**Author details**

20 steps/minutes, respectively [44]. In the evaluation of Rewalk exoskeleton on safety and tolerance in SCI patients, Zeilig et al. reported that mean time to walk 10 m was 47 seconds following training when using the Rewalk [45]. In another study, distance walked for 50–100 m announced between 5 and 10 minutes continually. The mean walking speed was 0.25 m/s [46]. In the evaluation of the wearable power assist locomotor orthosis (WPAL) on walking, physiological cost index (PCI) and muscle activity of the upper extremities in SCI subjects, Tanabe et al. reported all patients walked independently with the new powered device. The increased walking duration and distance of walking and reduction of the PCI and muscle activity of upper limbs with the WPAL compared to that the Primewalk orthosis [47]. Based on the literature in this field, we can conclude that PGOs can enable safe walking and reduce

energy expenditure compared to mechanical orthoses in SCI subjects.

announced trunk and hip stability and facilitate forward progression.

**with FES) in SCI**

116 Essentials of Spinal Cord Injury Medicine

**9. Orthotic gait training protocol**

the SCI patients will be beneficial in this field.

**8. Orthotic gait training with hybrid system (bracing combined** 

High level of energy demand and high effort and loads on the upper limb joints announced the main complication of the orthotics gait rehabilitation with mechanical orthoses. Combination of the mechanical orthoses and FES innovated to improve gait parameters and reduce the loads and energy demand in SCI subjects. The main concept of the using this type of approach

Different studies in this field evaluated the hybrid systems on the walking capacity in SCI subjects [38, 40, 48, 49]. Distance walked was announced as 180–1400 m in these studies [38, 40, 48, 49]. Although there was no significant improvement in the walking speed, but improvement in the distance walked was observed in trails in this field. The rate of the distance walked was announced between 3 and 400 m when the FES or orthoses were trained alone [38, 40, 48]. In subjects with incomplete level of spinal cord injury, the gait training with hybrid systems provided improvement in ambulation capacity compared to bracing or FES using alone [50].

The training approach announced different among the studies on SCI population [51]. Training protocol has been performed different for powered and mechanical orthoses. Based on the time of the training program, five studies had a shorter training period [26, 45, 52–55], while several weeks to months were reported in other studies [32, 51]. Training protocol was being done on the different surfaces including sidewalk, grass, or stairs [56–58]. Yong et al. used the training protocol with powered gait orthosis on the treadmill to increase confidence of SCI subjects and improvement of the walking speed on them [59]. While in using powered gait orthosis, Arazpour et al*.* [60] performed upper extremity strengthening and lower extremity stretching as the main section of the training during orthotic gait rehabilitation. Further study on how different training programs affected the walking ability outcomes in Mokhtar Arazpour1 \*, Guive Sharifi2 , Mohammad Ebrahim Mousavi<sup>1</sup> and Maryam Maleki1

\*Address all correspondence to: m.arazpour@yahoo.com

1 Department of Orthotics and Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

2 Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
