Abstract
Locomotor training holds tremendous appeal to people with spinal cord injury who are wheelchair dependent, as the reacquisition of gait remains one of the most coveted goals in this population. For the last few decades this type of training has remained primarily in the clinical environment, as it requires the use of expensive treadmills with bodyweight support or complex overhead suspension tracks to facilitate overground walking. The development of powered exoskeletons has taken locomotor training out of the clinic, both improving accessibility and providing a potential option for community ambulation in people with lower limb paralysis. A question that has yet to be answered, however, is whether or not locomotor training offers a sufficiently intense stimulus to induce improvements in fitness or health. As inactivity-related secondary health complications are a major source of morbidity and mortality in people with SCI, it would be important to characterize the potential of locomotor training to not only improve functional walking ability, but also improve health-related fitness. This narrative review will summarize the key literature in this area to determine whether locomotor training challenges the cardiovascular, muscular or metabolic systems enough to be considered a viable form of exercise.
Similar content being viewed by others
Login or create a free account to read this content
Gain free access to this article, as well as selected content from this journal and more on nature.com
or
References
Martin Ginis K, van der Scheer J, Latimer-Cheung AE, Barrow A, Bourne C, Carruthers P, et al. Evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline. Spinal Cord. 2018;56:308–21.
Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100:126–31.
Martin Ginis KA, Arbour-Nicitopoulos KP, Latimer AE, Buchholz AC, Bray SR, Craven BC, et al. Leisure time physical activity in a population-based sample of people with spinal cord injury part II: activity types, intensities, and durations. Arch Phys Med Rehabil. 2010;91:729–33.
Lai YJ, Lin CL, Chang YJ, et al. Spinal cord injury increases the risk of type 2 diabetes: a population-based cohort study. Spine J. 2014;14:1957–64.
Myers J, Lee M, Kiratli J. Cardiovascular disease in spinal cord injury: an overview of prevalence, risk, evaluation, and management. Am J Phys Med Rehabil. 2007;86:142–52.
Buchholz AC, Martin Ginis KA, Bray SR, Craven BC, Hicks AL, Hayes KC, et al. Greater daily leisure time physical activity is associated with lower chronic disease risk in adults with spinal cord injury. Appl Physiol Nutr Metab. 2009;34:640–7.
Ditunno J, Scivoletto G. Clinical relevance of gait research applied to clinical trials in spinal cord injury. Brain Res Bull. 2009;78:35–42.
Dobkin BH, Duncan PW. Should body weight-supported treadmill training and robotic-assistive steppers for locomotor training trot back to the starting gate? Neurorehabil Neural Repair. 2012;26:308–17.
Morawietz C, Moffat F. Effects of locomotor training after incomplete spinal cord injury: a systematic review. Arch Phys Med Rehabil. 2013;94:2297–308.
Chang SR, Kobetic R, Triolo RJ. Effect of exoskeletal joint constraint and passive resistance on metabolic energy expenditure: Implications for walking in paraplegia. PLoS ONE. 2017;12:e0183125. https://doi.org/10.1371/journal.pone.0183125.
Ferris DP, Sawicki GS, Daley MA. A physiologist’s perspective on robotic exoskeletons for human locomotion. Int J HR. 2007;4:507–28.
Garber C, Blissmer B, Deschenes M, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43:1334–59.
Fenuta AM, Hicks AL. Metabolic demand and muscle activation during different forms of bodyweight supported locomotion in men with incomplete SCI. Biomed Res Int. 2014;2014:632765. https://doi.org/10.1155/2014/632765.
Israel JF, Campbell DD, Kahn JH, Hornby GT. Metabolic costs and muscle activity patterns during robotic- and therapist-assisted treadmill walking in individuals with incomplete spinal cord injury. Phys Ther. 2006;86:1466–78.
Escalona MJ, Brosseau R, Vermette M, Comtois AS, Duclos C, Aubertin-Leheudre M, et al. Cardiorespiratory demand and rate of perceived exertion during overground walking with a robotic exoskeleton in long-term manual wheelchair users with chronic spinal cord injury: a cross-sectional study. Ann Phys Rehabil Med. 2018;61:215–23.
Evans N, Hartigan C, Kandilakis C, Pharo E, Clesson I. Responses during exoskeleton-assisted walking overground among persons with chronic spinal cord injury. Top Spinal Cord Inj Rehabil. 2015;21:122–32.
Asselin P, Knezevic S, Kornfeld S, Cirnigliaro C, Agronaova-Breyter PT, Bauman WA, et al. Heart rate and oxygen demand of powered exoskeleton-assisted walking in persons with paraplegia. JRRD. 2015;52:147–58.
Maher JL, Baunsgaard CB, van Gerven J, Palermo AE, Biering-Sorensen F, Mendez A, et al. Differences in acute metabolic responses to bionic and nonbionic ambulation in spinal cord injured humans and controls. Arch Phys Med Rehabil. 2020;101:121–9.
Kressler J, Wymer T, Domingo A. Respiratory, cardiovascular and metabolic responses during different modes of overground bionic ambulation in persons with motor-incomplete spinal cord injury: a case series. J Rehabil Med. 2018;50:173–80.
Currie KD, West CR, Hubli M, Gee CM, Krassioukov AV. Peak heart rates and sympathetic function in tetraplegic nonathletes and athletes. Med Sci Sports Exerc. 2015;47:1259–64.
Borg G. A category scale with ratio properties for intermodal and interindividual comparisons. Psychophysical Judgement and the process of perception. In: Geissler G, Petzol P, editors. Proceedings of the 22nd International Congress of Psychology. Amsterdam: North Holland; 1980. p. 25–34.
Gossey-Tolfrey VL, Paulson TA, Tolfrey K, Easton RG. Prediction of peak oxygen uptake from differentiated ratings of perceived exertion during wheelchair propulstion in trained wheelchair sportspersons. Eur J Appl Physiol. 2014;114:1251–8.
Pelletier CA, Totosy de Zepetnek J, MacDonald M, Hicks A. A 16-week randomized controlled trial evaluating the physical activity guidelines for adults with spinal cord injury. Spinal Cord. 2015;53:363–7.
van der Scheer JW, Hutchinson M, Paulson T, Martin Ginis KA, Goosey-Tolfrey VL. Reliability and validity of subjective measures of aerobic intensity in adults with spinal cord injury: a systematic review. PMR. 2018;10:194–207.
Kawashima N, Taguchi D, Nakazawa K, Akai M. Effect of lesion level on the orthotic gait performance in individuals with complete paraplegia. Spinal Cord. 2006;44:487–94.
Kressler J, Nash MS, Burns PA, Field-Fote EC. Metabolic responses to 4 different body weight-supported locomotor training approaches in persons with incomplete spinal cord injury. Arch Phys Med Rehabil. 2013;94:1436–42.
Gorman PH, Scott W, York H, Theyagaraj M, Price-Miller N, McQuaid J, et al. Robotically assisted treadmill exercise training for improving peak fitness in chronic motor incomplete spinal cord injury: a randomized controlled trial. JSCM. 2016;39:32–44.
Faulkner J, Martinelli L, Cook K, Stoner L, Ryan-Stewart H, Paine E, et al. Effects of robotic-assisted gait training on the central vascular health of individuals with spinal cord injury: a pilot study. J Spinal Cord Med. 2019. https://doi.org/10.1080/10790268.2019.1656849.
Gorgey AS, Wade R, Sumrell R, Villadelgado L, Khalil RE, Lavis T. Exoskeleton training may improve level of physical activity after spinal cord injury: a case series. Top Spinal Cord Inj Rehabil. 2017;23:245–55.
Shackleton C, Evans R, Shamley D, West S, Albertus Y. Effectiveness of over-ground robotic locomotor training in improving walking performance, cardiovascular demands, secondary complications and user satisfaction in individuals with spinal cord injuries: a systematic review. J Rehabil Med. 2019. https://doi.org/10.2340/16501977-2601.
Castro MJ, Apple DF Jr, Staron RS, Campos GE, Dudley GA. Influence of complete spinal cord injury on skeletal muscle within 6 mo of injury. J Appl Physiol. 1999;86:350–8.
Giangregorio LM, Webber CE, Phillips SM, Hicks AL, Craven BC, Bugaresti JM, et al. Can body weight supported treadmill training increase bone mass and reverse muscle atrophy in individuals with chronic incomplete spinal cord injury? Appl Physiol Nut Metab. 2006;31:283–91.
Jayaraman A, Shah P, Gregory C, Bowden M, Stevens J, Bishop M, et al. Locomotor training and muscle function after incomplete spinal cord injury: case series. J Spinal Cord Med. 2008;31:185–93.
Giangregorio LM, Hicks AL, Webber CE, Phillips SM, Craven BC, Bugaresti JM, et al. Body weight supported treadmill training in acute spinal cord injury: impact on muscle and bone. Spinal Cord. 2005;43:649–57.
Karelis AD, Carvalho LP, Escalona MJ, Gagnon DH, Aubertin-Leheudre M. Effect on body composition and bone mineral density of walking with a robotic exoskeleton in adults with chronic spinal cord injury. J Rehabil Med. 2017;49:84–7.
Stewart BG, Tarnopolsky MA, Hicks AL, McCartney N, Mahoney DJ, Staron RS, et al. Treadmill training-induced adaptations in muscle phenotype in persons with incomplete spinal cord injury. Muscle Nerve. 2004;30:61–8.
Adams MM, Ditor DS, Tarnopolsky MA, Phillips SM, McCartney N, Hicks AL. The effect of body weight-supported treadmill training on muscle morphology in an individual with chronic, motor-complete spinal cord injury: a case study. J Spinal Cord Med. 2006;29:167–71.
Piira A, Lannem AM, Sorensen M, Glott T, Knutsen R, Jorgensen L, et al. Robot-assisted locomotor training did not improve walking function in patients with chronic incomplete spinal cord injury: a randomized clinical trial. J Rehabil Med. 2019;51:385–9.
van der Scheer JW, Martin Ginis KA, Ditor DS, Goosey-Tolfrey VL, Hicks AL, West CR, et al. Effects of exercise on fitness and health of adults with spinal cord injury. A systematic review. Neurology. 2017;89:736–45.
Phillips SM, Stewart BG, Mahoney DJ, Hicks AL, McCartney N, Tang JE, et al. Body-weight-support treadmill training improves blood glucose regulation in persons with incomplete spinal cord injury. J Appl Phsiol. 2004;97:716–24.
Jones ML, Evans N, Tefertiller C, Backus D, Sweatman M, Tansey K, et al. Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial. Arch Phys Med Rehabil. 2014;95:2239–46.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The author declares that they have no conflict of interest.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Hicks, A.L. Locomotor training in people with spinal cord injury: is this exercise?. Spinal Cord 59, 9–16 (2021). https://doi.org/10.1038/s41393-020-0502-y
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41393-020-0502-y
This article is cited by
-
Multi-omics uncovers immune-modulatory molecules in plasma contributing to resistance exercise-ameliorated locomotor disability after incomplete spinal cord injury
Genome Medicine (2025)
-
Wearable Robotic Exoskeletons for Overground Walking in Rehabilitation: Specific Contexts of Use and Improvement Opportunities
Current Robotics Reports (2020)
