This discussion + podcast is the fourth of a 10-part series that accompanies our book on SCI recovery, From the Ground Up: A Human-Powered Framework for Spinal Cord Injury Recovery. It will introduce the uninitiated reader to topics discussed in Chapter 4 of the book, but some vocabulary or context may not be fully defined.

There’s a certain amount of irony in the difference between what people say – “Every spinal cord injury is completely different!” – and what they do for therapy – which, for the most part, looks very much the same for different bodies working to regain movement function after SCI.

The most popular forms of rehab (“modalities”) after paralyzing spinal cord injury – which can be optimized for individual goals – include:

• Hospital-based physical & occupational therapy

• Activity-based therapy

• Gait-training, using a robotic treadmill, an exoskeleton, or a walker/trainer combo

• Functional electrical stimulation (FES)

• Stem cell and spinal stimulation therapies, which are recent but growing in use

• …and hopefully soon, Pilates-based and other forms will become more widespread!

Due to the vast differences in SCI (type of injury, location, severity, and impairments - see Chapter 3), it is essential to consider how each of these options for SCI rehab can be best used for each unique case of SCI. Get the most of these programs by asking these essential questions:

• What’s a reasonable goal to achieve in a one-hour session of “Therapy X”? This forces you to consider how you’ll assess progress within a session. How will you know if a particular exercise is “working”?

• What’s a reasonable goal to achieve in one month, doing Y sessions/week of “Therapy X”? This focuses your attention on what the modality has to offer you. For example, if it is aquatic therapy or swimming, the goal is more likely to be “increasing stamina” than “being able to walk.”

• What are the top 3 things you gain from this therapy/professional? Can other aspects be “outsourced” to another professional?

• Are there components of this rehab modality that could be done on your own (or with a simple helper) for a fraction of the cost? 

• How will you know when you are ready to “graduate” from this modality?

You can ask yourself these questions relative to every modality you practice in order to ensure you’re using those resources as effectively as possible. Don’t forget that you can engage in multiple modalities at once, optimizing each for their strengths for a super-charged rehab program.

Types of SCI rehab gait training

Let’s zoom in on a very popular category: gait training. There are many ways to do it, with differing levels of support, speed, and repeatability. 

Common types of spinal cord injury rehab gait training include:

• Walker & trainer, over-ground

• Bodyweight-supported treadmill training (BWSTT)

• Robotic exoskeleton, on a treadmill

• Robotic exoskeleton, over-ground

Walker & trainer, overground: This type of gait training allows the athlete to feel their body weight in stance and work on the push-off phase in the gait cycle to locomote over-ground, a more functional and applicable approach to gait training than treadmills. With this method, speed is limited to what the trainer can support and so fewer repetitions are performed within a session.

Bodyweight-supported treadmill training (BWSTT): Most SCI gait training research is conducted with an athlete suspended in a harness over a treadmill while a trainer (or three) move their legs through the gait cycle. The harness supports as much or as little weight as necessary. This set-up reduces the risk of falling and allows for greater repetition and faster cadence, but is limited by the logistical and physical demands of the trainer(s) moving the leg repeatedly. It does not allow for full-bodyweight-bearing or the reflexive muscle-stimulation that comes with ground-forces through the body.

Robotic exoskeletons: These robotic devices strap onto the athlete’s body and robotically replicate the walking motion at the hip, knee and ankle, either over-ground or over a treadmill (similar to BWSTT). This allows for high repetition, faster cadence and precise steps for the athlete with little physical work on the part of the trainer, however, these exoskeletons limit the amount of natural rotations in the pelvis, spine, foot that occur in normal gait (an important component for mechanical efficiency in walking!).

Clearly, each of these options for gait training offer pros and cons for someone learning to walk again after SCI. Due to unique circumstances and needs of the individual, one option may be better for someone, while that same option may be the least ideal for someone else. Individuals SCI and SCI rehab trainers should weigh each option carefully to optimize the time and resources spent while gait training. 

Intention matters

Just has making intentional decisions about which SCI rehab modality is best for you, the way you execute exercises matters as well. 

As an introduction to the importance of intention within an exercise, consider the images below. The SCI athlete is “standing” in both images, but when it comes to biomechanical alignment – how the bones are positioned relative to each other – not all standing is made equal!

Notice the dashed line which shows an imagined “midline” of the body. It’s clear to see how much better the posture on the right is for practicing proper standing technique. 

Being intentional about how you do exercises can dramatically change how effective those exercises are. Spending 15 minutes in therapy doing an exercise with sub-par execution (on the part of the SCI athlete or trainer) is time and money wasted. In quest for rehab optimization, continually ask yourself: what can I reasonably expect from this? Can this be done better? How? With (or without) who? 

As you progress through you SCI recovery, your program should evolve with you as well. If you find yourself in a progress plateau, give yourself permission to change it up: perhaps you need something different now than you did before.

Explore these concepts in greater detail in our book, From the Ground Up: a Human-Powered Framework for Spinal Cord Injury Recovery, available in print & e-book format.

Chapter / Episode 4 topics include:

• What individuals with paralysis can reasonably expect from hospital-based therapy, neuro activity-based therapy, and gait-training

• Importance of clarifying your intention for participating in a healing approach – and how to be strategic about accomplishing that goal

• How “walking ability” is used as a metric to assess the effectiveness of novel therapies – and why this is woefully inadequate

• Why stem cell therapies as a cure for paralysis, while exciting, necessarily require simultaneous movement intervention

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