ∼8weeks), both of these subjects could train without needof any manual assistance. All subjects in the TM groupused the forward-placed grab handles for stabilization
during gait. However, the position of these handles precluded any useful unloading of the lower limbs during gait.
None of the subjects in the TRK group required assistance to advance their leg, even during the initial training
sessions. At their own initiative, two of these subjects
adopted a less-restrictive assistive device during training,both shifting from a walker to Lofstrand crutches.
Ten of the 11 subjects in the PT group adopted a lessrestrictive assistive ambulatory device – or abandoned
their original device altogether – during the ‘walking’component of their PT session.

Speed
The range of maximum walking speeds at the outset oftraining varied from a low of 0 m/second (one subject(#33) was unable to take any overground steps initially)
to a high of 1.2 m/second. There was no significant
difference in pre-training walking speed among PT,

TRK, and TM groups. Almost all subjects – regardlessof training group – increased their maximum 10-mwalking speed after completing the training program(Fig. 3A). Combining all subjects, independent of training group, the average pre- and post-training maximal
walking speeds over a 10-m distance were 0.35 ± 0.29
and 0.47 ± 0.35 m/second, respectively. Broken down
to group means, the pre-training speeds were: (1) PT:
0.41 ± 0.34 m/second; (2) TRK: 0.33 ± 0.29 m/
second; and (3) TM: 0.30 ± 0.26 m/second. The mean
post-training speeds were: (1) PT: 0.51 ± 0.36 m/
second; (2) TRK: 0.44 ± 0.33 m/second; and (3) TM:
0.46 ± 0.40 m/second. Fig. 3B illustrates the percent
change in mean walking speed for each of the threegroups. Analysis revealed a significant increase inwalking speed across groups (P < 0.001); however, theGroup main effect and the Interaction of Group ×Time were not significant. Bonferroni-adjusted contrasts
revealed significant increases in speed Pre-to-Post in all
three groups (P < 0.01 for each comparison). Thus,
each of the three training groups showed a significant
increase in maximum walking speed over a 10-m

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Figure 3 Results of the 10-m maximal walking speed test in subjects of three training groups before and after completion oftraining. Individual results for each subject in the PT (○), TRK (∇), and TM (□) groups are plotted in ‘A’, where each data point is
positioned at the intersection of each individual’s post-training (ordinate) and pre-training (abscissa) values. The dashed line showswhere data points would lie if there was no difference between pre-training and post-training values. In ‘B’, each subject’s posttraining measure was expressed as a percentage of his/her pre-training data, then averaged within each training group and plotted
as group averages (±SD). All three groups showed a significant (*) post-training increase in walking speed over this 10 m distance.

Figure 4 Maximal 10-m walking speeds before and after
training for all 35 subjects studied. Data are arranged from theslowest to the fastest pre-training walking speed (i.e.
independent of training group). The pre-training walking speed
is shown by black bars. Gray bars show the amount by which
the final walking speed changed from the pre-training value.
Thus most gray bars are stacked above the black bars, showingthat final walking speeds were higher than initial values formost subjects. This was not the case for three subjects, who
had slower walking speeds after training compared to pretraining values; these are shown where the gray-filled bar lies
below the zero-value line. A few subjects had improvements infinal walking speed that were too small (≤0.005 m/second) tobe resolved in this figure; these cases are indicated with an ‘*’.
The dashed horizontal line represents a widely cited ‘Mostlimited community’ walking speed of 0.4 m/second, considered
the minimum necessary to be functional in the community (30).
Eight subjects in this study (indicated by ‘+’) began training
with a walking speed below this 0.4 m/second value, butreached or exceeded this value by the end of training. Finally,
the arrow (↑) symbols indicate those subjects who werewheelchair-independent ambulators at the beginning oftraining.

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distance, but there were no significant differences
between groups in the amount of improvement.
Fig. 4 summarizes additional features of walking
speed not evident in Fig. 3. Most subjects (n = 30)
walked at a faster speed after training. A walking
speed of 0.4 m/second (indicated by dashed horizontalline) is considered to be a minimal speed for walking
in the community.30 The majority of subjects (n = 25)
were unable to walk at this speed at the beginning oftraining, but 8 of these 25 subjects (indicated by ‘+’
signs) did achieve a post-training maximum walking
speed that equaled or exceeded 0.4 m/second by theend of the training sessions. Of these eight subjects, six
were wheelchair-dependent prior to training onset.
Four had trained on the track, three were from theTM group, and one subject had been in the PT group.
Two subjects who had low pre-training walking
speeds of ∼0.1 m/second (cases #7 and #9 from theY-axis of Fig. 4; indicated by asterisks) showed such asmall improvement in post-training walking speed that
this increase could not be resolved in Fig. 4. Anothersubject (case #1; the other asterisk in Fig. 4) was
unable to complete any overground steps prior to training onset, resulting in a pre-training walking speed ofzero. By the end of training (TM group), she walked∼10 feet overground, without assistance or BWS.
Finally, three subjects showed a decline in maximum
walking speed (indicated by a down-going shaded barin Fig. 4) following training. In the first two cases(first and second instances from the Y-axis origin),both subjects had developed walking-related injuries(see Results – Training complications). The third

Alexeeva et al.

subject in this category (seventh bar from the right ofFig. 4) deliberately chose to walk at a slower pace inthe final few weeks of training, concentrating on
improving the symmetry of his gait by limiting hip circumduction. These adjustments led to a slight decline
in total training distance in the last few weeks of his
study participation. It is highly probable that had hewalked as quickly as he was capable of, without
regard to walking mechanics, the post-training walking
speed of this subject (#22 from Table 1) would haveincreased compared to his pre-training value.

Balance
There was a wide range of pre-training balance scores(0–16) between subjects (average = 10.2 ± 3.9). Mean
pre-training balance scores (PT = 10.1 ± 3.6; TRK =10.5 ± 3.4; TM = 9.8 ± 5.4) were not significantly
different between groups. Post-training balance scores
all improved (PT = 12.9 ± 2.7; TRK = 11.9 ± 2.5;
TM = 10.4 ± 5.0). Fig. 5A shows individual post-training balance scores plotted against pre-training values.
As for walking speed, values lying above the dashedline show improvement, and the majority of data
points lie in this region. Fig. 5B shows that groupmean post-training balance scores (normalized)
increased the most for the PT group, with TRK and
TM groups showing progressively smaller average
improvements.
With ANOVA testing, we found a significant Time ×Group interaction (P < 0.05), suggesting that thegroups differ in terms of their Pre/Post balance differences. Bonferroni-adjusted pairwise testing revealed significant improvements in balance Pre-to-Post in the PT
group (P < 0.001) and in the Track group (P < 0.01),

Ambulation training methods after SCI

but no significant difference Pre-to-Post for the TM
group (P = 0.23).
There was a good correlation between the pre- andpost-training measures of maximal 10-m walking
speed and balance ( pre-training r = 0.79; post-trainingr = 0.83). The correlation coefficient was somewhat
weaker for comparisons with Walking Index for Spinal
Cord Injury (WISCI) II scores of maximum pre-training
walking speed (r = 0.58) and balance (r = 0.67). Only
the pre-training WISCI II scores were considered,since our post-training walking assessment constrained
subjects to use the same assistive devices and/or
orthose(s) as they used during the pre-training
assessment.

Strength
There was no significant difference in pre-training
measures of muscle strength among PT, TRK, andTM group subjects, with the average MMT scorebeing 76.3 ± 11.6 in the PT group, 69.5 ± 12.1 in the
TRK group, and 71.5 ± 15.1 in the TM group. Most
subjects showed an increase in strength after training(Fig. 6A). Post-training MMT score averaged 81.8 ±11.0, 73.3 ± 11.5, and 78.1 ± 15.3 in PT, TRK, andTM groups, respectively. Fig. 6B shows that the meanchange in muscle strength (normalized to pre-training
values) increased by 6–9% across groups. There was asignificant increase in strength across groups (P <0.01), but no difference between groups. That is, themagnitude of strength increase within each group was
roughly equal, regardless of training condition.
Pairwise testing showed that strength improvements
were significant for each of the three training groups(P < 0.05 for each).

Figure 5 Results of the Tinetti balance test for the three training groups. Description as for Fig. 3. Note that the difference inbalance scores was not significant for the TM group. Note also that one subject in the TM group (□) was unable to maintain standingbalance prior to training onset (thereby scoring a ‘zero’), but scored a ‘3’ in this measure following training. Since normalization was
not possible for this measure, it was not included in the average for the TM group.

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Figure 6 Results of aggregate muscle strength testing (upper-limbs + lower-limbs) in subjects of three training groups before andafter completion of training. Description as for Fig. 3. All three groups showed a significant (*) post-training increase in muscle
strength after training, and there were no differences between groups.

Most of the observed improvement in strength acrosssubjects was confined to the lower limbs. Average preand post-training LEMS were 31.2 ± 10.4 and 35.1 ±9.9, 25.3 ± 12.3 and 28.3 ± 10.9, and 33.5 ± 11.2 and37.4 ± 10.7 for the PT, TRK, and TM groups, respectively. Not surprisingly, leg muscles were significantly
stronger in subjects who were already community ambulators at the time of study enrollment ( pre-training
LEMS: 37.3 ± 8.4) compared with wheelchair-dependent subjects (LEMS: 27.8 ± 11.4), but both groups
showed comparable gains in strength following training(42.8 ± 4.9 for wheelchair-independent and 30.9 ± 10.7
for wheelchair-dependent subjects).

Fitness
Values of pre-training VO2peak for the population
as a whole ranged from ∼10 to 26 ml/kg/minute(Fig. 7A). Comparisons of normalized VO2peak values
across training groups are illustrated in Fig. 7B. In all
three groups there was a modest post-training increasein average normalized VO2peak (∼12% in each group),
but these differences were not significant according to
ANOVA.

Quality-of-life and functional independence
Table 3 summarizes results of the questionnaires on
quality-of-life issues that were completed before,
immediately after, and 1 month after the training protocol. Immediately following the training program, 28 outof the 35 study participants (i.e. 80%) reported better
satisfaction with abilities and well-being (SAWS; category 1 in Table 3). The degree of score improvement(where a lower value reflects higher satisfaction) was
roughly constant across training groups, and the

Figure 7 Results of the graded maximum arm-ergometry test showing averaged peak VO2 test for the three training groups.
Description as for Fig. 3. None of the differences were significant within- or between-groups.

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Alexeeva et al.

Table 3Ambulation training methods after SCI

Changes in QOL scores after ambulation training

Quality-of-life components

PT

1. Satisfaction with disabilities and well-being (SAWS)
Pre-training
35.6 ± 9.9
Post-training
29.0 ± 7.9
Re-evaluation 1 month later
31.4 ± 5.5
2. General health perception
Pre-training
3.2 ± 0.8
Post-training
2.8 ± 0.8
Re-evaluation 1 month later
2.9 ± 0.7
3. Energy
Pre-training
12.8 ± 4.1
Post-training
11.8 ± 2.9
Re-evaluation 1 month later
11.4 ± 2.7
4. Mental health perception
Pre-training
7.6 ± 2.0
Post-training
7.5 ± 1.6
Re-evaluation 1 month later
7.3 ± 1.7
5. Fatigue
Pre-training
24.0 ± 2.7
Post-training
24.6 ± 2.8
Re-evaluation 1 month later
23.6 ± 3.4

TRK

TM

All 3 groups

35.9 ± 6.9
32.4 ± 7.6
32.4 ± 6.4

39.3 ± 8.3
35.2 ± 8.7
31.2 ± 7.8

36.7 ± 8.3
32.0 ± 8.1
31.7 ± 6.1

2.6 ± 0.8
2.5 ± 0.7
2.6 ± 1.0

2.4 ± 1.0
2.6 ± 1.1
2.2 ± 1.3

2.8 ± 0.9
2.6 ± 0.8
2.6 ± 1.0

12.4 ± 3.6
10.8 ± 3.0
14.7 ± 2.7

10.9 ± 3.9
10.9 ± 3.2
9.8 ± 4.5

12.2 ± 3.8
11.1 ± 3.0
12.1 ± 3.7

8.1 ± 1.8
8.0 ± 1.9
7.7 ± 2.0

8.9 ± 1.8
8.7 ± 1.7
7.0 ± 1.9

8.1 ± 1.8
8.0 ± 1.8
7.3 ± 1.7

23.4 ± 3.7
24.6 ± 2.5
23.2 ± 3.9

25.1 ± 3.2
24.4 ± 3.2
25.0 ± 3.7

24.0 ± 3.2
24.6 ± 2.7
23.8 ± 3.5

For measures #1–3, a lower score is desirable; for measures #4–5, a higher score is desirable. Scores are mean ± SD. Measures #2–5
are derived from SF-36. Post-training scores that are significantly-better than pre-training values are in italics. There were no values thatwere significantly worse than pre-training values.

overall effect across groups was significant (P = 0.03).
These improvements were retained, for the most part,at the 1-month follow-up evaluation.
None of the other measures in Table 3 showed significant change either between groups or within groups following training. Also unchanged by training were FIM
motor scores, where the overall average before-training
score (66.3 ± 17.2) showed only a slight increase after
training (68.4 ± 13.5).
To test whether there was a relationship between
SAWS measures and functional improvement, changes

in walking speed (Fig. 8A) and balance (Fig. 8B) areplotted against change in SAWS score for all the subjects
tested before and immediately after training, independent of training group. This figure shows that changes
in performance were not always consistent with SAWS
score. For example, Fig. 8A shows that in 3 out of 28
subjects, improvement in SAWS scores occurred in theabsence of post-training increase in walking speed,
whereas the 6 subjects who reported a worse SAWS
score after training all showed an increase inmaximum walking speed. For balance, the trend was

Figure 8 Percent change in individual post-training score relative to pre-training score for walking speed (‘A’; ordinate) versus
Satisfaction with Abilities and Well-Being Scale (SAWS; abscissa) and for balance score (‘B’) versus SAWS score. For most subjects,
both speed and balance scores showed improvement, as did SAWS scores. However, there were subjects who showed
improvement in walking speed (n = 6) and/or balance (n = 3) compared to their pre-training value (i.e. data points above the x-axis),
yet they reported no change or a decrease in satisfaction with their abilities and/or well-being (i.e. data points to the left of they-axis).

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that improved balance scores were associated with abetter SAWS score, but again there were a few exceptions, as seen in Fig. 8B.

Training complications
Many subjects experienced a variety of aches and pains
while in the study, but in most cases these did not hinder
the training routine. Two subjects had to drop out of the
training protocol shortly (1–2 weeks) after starting; eachexperienced an episode of acute cardiorespiratory distress on the weekend (i.e. this did not occur during a
training session), leading to an emergency department
visit. In both cases, subjects were treated with cardiac
artery stents and underwent cardiac rehabilitation.
Both subjects ultimately returned to successfully complete the protocol, re-starting no sooner than 6 months
following cardiac rehabilitation.
There were two subjects whose post-training walking
speeds were slower than their pre-training values, due toinjury. Both had experienced an exacerbation of spasticity over the final ∼25% of their training sessions. The
decrement in post-training performance was mirroredby a decline in the length of time spent actually training
in each session, a reduction in average heart-rate (indicating less work being done), and an increase in selfreported symptoms of generalized leg weakness andincreased spasticity.

Discussion
Our goal in this study was not to design the optimal
intervention that would maximize functional recovery
in subjects with chronic, motor-incomplete SCI.
Rather it was to test the ability of two different devices –a TM and an overground track – coupled with BWS tofacilitate functional improvements in walking, without
the benefit of additional coaching, targeted strength
training, or assistive-device fitting that are the hallmarksof PT. If either device on its own could match the
improvements seen in the PT group, we would safely
conclude that the effect was robust and could be generalized to the clinic setting, where control of study variables might not be as tightly maintained.
We found a robust effect of both devices, in spite of
the study’s design elements that prevented establishmentof an ideal or optimal training paradigm. The main findings were: (1) overground maximum walking speed following training was improved by a significant amountin each of the three training groups, with no difference
between groups in the amount of improvement; (2)balance showed a significant improvement in persons
receiving PT and TRK training; (3) all three groups
showed a significant increase in strength, with no374

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difference between groups in the amount of improvement; (4) some persons were able to achieve functional
walking speeds as a result of training; (5) satisfaction
with abilities and well-being showed significant
improvement in all three groups; and (6) there were no
significant training effects on fitness. Since all subjects
were at least 1 year post-injury and did not take partin any other SCI-related therapeutic studies, we attributethe observed improvements to training.

Subject population
A defining characteristic of the study population was theextremely wide range of pre-training walking speed (i.e.
see Table 2; Figs 3 and 4), despite having rather specificinclusion criteria. Thirty-four of the 35 subjects whocompleted the training protocol were able to walk
immediately prior to training onset. Even so, nine ofthese subjects could not even achieve a walking speedof 0.1 m/second, considered the minimum thresholdfor ‘Physiological’ walking.30 More than 50% of all subjects could not achieve a ‘Most-limited community’
walking speed of 0.4 m/second30 before training.

Training adaptations during the protocol
As illustrated in Fig. 2, the average values for three ofthe four training parameters we followed (walking
distance and duration; total heart-beats) showed aplateau by training session #26 (roughly 9 weeks into
the protocol). For comparison, a different study inpersons with chronic SCI subjects utilized a BWS/TM
training protocol that lasted an entire year,10 with subjects plateauing in speed and distance between 9 and12 months. However, subjects in that study were
almost all unable to stand or walk at the beginning oftraining,10 whereas only one of our subjects (#33) fits
this description. In light of these substantial differences
in initial walking capabilities between the two subject
populations, a direct comparison of optimal training
durations between the present study and that by Hicks
and colleagues10 is not warranted. Another group used
BWS-supported TM training in persons with incomplete SCI, showing a very wide range of training
durations – from 10 to 28 weeks – during which
improvements in overground locomotion continued to
accrue.17,31 These studies17,31 did not employ a consistent protocol, however, so direct comparisons to thepresent study are not possible.

Training schedule
Animal studies of activity-dependent spinal cord plasticity routinely utilize daily exercise sessions,32,33 andeven twice-daily sessions have been described.34 It is
possible that we limited the potential training gains

Alexeeva et al.

among our population by adopting an alternate-day
training regimen. However, the impractical aspects ofdaily exercise for both subjects (e.g. transportation;
bowel program) and the investigative team (e.g. staffing;data management), combined with the physical fatigue
experienced by most subjects after each training
session, caused us to avoid a daily training schedule.
As a case in point, and in response to informal questioning, many subjects reported that they felt stronger andbetter-able to exercise on the Monday of a given training
week. This was attributed to the extra day’s rest affordedby the prior weekend. We chose the training frequency(3 times/week) and total duration (13 weeks; 39 sessions) for reasons related to neuromuscular adaptation
to exercise (see Methods; Procedure), but more importantly to be consistent with a typical real-world outpatient rehabilitation setting, for which reimbursement on acontinual basis could not be expected.

Ambulation training methods after SCI

While the overhead suspension apparatus provided
direct vertical support, the support cable was not
restricted in lateral or anterior/posterior movements,
such that the subject could stumble if he/she was notcareful.
In contrast, and in contradiction to numerous otherstudies,3,6,13,18,41 the post-training balance scores of subjects in the TM group did not improve significantly frompre-training values. One possibility for this is that weallowed these subjects to use handles at the front of
the TM. In addition, and as seen in Table 1, a high percentage of subjects randomized to the TM group hadsustained cervical injury. We cannot rule out the possibility of a neurological explanation for the absence ofbalance improvement in the TM group. However, thesimilar initial walking capabilities of subjects in the
TM group compared with the two other groups would
argue against this being the primary cause of the difference in balance improvements seen.

Walking speed and balance
Walking speed is considered a reproducible measure forassessing walking ability in patients with neurologicalmovement disorders. The 10-m speed test used in ourstudy evaluates short-duration ambulation ability and,along with other timed tests (e.g. Timed Up and Go;
6-minute walking), has been validated to assess
walking function after SCI.35–38 In agreement with ourfindings, these tests have been shown to correlate witheach other as well as with the WISCI II index, especiallyin those patients who are independent walkers.35,39
Without regard for training group, there was a significant and positive correlation in the present study
between the subject’s pre-training walking speed andbalance. Following training, this relationship was evenstronger. As a contributor to improvements in bothmaximum speed and balance, all three groups showeda significant increase in strength after training. Since
walking requires a combination of stability and mobility, balance (both static and dynamic) improvement ofsubjects with movement disorders is a common goal oftherapists.40 In our study, post-training balance
showed greatest improvement in subjects who received
either PT- or TRK-based training; improvements weresignificant for both groups. It comes as no surprisethat balance improved the most in subjects in the PT
group, because the therapist was free to concentrate on
specific deficiencies in each subject’s function, and thisalways included core balance and coordination exercises. Significant improvements in balance for subjects
in the TRK-based group likely reflected their need tocontinually reposition both themselves and their assistive ambulatory devices in order to move forward.

Strength
A number of studies utilizing BWS for improving
walking in persons with SCI have reported improvements in lower-limb strength for both chronic
SCI3,13,17,42 and after sub-acute injury.4,43 Consistent
with these reports, the present study further expandson the notion that PT alone after chronic and neurologically incomplete SCI can also lead to significant
strength gains. Similar conclusions have been previously
arrived at from studies on locomotor training after acute
SCI.4,43
Leg strength is a good predictor of walking ability inpersons with SCI, with aggregate scores of <20 (of amaximum 50) being associated with poor ambulation
capability, whereas scores >30 were common inpersons with functional (or ‘community’) ambulation.44,45 Subjects in the present study who were100% wheelchair-dependent for mobility had average
lower-limb motor scores of 27 ( pre-training), while
those who were wheelchair-independent had a mean
aggregate lower-limb motor score of 37. There was no
significant relationship between improvement in lowerlimb motor scores and improvement in walking speed
for either group, in agreement with other studies.44,45

Fitness
Subjects in the TRK group showed the highest mean
heart-rate across all training sessions, suggesting they
were working the hardest during their training sessions,whereas subjects in the PT group had the lowest
average heart rate. Other than this measure, though,direct comparisons across all three training groups of

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the training-related change in work performance are
difficult.
The significant training-related improvements inwalking speed, balance, and strength described thus
far did not carry over to peak oxygen uptake(VO2peak). Both pre- and post-training VO2peak values
in our SCI subject population are comparable tomeasures reported by others,46,47 but are far below
typical values of an untrained able-bodied cohort (e.g.
a man aged 40–49 years at the 50th percentile would
be expected to have a VO2peak of 40.4 ml/kg/
minute).48 Despite the significant improvement inmaximum walking speed for all three groups, and the
doubling of training distance walked for two groups(TRK and TM) in which this metric was available,
there was no increase in peak oxygen consumption
within groups. The simplest explanation for thisoutcome is that training was insufficient in volume
and/or intensity to induce positive adaptations incentral cardiorespiratory functioning. Subjects withthoracic-level injury demonstrated higher VO2peakvalues than most persons with cervical injury (notshown), but there were no consistent improvements inthese values after training. Another explanation reflects
the necessity to test VO2peak using arm ergometry,
whereas training was directed primarily to the legs. It
is widely recognized that arm-based ergometry resultsin VO2peak values that are only 70–80% of thoseobtained during TM-based testing in able-bodied subjects.49 It is possible in the present study that the limiting
factor in defining peak workload was arm strength and/or fatigue resistance, rather than a limitation in oxygen
delivery. As mentioned previously, autonomic dysfunction in persons with SCI rostral to T6 could limit HR
increase, also contributing to a limitation of peakwork output.23 Thus the arm-based test for the population studied may have lacked sensitivity to detect any
improvement in cardiorespiratory function that might
have been caused by subject’s participation in this protocol. This conclusion stands in contrast to numerous
other studies of exercise after SCI, in which multiple cardiorespiratory parameters have been reported to show
significant improvement following strengthening exercises,50–52 FES-assisted ambulation,47 and BWS
ambulation.53,54

Quality-of-life measures
The quality-of-life measure that we used combined
elements from the SAWS and SF-36 instruments,
largely to avoid employment-related questions. Mostof the subjects in our study traveled from out of town.
The few subjects who were employed on a regular

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basis at the time of study participation had to take aleave-of-absence to participate. Therefore, we decided
it was better to eliminate these work-related questions
entirely.
The majority of our subjects reported enhanced satisfaction with their abilities and well-being (SAWS) after
completing the training program, irrespective of the
training method. Other training studies after SCI havereported similar findings.10,13,55–57
The positive effects on SAWS seen immediately after
training conclusion were maintained at the 1-monthfollow-up evaluation, in agreement with otherstudies.10,50,57 Other quality-of-life measures at the
1-month follow-up were unchanged from pre-training
or immediately post-training results.
Activities of daily living such as self-care, sphincter
control, and mobility were assessed by the physicaltherapist via Functional Independence Measure(FIM).58 We excluded the FIM cognition domain,
because of the known ceiling effect in persons with
SCI.59 A ceiling effect for FIM motor scores (74.9 ±1.7 of a possible 77 during pre-training testing) in our
subject pool explains the absence of significant improvement following training in this study. Consistent with
our findings, locomotion training failed to influence
measures of the Instrumental Activities of Daily
Living (IADL) in BWS-trained individuals withchronic SCI,10 and FIM scores were stable throughout
a protocol involving gait training in persons withstroke.60 An alternative explanation is that FIM may
not be sensitive to detect changes in walking ability
following ambulation therapy in persons with motorincomplete (i.e. AIS ‘C’ and ‘D’) SCI,38 especially inthose who are able to ambulate more independently.3,4

Other BWS-based training studies
An early and influential study reported that BWS/TM
training in 89 persons with motor-incomplete SCI(AIS ‘C’ and ‘D’ grades) improved ambulation to amuch greater degree than conventional therapy.6 Inthat study, improvement was observed in subjects
when training started at both sub-acute and chronic
stages following injury. That study6 did not directlycompare TM-based training to PT, was not randomized,
and subjects participated for varying lengths of time.
One study that did compare BWS/TM training to PT
after acute SCI concluded that the former approach
was more effective than PT alone, but in this case the
TM training was combined with functional electricalstimulation to facilitate the stepping motion.43 One
case report examining the impact of ∼7 months ofTM training sessions with BWS on a subject with

Alexeeva et al.

chronic AIS ‘B’ SCI showed evolution of muscle recruitment patterns more consistent with a walking patternversus simple stretch-reflex activities.61
More recent – and arguably more carefully designed –studies of TM training with BWS have not been able
to replicate the positive findings summarized above.6
The SCILT compared conventional PT for mobility
versus the same duration and intensity of BWS/TM
training in subjects with acute SCI graded AIS ‘B’,
‘C’, and ‘D’.4,19,20 This randomized multi-center study
did not reveal significant group differences for its
primary outcome measures, which were the level of
independence for ambulation and, for those who wereable to walk, the maximal walking speed over a 50foot (∼15 m) distance.4 Similarly, in individuals with
sub-acute stroke, the BWS/TM training method was
no more effective than PT at improving gait.62,63
To our knowledge, there have been no randomized
studies comparing equal durations of BWS-based gait
training to PT in persons with chronic SCI, nor havethe two forms of BWS training used in the present
study been independently studied. We were encouraged
to see that the great majority of subjects in all threegroups improved in their walking ability, sometimes byconsiderable amounts. Based on our results and thosefrom previous studies that have utilized different gait
training protocols,3,10,12,13,17,18,64,65 there can nolonger be any doubt that ambulatory individuals withchronic SCI are capable of improving their walking
abilityfollowing
intensive
ambulation-oriented
therapy, regardless of the training method used. In
some cases – depending on their level of disability at
the onset of training – this can lead to marked improvements in functional walking capabilities. In spite of the
improvements seen, we are not suggesting that methods
employed in the study described herein were optimal for
improving walking function in our subjects, as expanded
on in a following section.
Lastly, most subjects showed improvement inwalking speed, even though the two BWS groups
trained at a self-selected walking pace. The publisheddata on the effect of training speed on locomotor
recovery after neurological injury are inconsistent.
After SCI or stroke, it has been reported that walking
is improved to a greater degree when training is at
speeds approaching normal.3,66,67 Conversely, thebenefit of using slower training speeds for improving
walking function after SCI and stroke has also beenreported.13,17,18,43,68,69 While the initial maximal
walking speed of our subjects (0.36 m/second) was
only slightly slower than the minimum speed (0.4 m/
second) associated with functional walking,30 thisAmbulation training methods after SCI

value was skewed upwards by much higher initial
walking speeds in a small number of our subjects.
Other subjects in our study were initially incapable ofwalk-training at even one-half of this group average.
Therefore, given that a minimally normal walking
speed was not achievable by the majority of our subjects prior to training onset, a self-selected training
pace was adopted.

Summary, study limitations, andrecommendations
The present study has demonstrated that many persons
with neurologically incomplete SCI can improve their
walking ability and psychological well-being following
a concentrated period of ambulation therapy – evenwhen initiated years after injury – regardless of the training method. Improvement in walking speed appeared tobe due to a combination of increased balance andmuscle strength. These individuals appear to have movement capabilities that are not fully exploited, and which
can be improved upon with regular training involving
relatively unsophisticated techniques. That is, theimprovements seen with devices incorporating BWSbased gait training as tested herein – either overgroundor on a TM – match but do not surpass the benefits
associated with traditional, comprehensive PT for
improving walking speed in this population.
Given the significant gains seen in walking speed,balance and strength of subjects receiving PT training
alone, it is possible that the benefits that accrued tosubjects randomized to either of the devices utilizing
BWS-based protocols would have been enhanced had
the study protocol allowed some level of training
advice or recommendations from a physical therapist
or other gait expert. Although our decision to withhold such training recommendations was a deliberatepart of the study design, we recognize that thisdecision probably provided some amount of advantage
to subjects in the PT group. Another potential study
weakness is that two different ergometer and metabolic
systems were used to measure peak work capacity, butstandard operating procedures were identical and calibration with the same known references gases was performed. Finally, several of the instruments we used forassessing our subject’s level of satisfaction with thestudy and their outcomes have not been validated,because we selected only a portion of each instrument
for use.
Based on our findings, we suggest that the ‘optimal’training approach for improving walking ability inpersons with neurologically incomplete SCI of longstanding origin is as follows: overground walk-training

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Ambulation training methods after SCI

with 30% BWS, with training sessions lasting 1 hour,
3 times per week, for 10 weeks. The cost-savings ofrestricting the overall training duration to 10 rather
than 13 weeks would, in our opinion, outweigh thelimited further gains a minority of subjects might experience through participating in a longer training program.
This shorter study duration would also be less likely tocause training-related injuries. In addition, a physicaltherapist would make weekly observations and recommendations regarding the walk-training (e.g. use oforthoses; assistive devices; gait strategies), and would
spend 1 hour per week working hands-on with thesubject to target specific factors limiting walking performance, providing the subject with instructions forworking independently on non-training days on theseand related tasks. Clearly, this strategy will not beappropriate for persons with more significant neurological disability, for whom advancing even one leg for one
step would be problematic; for these persons, a treadmill-based training strategy would be called for.4,20

Acknowledgements
This work was supported by the NIH (U01 HD37460),by the State University of New York – Upstate Medical
University, and by the Miami Project to Cure Paralysis –The University of Miami. The skill and dedication ofCorrine Luria, Rosemary Grabowski, and Todd
Charland – providers of the physical therapy treatment
arm – were instrumental to this study, and their efforts
are gratefully acknowledged.

References
1 Jackson AB, Dijkers M, DeVivo MJ, Poczatek RB. A demographic
profile of new traumatic spinal cord injuries: change and stability
over 30 years. Arch Phys Med Rehabil 2004;85(11):1740–8.
2 Calancie B, Molano MR, Broton JG. Epidemiology and demography of acute spinal cord injury in a large urban setting. J Spinal
Cord Med 2005;28(2):92–6.
3 Behrman AL, Harkema SJ. Locomotor training after humanspinal cord injury: a series of case studies. Phys Ther 2000;80(7):688–700.
4 Dobkin B, Apple D, Barbeau H, Basso M, Behrman A, Deforge
D, et al. Weight-supported treadmill vs over-ground training forwalking after acute incomplete SCI. Neurology 2006;66(4):484–93.
5 Wernig A, Müller S. Laufband locomotion with body weightsupport improved walking in persons with severe spinal cord injuries. Paraplegia 1992;30(4):229–38.
6 Wernig A, Müller S, Nanassy A, Cagol E. Laufband therapy basedon ‘rules of spinal locomotion’ is effective in spinal cord injured
persons. Eur J Neurosci 1995;7(4):823–29.
7 Somers MF. Spinal cord injury: functional rehabilitation.
Norwalk, CN: Appleton & Lange; 1992.
8 Mehrholz J, Kugler J, Pohl M. Locomotor training for walking
after spinal cord injury. Spine (Phila Pa 1976) 2008;33(21):
E768–77.
9 Wirz M, Colombo G, Dietz V. Long term effects of locomotor
training in spinal humans. J Neurol Neurosurg Psychiatry 2001;
71(1):93–6.
10 Hicks AL, Adams MM, Martin GK, Giangregorio L, Latimer A,
Phillips SM, et al. Long-term body-weight-supported treadmill

378

The Journal of Spinal Cord Medicine

2011

VOL. 34

NO. 4

training and subsequent follow-up in persons with chronic SCI:
effects on functional walking ability and measures of subjective
well-being. Spinal Cord 2005;43(5):291–8.
11 Jayaraman A, Shah P, Gregory C, Bowden M, Stevens J, Bishop
M, et al. Locomotor training and muscle function after incomplete
spinal cord injury: case series. J Spinal Cord Med 2008;31(2):
185–93.
12 Nooijen CF, Ter Hoeve N, Field-Fote EC. Gait quality is improved
by locomotor training in individuals with SCI regardless of training approach. J Neuroeng Rehabil 2009;6:36.
13 Field-Fote EC. Combined use of body weight support, functional
electric stimulation, and treadmill training to improve walking
ability in individuals with chronic incomplete spinal cord injury.
Arch Phys Med Rehabil 2001;82(6):818–24.
14 Harkema SJ. Plasticity of interneuronal networks of the functionally isolated human spinal cord. Brain Res Rev 2008;57(1):255–64.
15 Beres-Jones JA, Harkema SJ. The human spinal cord interprets
velocity-dependent afferent input during stepping. Brain 2004;
127(Pt 10):2232–46.
16 Edgerton VR, Tillakaratne NJ, Bigbee AJ, deLeon RD, Roy RR.
Plasticity of the spinal neural circuitry after injury. Annu Rev
Neurosci 2004;27:145–67.
17 Thomas SL, Gorassini MA. Increases in corticospinal tract function by treadmill training after incomplete spinal cord injury.
J Neurophysiol 2005;94(4):2844–55.
18 Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V,
et al. Effectiveness of automated locomotor training in patientswith chronic incomplete spinal cord injury: a multicenter trial.
Arch Phys Med Rehabil 2005;86(4):672–80.
19 Dobkin BH, Apple D, Barbeau H, Basso M, Behrman A, Deforge
D, et al. Methods for a randomized trial of weight-supported treadmill training versus conventional training for walking during inpatient rehabilitation after incomplete traumatic spinal cord injury.
Neurorehab Neural Repair 2003;17(3):153–67.
20 Dobkin B, Barbeau H, Deforge D, Ditunno J, Elashoff R, AppleD, et al. The evolution of walking-related outcomes over the
first 12 weeks of rehabilitation for incomplete traumatic
spinal cord injury: the multicenter randomized Spinal Cord
Injury Locomotor Trial. Neurorehab Neural Repair 2007;21(1):25–35.
21 Klose KJ, Jacobs PL, Broton JG, Guest JG, Needham-Shropshire
BM, Lebwohl N, et al. Evaluation of a training program forpersons with SCI paraplegia using the Parastep 1 ambulation
system. Part 1. Ambulation performance and anthropometricmeasures. Arch Phys Med Rehabil 1997;78(8):789–93.
22 Fredrickson E, Ruff RL, Daly JJ. Physiological cost index as aproxy measure for the oxygen cost of gait in stroke patients.
Neurorehab Neural Repair 2007;21(5):429–34.
23 Krassioukov A, Eng JJ, Warburton DE, Teasell R, Spinal Cord
Injury Rehabilitation Evidence Research Team. A systematic
review of the management of autonomic dysreflexia after spinal
cord injury. Arch Phys Med Rehabil 2009;90(4):682–95.
24 Figoni SF, Kiratli BJ, Sasak R. ACSM’s resources for clinicalexercise physiology: musculoskeletal, neuromuscular, neoplastic,
immunologic, and hematologic conditions. 2nd ed., Baltimore:
Lippincott, Williams & Wilkins; 2010.
25 Tinetti ME. Performance oriented assessment of mobility
problems in elderly patients. J Am Geriatr Soc 1986;34(2):119–26.
26 Waring WP, 3rd, Biering-Sorensen F, Burns S, Donovan W, Graves
D, Jha A, et al. 2009 Review and revisions of the International
Standards for the Neurological Classification of Spinal Cord
Injury. J Spinal Cord Med. 2010;33(4):346–52.
27 Katz PP, Alfieri WS. Satisfaction with abilities and well-being:development and validation of a questionnaire for use among
persons with rheumatoid arthritis. Arthritis Care Res 1997;10(2):89–98.
28 Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form healthsurvey (SF-36). I. Conceptual framework and item selection. Med
Care 1992;30(6):473–83.
29 Tabachnick BG, Fidell LS. Using multivariate statistics. 2nd ed.,New York: Harper & Collins; 1989.
30 Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification ofwalking handicap in the stroke population. Stroke 1995;26(6):982–9.

Alexeeva et al.

31 Gorassini MA, Norton JA, Nevett-Duchcherer J, Roy FD, Yang
JF. Changes in locomotor muscle activity after treadmill training
in subjects with incomplete spinal cord injury. J Neurophysiol
2009;101(2):969–79.
32 Reese NB, Skinner RD, Mitchell D, Yates C, Barnes CN, Kiser
TS, et al. Restoration of frequency-dependent depression of the
H-reflex by passive exercise in spinal rats. Spinal Cord 2006;
44(1):28–34.
33 Ying Z, Roy RR, Edgerton VR, Gomez-Pinilla F. Exercise restoreslevels of neurotrophins and synaptic plasticity following spinal
cord injury. Exp Neurol 2005;193(2):411–19.
34 Vaynman S, Ying Z, Gomez-Pinilla F. Hippocampal BDNF mediates the efficacy of exercise on synaptic plasticity and cognition.
Eur J Neurosci 2004;20(10):2580–90.
35 van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking
tests. Arch Phys Med Rehabil 2005;86(2):190–6.
36 van Hedel HJ, Wirz M, Curt A. Improving walking assessment insubjects with an incomplete spinal cord injury: responsiveness.
Spinal Cord 2006;44(6):352–6.
37 Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszinski MH,
Ditunno JF, et al. Guidelines for the conduct of clinical trials forspinal cord injury (SCI) as developed by the ICCP panel: clinical
trial outcome measures. Spinal Cord 2007;45(3):206–21.
38 Jackson AB, Carnel CT, Ditunno JF, Read MS, Boninger ML,
Schmeler MR, et al. Outcome measures for gait and ambulationin the spinal cord injury population. J Spinal Cord Med 2008;
31(5):487–99.
39 Marino RJ, Scivoletto G, Patrick M, Tamburella F, Read MS,
Burns AS, et al. Walking index for spinal cord injury version 2(WISCI-II) with repeatability of the 10-m walk time: inter- andintrarater reliabilities. Am J Phys Med Rehabil 2010;89(1):7–15.
40 Bohannon RW. Standing balance, lower extremity muscle strength,
and walking performance of patients referred for physical therapy.
Percept Mot Skills 1995;80(2):379–85.
41 Visintin M, Barbeau H. The effects of body weight support on thelocomotor pattern of spastic paretic patients. Can J Neurol Sci
1989;16(3):315–25.
42 Dietz V, Wirz M, Colombo G, Curt A. Locomotor capacity andrecovery of spinal cord function in paraplegic patients: a clinicaland electrophysiological evaluation. Electroencephalogr Clin
Neurophysiol 1998;109(2):140–53.
43 Postans NJ, Hasler JP, Granat MH, Maxwell DJ. Functional electric stimulation to augment partial weight-bearing supported
treadmill training for patients with acute incomplete spinal cord
injury: a pilot study. Arch Phys Med Rehabil 2004;85(4):604–10.
44 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. Arch Phys Med Rehabil
1994;75(7):756–60.
45 Kim CM, Eng JJ, Whittaker MW. Level walking and ambulatory
capacity in persons with incomplete spinal cord injury: relationshipwith muscle strength. Spinal Cord 2004;42(3):156–62.
46 El-Sayed MS, Younesian A. Lipid profiles are influenced by arm
cranking exercise and training in individuals with spinal cord
injury. Spinal Cord 2005;43(5):299–305.
47 Jacobs PL, Nash MS, Klose KJ, Guest RS, Needham-Shropshire
BM, Green BA. Evaluation of a training program for persons
with SCI paraplegia using the Parastep 1 ambulation system:
part 2. Effects on physiological responses to peak arm ergometry.
Arch Phys Med Rehabil 1997;78(8):794–8.
48 Thompson WR editor. ACSM’s guidelines for exercise testing &prescription. 8th ed., Philadelphia, PA: Wolters Kluwer; 2010.
49 Franklin BA. Exercise testing, training and arm ergometry. Sports
Med 1985;2(2):100–19.
50 Hicks AL, Martin KA, Ditor DS, Latimer AE, Craven C,
Bugaresti J, et al. Long-term exercise training in persons withspinal cord injury: effects on strength, arm ergometry performanceand psychological well-being. Spinal Cord 2003;41(1):34–43.

Ambulation training methods after SCI

51 Zoeller RF, Jr, Riechman SE, Dabayebeh IM, Goss FL, Robertson
RJ, Jacobs PL. Relation between muscular strength and cardiorespiratory fitness in people with thoracic-level paraplegia. Arch
Phys Med Rehabil 2005;86(7):1441–6.
52 Jacobs PL. Effects of resistance and endurance training in persons
with paraplegia. Med Sci Sports Exerc 2009;41(5):992–7.
53 Stewart BG, Tarnopolsky MA, Hicks AL, McCartney N,
Mahoney DJ, Staron RS, et al. Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal
cord injury. Muscle Nerve 2004;30(1):61–8.
54 Ditor DS, Macdonald MJ, Kamath MV, Bugaresti J, Adams M,
McCartney N, et al. The effects of body-weight supported treadmill training on cardiovascular regulation in individuals withmotor-complete SCI. Spinal Cord 2005;43(11):664–73.
55 Lannem AM, Sorensen M, Froslie KF, Hjeltnes N. Incomplete
spinal cord injury, exercise and life satisfaction. Spinal Cord2009;47(4):295–300.
56 Effing TW, van Meeteren NL, van Asbeck FW, Prevo AJ. Body
weight-supported treadmill training in chronic incomplete spinal
cord injury: a pilot study evaluating functional health status andquality of life. Spinal Cord 2006;44(5):287–96.
57 Ditor DS, Latimer AE, Ginis KA, Arbour KP, McCartney N,
Hicks AL. Maintenance of exercise participation in individuals
with spinal cord injury: effects on quality of life, stress and pain.
Spinal Cord 2003;41(8):446–50.
58 Ditunno JF, Jr. Functional assessment measures in CNS trauma.
J Neurotrauma 1992;9(Suppl 1):s301–5.
59 Hall KM, Cohen ME, Wright J, Call M, Werner P. Characteristicsof the functional independence measure in traumatic spinal cord
injury. Arch Phys Med Rehabil 1999;80(11):1471–6.
60 Peurala SH, Tarkka IM, Pitkanen K, Sivenius J. The effectivenessof body weight-supported gait training and floor walking inpatients with chronic stroke. Arch Phys Med Rehabil 2005;86(8):1557–64.
61 Forrest GF, Sisto SA, Barbeau H, Kirshblum SC, Wilen J, Bond
Q, et al. Neuromotor and musculoskeletal responses to locomotor training for an individual with chronic motor
complete AIS-B spinal cord injury. J Spinal Cord Med 2008;
31(5):509–21.
62 Hesse S, Werner C, von Frankenberg S, Bardeleben A. Treadmill
training with partial body weight support after stroke. Phys Med
Rehabil Clin N Am 2003;14(1 Suppl):S111–23.
63 Dickstein R. Rehabilitation of gait speed after stroke: a criticalreview of intervention approaches. Neurorehabil Neural Repair
2008;22(6):649–60.
64 Hornby TG, Zemon DH, Campbell D. Robotic-assisted, bodyweight-supported treadmill training in individuals following
motor incomplete spinal cord injury. Phys Ther 2005;85(1):52–66.
65 Adams MM, Ditor DS, Tarnopolsky MA, Phillips SW,
McCartney N, Hicks AL. The effect of body weight-supported
treadmill training on muscle morphology in an individual withchronic, motor-complete spinal cord injury: a case study.
J Spinal Cord Med 2006;29(2):167–71.
66 Visintin M, Barbeau H. The effects of parallel bars, body weightsupport and speed on the modulation of the locomotor patternof spastic paretic gait. A preliminary communication. Paraplegia
1994;32(8):540–53.
67 Sullivan KJ, Knowlton BJ, Dobkin BH. Step training with bodyweight support: effect of treadmill speed and practice paradigms
on poststroke locomotor recovery. Arch Phys Med Rehabil 2002;
83(5):683–91.
68 Hesse S, Bertelt C, Jahnke MT, Shaffrin A, Baake P, Malezic M,
et al. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients.
Stroke 1995;26(6):976–81.
69 Field-Fote EC, Lindley SD, Sherman AL. Locomotor training
approaches for individuals with spinal cord injury: a preliminary
report of walking-related outcomes. J Neurol Phys Ther 2005;
29(3):127–37.

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