**3. Early gait rehabilitation interventions after spinal cord injury (Erigo therapy)**

SCI subjects, in acute stages, are disposed to orthostatic hypotension occurrences while transferred from a horizontal to an upright position due to the lack of sympathetic activity and also leg muscle contractions that finally lead to delay in starting the functional gait training [18, 19]. On the other hand, the mobilization and verticalization of SCI patients in acute care with limited or no capacity for cooperation can be very challenging. One approach to decrease the orthostatic hypotension incidences is utilizing tilt table. Many limitations related to the use of traditional tilt table have been reported such as no leg movements, limited training duration due to the lack of patient's cardiovascular stability and excessive labor load on therapist for passive movements. Therefore, for overcoming of such limitations a novel, robotic tilt table so-called Erigo was designed and developed, which offered a locomotion therapy at a very early stage of rehabilitation. These types of approaches through utilizing a safe mobilization and intensive sensorimotor stimulation, ambulates the lower extremity, and suggests a wide range of positive impacts and functions to enhance early rehabilitation of SCI patients [18–20].

The design and construction of the "Erigo" was based on the conventional tilt table but combines gradual verticalization plus robotic leg movement's therapy and functional electrical stimulation [18] (**Figure 2**). The main superiority of "Erigo" to the traditional tilt table was utilizing the robotic leg movement and the cyclic leg loading that produce critical afferent stimuli for the central nervous system [18, 20, 21]. These afferent stimuli result in muscle activation, improved muscle pump function and venous return, which eventually result in improved cardiovascular stability in SCI subjects. There are a few studies about the efficacy of "Erigo" following spinal cord injury [18, 22, 23]. According to the previous research by Colombo et al*.*, using Novel tilt table (tilted to 60° upright position) in five subjects with complete SCI (ASIA impairment scale A between C4 and C7) resulted in the increase of blood pressure and after stopping the automated movement, the mean arterial pressure decreased statistically significant(P < 0.0001) [14]. Although this study showed the positive effects of passive movements of leg through using "Erigo" therapy on circulatory system in SCI patients, it has to be stated that further studies are necessary to test this type of approach in a larder patients group of SCI with different level of injury and also in the long term to indicate the direct effects of "Erigo" therapy.

Also integrating functional electrical stimulation (FES) into "Erigo" provides more physiological and clinical benefits (**Figure 3**). The nerve endings are stimulated through attaching electrodes to the skin, which results in contraction and activation of muscles. Many positive effects have been reported by using of "Erigo" plus FES like improving in the cardiovascular system and metabolism condition, decreasing spasticity, improving the muscle tone, reducing long-term consequences due to the lack of muscle activity, inducing functional movements, increasing cardiovascular stability during upright position, and promoting the orthostatic tolerance by enhancing venous return in individual with SCI [18, 22, 25, 26]. Thrasher et al*.* compared the effects of isometric FES and dynamic FES on cardiovascular parameters on an active tilt-table stepper in 16 young and healthy adults. They stated that isometric FES led to short-term increases in blood pressure and also heart rate, but dynamic FES maintained increase in blood pressure over the long term. They postulated that however FES has potential to counteract orthostatic stress it should be combined with movements of leg [27]. In a pilot study, Yoshida et al. found that through applying FES cyclically to the leg muscles of 10 SCI subjects at T6 or higher, they could better retain their blood pressure. Although FES and

Role of Gait Training in Recovery of Standing and Walking in Subjects with Spinal Cord Injury

http://dx.doi.org/10.5772/intechopen.71312

109

**Figure 2.** Erigo components.

Also Laubacher et al. indicated that the "Erigo" therapy is practical for respiratory and cardiopulmonary training and evaluation of incomplete SCI subjects and they found it was a tolerable and implementable approach [22]. Another approach in the rehabilitation of SCI subjects is combining the tilt table with vibrating foot plates (whole-body vibration) that focus on the activation of muscular and vascular systems. Herrero et al*.*, found that whole body vibration (WBV) is an effective approach to enhance leg blood flow and to stimulate muscle activity in SCI subjects; therefore, they concluded that this approach could be incorporated in the rehabilitation programs of SCI subjects. So in future studies, we need to compare the efficacy of Erigo therapy and whole body vibration (WBV) on orthostatic, blood pressure, and EMG in subjects with SCI [24].

Role of Gait Training in Recovery of Standing and Walking in Subjects with Spinal Cord Injury http://dx.doi.org/10.5772/intechopen.71312 109

**Figure 2.** Erigo components.

**3. Early gait rehabilitation interventions after spinal cord injury (Erigo** 

SCI subjects, in acute stages, are disposed to orthostatic hypotension occurrences while transferred from a horizontal to an upright position due to the lack of sympathetic activity and also leg muscle contractions that finally lead to delay in starting the functional gait training [18, 19]. On the other hand, the mobilization and verticalization of SCI patients in acute care with limited or no capacity for cooperation can be very challenging. One approach to decrease the orthostatic hypotension incidences is utilizing tilt table. Many limitations related to the use of traditional tilt table have been reported such as no leg movements, limited training duration due to the lack of patient's cardiovascular stability and excessive labor load on therapist for passive movements. Therefore, for overcoming of such limitations a novel, robotic tilt table so-called Erigo was designed and developed, which offered a locomotion therapy at a very early stage of rehabilitation. These types of approaches through utilizing a safe mobilization and intensive sensorimotor stimulation, ambulates the lower extremity, and suggests a wide range of positive

The design and construction of the "Erigo" was based on the conventional tilt table but combines gradual verticalization plus robotic leg movement's therapy and functional electrical stimulation [18] (**Figure 2**). The main superiority of "Erigo" to the traditional tilt table was utilizing the robotic leg movement and the cyclic leg loading that produce critical afferent stimuli for the central nervous system [18, 20, 21]. These afferent stimuli result in muscle activation, improved muscle pump function and venous return, which eventually result in improved cardiovascular stability in SCI subjects. There are a few studies about the efficacy of "Erigo" following spinal cord injury [18, 22, 23]. According to the previous research by Colombo et al*.*, using Novel tilt table (tilted to 60° upright position) in five subjects with complete SCI (ASIA impairment scale A between C4 and C7) resulted in the increase of blood pressure and after stopping the automated movement, the mean arterial pressure decreased statistically significant(P < 0.0001) [14]. Although this study showed the positive effects of passive movements of leg through using "Erigo" therapy on circulatory system in SCI patients, it has to be stated that further studies are necessary to test this type of approach in a larder patients group of SCI with different level of injury and also in the long term to indicate the

Also Laubacher et al. indicated that the "Erigo" therapy is practical for respiratory and cardiopulmonary training and evaluation of incomplete SCI subjects and they found it was a tolerable and implementable approach [22]. Another approach in the rehabilitation of SCI subjects is combining the tilt table with vibrating foot plates (whole-body vibration) that focus on the activation of muscular and vascular systems. Herrero et al*.*, found that whole body vibration (WBV) is an effective approach to enhance leg blood flow and to stimulate muscle activity in SCI subjects; therefore, they concluded that this approach could be incorporated in the rehabilitation programs of SCI subjects. So in future studies, we need to compare the efficacy of Erigo therapy and whole body vibration (WBV) on orthostatic, blood pressure, and

impacts and functions to enhance early rehabilitation of SCI patients [18–20].

**therapy)**

108 Essentials of Spinal Cord Injury Medicine

direct effects of "Erigo" therapy.

EMG in subjects with SCI [24].

Also integrating functional electrical stimulation (FES) into "Erigo" provides more physiological and clinical benefits (**Figure 3**). The nerve endings are stimulated through attaching electrodes to the skin, which results in contraction and activation of muscles. Many positive effects have been reported by using of "Erigo" plus FES like improving in the cardiovascular system and metabolism condition, decreasing spasticity, improving the muscle tone, reducing long-term consequences due to the lack of muscle activity, inducing functional movements, increasing cardiovascular stability during upright position, and promoting the orthostatic tolerance by enhancing venous return in individual with SCI [18, 22, 25, 26]. Thrasher et al*.* compared the effects of isometric FES and dynamic FES on cardiovascular parameters on an active tilt-table stepper in 16 young and healthy adults. They stated that isometric FES led to short-term increases in blood pressure and also heart rate, but dynamic FES maintained increase in blood pressure over the long term. They postulated that however FES has potential to counteract orthostatic stress it should be combined with movements of leg [27]. In a pilot study, Yoshida et al. found that through applying FES cyclically to the leg muscles of 10 SCI subjects at T6 or higher, they could better retain their blood pressure. Although FES and

**Figure 3.** Functional electrical stimulation synchronized with leg cycling in "Erigo".

passive stepping by Erigo achieves this function by inducing venous return, passive stepping was less effective than FES in this study [23]. Finally, many studies are needed to extend these findings to the community of people with SCI with different levels of injury.
