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Design: Single cases. Objective: To compare the e ects of manually assisted locomotor training in paraplegic patients with the automated training by a driven gait orthosis. Setting: ParaCare, University Hospital Balgrist in Zurich, Switzerland. Methods: Treadmill training with manual assistance and by a driven gait orthosis was applied to two spinal cord injured patients. The ®rst patient had an incomplete lesion at C3, the second a complete lesion at C5. They were selected by convenience sample. The EMG activity of the leg muscles rectus femoris, biceps femoris, gastrocnemius medials (GM) and tibialis anterior (TA) was visually compared for the two training methods. GM and TA activity was also quanti®ed by calculating the variation ratio between the EMG of the patients and a set of healthy subjects. Results: No signi®cant di erence between the two training methods was found according to the leg muscle EMG activity. Conclusion: Neuronal centers in the spinal cord become activated in a similar way by the manually assisted and the automated locomotor training. With the driven gait orthosis training sessions can be prolonged and workload of therapists can be reduced, and therefore, the automated training represents an alternative to the conventional therapy. Spinal Cord (2001) 39, 252 ± 255

Study design: Prospective longitudinal study. Objectives: To investigate the responsiveness of the Walking Index for Spinal Cord Injury II (WISCI II), 6-Min Walk (6MWT) and 10-Meter Walk Tests (10MWT) for the assessment of walking capacity in incomplete spinal cord injury (iSCI) and to validate these tests with the lower extremity motor score (LEMS). Setting: European Multicenter Study of Human Spinal Cord Injury. Methods: The walking tests of 22 iSCI subjects who achieved functional ambulation and could stand or walk within 1 month after iSCI were analyzed at 3, 6 and 12 months after injury. Responsiveness was assessed by determining differences between the time intervals, and Spearman's correlation coefficient was calculated to quantify validity. Results: All walking tests were able to assess the improvement of walking capacity within the first 3 months after injury. Between 3 and 6 months, only the 10MWT and 6MWT were responsive to the ongoing improvement in locomotor capacity. Overall, correlations between the tests were good within the first month, but became poorer over time. Conclusion: The 6MWT and 10MWT were more responsive in demonstrating an improvement in walking capacity compared to the WISCI II. The testing of functional outcome after iSCI as provided by the ordinal ASIA motor score can be improved by interval scaled measures. This allows increasing the responsiveness of functional outcome measures and should be advantageous in assessing therapeutical approaches in iSCI subjects. In iSCI subjects with walking ability, we recommend the additional use of timed tests to monitor improvement in locomotor capacity.

Recent studies have shown that a locomotor pattern can be induced and utilized by paraplegic patients under conditions of body unloading using a moving treadmill. The present study investigated the behaviour of the locomotor pattern and also the relationship of its development to the spontaneous recovery of spinal cord function assessed by clinical and electrophysiological (tibial nerve somatosensory evoked potentials and motor evoked potentials) examinations. The earliest time that spinal locomotor activity could be induced was when signs of spinal shock had disappeared. This activity was distinct from spinal stretch re¯ex activity. In complete paraplegic patients the locomotor pattern improved spontaneously without training. This was coincident with both an increase of gastrocnemius electromyographic activity during the stance phase of gait and a decrease of body unloading. These eects reached a plateau after about 5 weeks. In complete and incomplete paraplegic patients a near linear increase of gastrocnemius electromyographic activity occurred during the stance phase of a step cycle with daily locomotor training over the whole training period of 12 weeks. This was also coincident with a signi®cant decrease of body unloading. In contrast to this, neither clinical nor electrophysiological examination scores improved after the onset of training in both patient groups. Only in incomplete paraplegic patients was there recovery, albeit statistically insigni®cant, of spinal cord function according to the sensory and motor scores obtained in the neurological examination during the time period before onset of training. An improvement of locomotor function by training was also seen in patients with paraplegia due to a cauda lesion. Such training eects on muscles and tendons could be separated from those on the spinal locomotor centres. The ®ndings of this study may be relevant for the future clinical treatment of paraplegic patients.

The long term eVects of locomotor training in patients with spinal cord injury (SCI) were studied. In patients with complete or incomplete SCI coordinated stepping movements were induced and trained by bodyweight support and standing on a moving treadmill. The leg extensor muscle EMG activity in both groups of patients increased significantly over the training period, associated with improved locomotor ability in those with incomplete SCI. During a period of more than 3 years after training, the level of leg extensor EMG remained about constant in incomplete SCI in those who regularly maintained locomotor activity. By contrast the EMG significantly fell in those with complete SCI. The results suggest a training induced plasticity of neuronal centres in the isolated spinal cord which may be of relevance for future interventional therapies. (J Neurol Neurosurg Psychiatry 2001;71:93-96)

Methods: In the EM-SCI, the walking tests were applied 2 weeks and 1, 3, 6 and 12 months after SCI. We identified the WISCI II categories that applied to the EM-SCI subjects at each time point and quantified the relationship between the 10MWT and the TUG using Spearman's correlation coefficients (r) and linear regression.Results: Five WISCI II categories applied to 71% of the EM-SCI subjects with walking ability, while 11 items applied to 11% of the subjects. The 10MWT correlated excellently with the TUG at each time point (r.0.80). However, this relationship changed over time. One year after SCI, the time needed to accomplish the TUG was 1.25 times greater than the 10MWT time.Discussion: Some categories of the WISCI II appear to be redundant, while some discriminate to an insufficient degree. In addition, there appear to be ceiling effects, which limit its usefulness. The relationship between the 10MWT and TUG is high, but changes over time. We suggest that, at present, the 10MWT appears to be the best tool to assess walking capacity in SCI subjects. Additional valuable information is provided by assessing the needs for walking aids or personal assistance. To ensure comparability of study results, proposals for standardized instructions are presented. [Neurol Res 2008; 30: 61-73]

The BBS proved to be reliable and to relate well with other mobility measures, fear of falling, and muscle strength. However, it was unable discriminate between people who did fall and people who did not fall.