**1. Introduction**

The act of learning how to walk (as a child, or more frequently, after sustaining an injury or disability) is so-called **gait training** or **gait rehabilitation**. In this chapter, we focus on gait training after spinal cord injury (SCI). The purpose of gait training for subjects with SCI is usually to increase walking endurance and to decrease subject's dependency. Standing and walking can help to prevent contractures of the lower limb joints, as well as osteoporosis, spasticity, bed sores and edema, complete discharge of bladder, and prevention of bladder infection in subjects with SCI [1–4].

Spinal cord injury is spinal cord damaging that causes changes in function, most frequently and importantly, disruption in lower limb motor and sensation. Inability to walk is the most

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

important limitation for affected patients [5]. Among lots of serious problem which patients encounter with, but after injury the first question is "will I ever walk again?" [6]. As a result, retraining the affected patients to achieve walking ability is important.

The main determinants of normal gait are [7]:


In patients with SCI, there are no main determinants of normal gait, but in recent years, there have been advancements in how the patients can increase the ability to walk. Rehabilitation procedures should focus on the development of outcome by using the neuroplasticity and by using a functional training.

Lovely et al*.* in 1990 demonstrated neuronal circuits below the level of lesion become activated by an appropriate afferent input. They established that stepping practice plays an important role in training [8]. When the practice of stepping is accomplished, walking can be done more effective than when it is not practiced. In spinal cord, when a motor task wants to be recognized in neural circuit, it should be practiced appropriately and sufficiently. The name of this process is training [9]. De Leon et al. in 1998 and Wirz et al., 2001 stated that appropriate afferent input activate neuronal networks below the level of injury in a SCI patients, and activated neural network generate electromyography activity for suitable function (even in complete SCI without supraspinal input) [10, 11]. Dietz et al*.* in different experiments in human and animals revealed externally assisted walking, with tools and equipment or therapist, when appropriate afferent input will drive to spinal cord, a locomotor pattern will train and muscle activity (EMG) will be turned on even in complete SCI; however, muscle activity in complete SCI is low in comparison with healthy subjects but muscle EMG will increase by practicing more and more during training sessions [12].

because the afferent input from foot pressure during the stance phase is essential for the activation of spinal neuronal network (**Figure 1**) [13]. Dietz in 2008 suggested that another important input after foot contact pressure is proprioceptive input from extensor hip muscles. Foot sole mechanoreceptor with hip extensor muscles proprioception provides load information

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

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

107

Until now, many therapeutic strategies have been developed for promoting locomotor activity of SCI subjects ranged from those that compensate for weakened or lost function (e.g. orthotic gait training) to strategies based on the concepts of central nervous system (CNS) plasticity (e.g. Erigo therapy and body weight–supported tread mill training) [15, 16]. Strategies that are based on the concept of CNS plasticity have shown improvement and enhancement in walking ability of SCI subjects through implementing the task-specific sensory input and repetitive

**2. Gait rehabilitation interventions following spinal cord injury**

**Figure 1.** Schematic drawing of the afferent input from load- and hip joint [14].

and intensive gait therapy [17, 18]. These strategies will be explained as following.

(**Figure 1**) [13].

One of the important afferent inputs is foot load receptor input. Researchers perceive the importance of these kinds of afferent input when they use externally assisted walking while patients are unloading. In this experiment, they understand unloading does not activate muscle EMG activity and they claim that, body unloading and reloading are considered to be of crucial importance to convince training effects upon the neurological locomotor centers, Role of Gait Training in Recovery of Standing and Walking in Subjects with Spinal Cord Injury http://dx.doi.org/10.5772/intechopen.71312 107

**Figure 1.** Schematic drawing of the afferent input from load- and hip joint [14].

important limitation for affected patients [5]. Among lots of serious problem which patients encounter with, but after injury the first question is "will I ever walk again?" [6]. As a result,

• Aerobic capacity out of which the first six factors are impaired in spinal cord injured

In patients with SCI, there are no main determinants of normal gait, but in recent years, there have been advancements in how the patients can increase the ability to walk. Rehabilitation procedures should focus on the development of outcome by using the neuroplasticity and by

Lovely et al*.* in 1990 demonstrated neuronal circuits below the level of lesion become activated by an appropriate afferent input. They established that stepping practice plays an important role in training [8]. When the practice of stepping is accomplished, walking can be done more effective than when it is not practiced. In spinal cord, when a motor task wants to be recognized in neural circuit, it should be practiced appropriately and sufficiently. The name of this process is training [9]. De Leon et al. in 1998 and Wirz et al., 2001 stated that appropriate afferent input activate neuronal networks below the level of injury in a SCI patients, and activated neural network generate electromyography activity for suitable function (even in complete SCI without supraspinal input) [10, 11]. Dietz et al*.* in different experiments in human and animals revealed externally assisted walking, with tools and equipment or therapist, when appropriate afferent input will drive to spinal cord, a locomotor pattern will train and muscle activity (EMG) will be turned on even in complete SCI; however, muscle activity in complete SCI is low in comparison with healthy subjects but muscle EMG will increase by practicing

One of the important afferent inputs is foot load receptor input. Researchers perceive the importance of these kinds of afferent input when they use externally assisted walking while patients are unloading. In this experiment, they understand unloading does not activate muscle EMG activity and they claim that, body unloading and reloading are considered to be of crucial importance to convince training effects upon the neurological locomotor centers,

retraining the affected patients to achieve walking ability is important.

The main determinants of normal gait are [7]:

• Stability and posture,

106 Essentials of Spinal Cord Injury Medicine

• Muscle strength,

• Muscle tone,

• Vision,

• Cognition,

individuals.

using a functional training.

more and more during training sessions [12].

• Proprioception,

• Range of motion (ROM),

• Co-ordinated motor control,

because the afferent input from foot pressure during the stance phase is essential for the activation of spinal neuronal network (**Figure 1**) [13]. Dietz in 2008 suggested that another important input after foot contact pressure is proprioceptive input from extensor hip muscles. Foot sole mechanoreceptor with hip extensor muscles proprioception provides load information (**Figure 1**) [13].
