Beyond Gait Speed: A Case Report of a Multidimensional Approach to Locomotor Rehabilitation Outcomes in Incomplete Spinal Cord Injury : Journal of Neurologic Physical Therapy

Secondary Logo

Journal Logo

Case Report

Beyond Gait Speed: A Case Report of a Multidimensional Approach to Locomotor Rehabilitation Outcomes in Incomplete Spinal Cord Injury

Bowden, Mark G. PT, MS; Hannold, Elizabeth M. PhD; Nair, Preeti M. PT, PhD; Fuller, Laura B. MEd; Behrman, Andrea L. PT, PhD

Author Information
Journal of Neurologic Physical Therapy 32(3):p 129-138, September 2008. | DOI: 10.1097/NPT.0b013e3181838291
  • Free



Spinal cord injury (SCI) is a disabling health problem presently affecting approximately 250,000 survivors in the United States,1 and paralysis resulting in the loss of the ability to walk is one of the major consequences. Locomotor rehabilitation therapies such as locomotor training (LT), incorporating body weight support (BWS), and a treadmill (TM) have emerged from animal models of neural plasticity2 and have been translated into human populations.3–7 The efficacy of the interventions in LT studies of human populations has primarily been focused on clinical measures of gait speed and functional independence.3,4,8–10 For example, a recent randomized, controlled trial of LT delivered within eight weeks of incomplete SCI used overground gait speed as one of its two primary outcome measures, with level of independence in walking as measured by the functional independence measure (FIM) being the other.5 Although gait speed correlates with functional ability in stroke populations,11 and undoubtedly has great implications for measuring physical performance in those with SCI as well, speed alone cannot capture the multifaceted outcomes that are associated with recovery of walking and return to independence.

Models of disablement/enablement illustrate the multiple factors that contribute to an individual’s health and well-being. Since Nagi12 first proposed his model of disability, healthcare practitioners have begun to realize the role of pathologies and impairments in both the physical functioning of the individual and the ability of the individual to interact with the world as he or she chooses. Modifications of the Nagi model have emphasized the role of personal and environmental factors in affecting quality of life and personal health status, and advocate a broad approach in not only the treatment, but also the assessment of people with disabling conditions. The World Health Organization recently published the International Classification of Functioning, Disability and Health (ICF) “to provide a unified and standard language and framework for the description of health and health-related states” (Fig. 1) by moving beyond existing rehabilitation models to define both health and health-related components of well-being.13 In particular, the ICF was the first model to systematically describe the contributions of the environment and personal factors on an individual’s health status. The ICF model, if broadly adopted and used, would allow this universal language to “facilitate communication and scholarly discourse across disciplines as well as across national boundaries, to stimulate interdisciplinary research, to improve clinical care, and ultimately to better inform health policy and management.”14

Figure 1.:
International Classification of Function, Disability and Health (ICF) model disability and health. The ICF presents the following definitions for elements of the model: body functions: physiological or psychological functions of body systems; body structures: anatomic parts of the body such as organs, limbs, and their components; impairments: problems in body function or structure; activity: execution of a task or involvement in a life situation in a controlled environment (capacity); participation: execution of a task or involvement in a life situation in an individual’s current environment (performance); environmental factors: make up the physical, social, and attitudinal environment in which people live and conduct their lives. Environmental factors may either be individual (including home, workplace, and school as well as the direct contact one may have with others in this environment) or societal (other social structures, services, and systems that may have an impact on an individual); Personal factors: the background of an individual’s life and living that are not part of a health condition or health state.14

The purpose of this case report is to describe a multidimensional approach to outcome measurement reflecting the ICF model, using as an example an individual with chronic, incomplete SCI and an American Spinal Injury Association (ASIA) Impairment Scale15 classification of D who underwent LT associated with a research study. The selected outcome measures included not only established activity-based outcome measures of walking independence, gait speed, and a composite index of walking function, but also participation-level measures of walking in the home and community. In addition, personal and environmental factors are investigated via qualitative participant interviews and a description of the individual’s return to independent living and employment in the community. This case report provides evidence supporting the value of assessments that address issues beyond traditional models of outcomes that focus exclusively on changes in the patient’s activity or functional level and toward evaluative models that examine interventional effects from all dimensions of the patient’s recovery process, namely, the patient’s independence, community integration, and quality of life.16



The participant was a 59-year-old male veteran who was injured in a motor vehicle accident that occurred 16 months before his beginning the LT program. Because of the accident, he sustained fractures at C2, C3, C5, C6, and C7 and was initially diagnosed as having incomplete tetraplegia, ASIA classification of B. Additional medical history included bilateral heterotopic ossification of the hip joints, pain in the left hip and thigh region, osteomyelitis of the sacrum, neurogenic bowel and bladder, deep vein thrombosis, and recurrent urinary tract infection.

After his accident, he was treated initially at a regional medical center and was then transferred to a Veterans Affairs (VA) Medical Center for continued inpatient care and eventual rehabilitation. He underwent a halo placement before his transfer to the VA Medical Center facility, and the halo was maintained for three months after the transfer. Acute rehabilitation therapy focused on postural control, standing activities, gait training in parallel bars, and upper extremity strengthening. Upon completion of his acute rehabilitation (six months after injury), the participant received seven months of continued care, including outpatient physical therapy two to six times per month for four months, outpatient occupational therapy one to two times per month, and therapeutic home care three to four times per month for seven months each. After completing the outpatient physical therapy, he began pool therapy (four to six times per month) for two months. The participant used a power wheelchair for his primary means of mobility, walking only with assistance from a therapist. He required assistance with bowel/bladder care, primarily because of requiring transfer assistance (he could not independently go from sitting to standing) and was unable to functionally use his upper extremities during walking because of the platform attachments. These limitations necessitated attendant care, but he had neither family nor caregiver support, and he did not have the financial means to hire part-time attendants. As a result, he was unable to live independently and was admitted to a skilled nursing facility. Upon acceptance into the research study, arrangements were made via VA resources for him to transfer to a local nursing home facility for the duration of his participation.

The participant met the research protocol criteria of having an incomplete SCI occurring between six months and three years previously, ambulating at a speed less than 0.8 m/sec, and having upper motor neuron involvement. Before participation, he reviewed and signed a consent form approved by the Institutional Review Board of the University of Florida Health Science Center. The participant was re-evaluated using the ASIA Impairment Scale and was found to have incomplete ASIA D tetraplegia. He was taking multiple medications for spasticity and pain, and the doses remained constant throughout the course of the study.


The LT intervention consisted of 45 training sessions, with each session consisting of 30 minutes of step training on the TM with BWS immediately followed by 20 minutes of level overground walking and community ambulation training. Including pretraining stretching, donning/doffing the harness, and additional time spent on the TM for stand training and standing rest breaks, the total session duration was approximately 75 to 90 minutes per day. With the aid of the BWS, TM speed, and manual assistance from trainers, the TM training environment facilitated delivery of locomotor-specific practice.6,17,18 Trunk, lower limb, and upper limb kinematics were consistently monitored by trainers to ensure approximation of normal walking. The goal for speed of stepping on the TM was a range consistent with normal walking, but was adjusted for this subject because of the high degree of dominance of flexor activity during walking. A decrease in speed was necessitated to accomplish an alternate stepping pattern with adequate loading and improved kinematics. Progression of training was achieved by decreasing BWS, altering speed, decreasing trunk support, decreasing manual assistance for limb control, and increasing the time spent walking on the TM per bout. An elaborate description of the training principles, parameters, and progression has been published elsewhere.3,4 Overground training consisted of an immediate assessment of the participant’s ability to stand and/or walk independently overground and an evaluation of the deficits limiting achievement of this goal. These deficits became the focus for goal-setting in the next day’s TM training session. Additionally, overground training addressed translation of the skills from the TM to the home and community identifying practical ways for the participant to incorporate new skills into his everyday activities. Consultation with care providers was incorporated as needed to encourage their support of the participant practicing new skills during his everyday routine.

Outcome Measures

The outcomes were selected using a multidisciplinary approach targeting all aspects of the ICF. Outcome assessments addressed (1) body structures and functions (ASIA Impairment Scale: upper extremity motor score [UEMS], and lower extremity motor score [LEMS]15),(2) activity (gait speed and spatial gait characteristics, level of walking independence19), and (3) participation (amount of home and community walking activity20). Furthermore, personal and environmental contributions to the participant’s health status were investigated via patient interviews and consultation with care providers.

A description of each assessment performed, its reported validity and reliability, and the assessment procedure follows. Data from each of the following outcome measures were collected before and after 45 sessions of LT. Interim measurements for gait speed, spatial characteristics of gait, and level of independence were conducted at the midpoint of training, and qualitative interviews were conducted at weeks three and eight during the training.

Body Structure and Functions

ASIA Assessment of Neurological Impairment

Testing for UEMS and LEMS was conducted according to ASIA guidelines before and after LT and by the same examiner to enhance reliability.15 Minimal detectable change (MDC) has not been calculated for the ASIA evaluation.


Gait Speed and Spatial Pattern of Walking

Testing for quantifiable spatiotemporal parameters of walking was completed by having the participant walk at least twice over a computerized pressure-sensitive mat (GaitMat 2 [software version 2.016], EQ Inc., Chalfont, PA) at his self-selected walking speed. The MDC has not been calculated in the SCI population but equals 0.08 m/sec in a sample of individuals after hip fracture21 and 0.30 m/sec in those after stroke.22 The GaitMat 2 recorded footfalls from the spatial-temporal distribution of switch closures and subsequent openings, and the analysis software calculated the gait parameters. The participant used his customary assistive device for initial and final testing. Step length symmetry was calculated by dividing the shorter step length by the longer, indicating that a symmetrical pattern would equal a value of 1.0. Dynamic balance and stabilization in walking were evaluated by calculating the ratio of amount of time spent in single-limb support to that spent in double-limb support on each side.23 In healthy populations, this ratio should be close to 4.0 and equal right and left, representing the single-limb support time of 40% and the double-limb support time of 10% on each side,24 and can be interpreted as an improved ability to balance on each limb while stepping.25 Cadence was calculated by measuring the number of steps taken per minute. Spatiotemporal outcomes derived from the GaitMat 2 do not have documented values for the MDC.

Gait Kinematics and Functional Activity

Each walking trial over the GaitMat 2 was videotaped from the lateral view. Tapes were then reviewed for a qualitative analysis of gait deviations and/or use of compensatory strategies for upright posture, limb advancement, weight support, and balance (eg, forward trunk posture, lack of right knee flexion, right hip hiking).26 The subject was also observed while performing functional activities during treatment sessions such as wheelchair to mat transfers and transitioning from sitting to standing. In addition, the participant provided daily information regarding his functional performance in his residence.

Level of Walking Independence

The Walking Index for SCI-Version II (WISCI II) was selected as an instrument to categorize the level of physical assistance and use of assistive devices or braces required for walking.19 The WISCI II is a 20-item scale ranging from a score of 0 (meaning the patient is unable to walk) to 20 (meaning the patient can walk with no assistive device, no braces, and no assistance for at least 10 m). MDC scores have not been calculated for the WISCI.


Walking Activity in the Home and Community

The participant’s amount of walking in the home and community was measured using a step activity monitor (SAM) (Cyma, Seattle, WA). The SAM is a small, lightweight device, about the size of a pager, which is worn on the ankle and does not interfere with walking. The device is a microprocessor-driven accelerometer, which is more reliable for step counting than other measurement devices such as pedometers,27 and is accurate and reliable in the SCI population.28 In addition, the programming capabilities of the microprocessor permit the clinician or researcher to both count the number of steps and observe amounts of activity during predetermined time spans, providing more information than basic accelerometers.20 The participant wore the device for four consecutive days, covering two weekdays and two weekend days, on two different occasions: before training and after 45 sessions of training had been completed. This type of measurement allows for measurement of step activity in the individual’s current environment (participation) and not simply the controlled environment of a clinic or research laboratory (activity).13 The MDC for the SAM is 223 steps per day in individuals with incomplete SCI.28

Contributions to Health Status: Personal and Environmental Influences

Participant Perspectives

Qualitative interviewing was used to capture the participant’s LT experiences, including his perceptions of LT outcomes, and the impact of personal and environmental factors. Narrative data were collected via single, in-depth interviews completed at two time points—the third and eighth week of LT. Both interviews were conducted privately with the participant, in a closed conference room, and were tape recorded. Semistructured interview guides consisting of open-ended questions were used to facilitate interviews. Audiotaped interviews were transcribed verbatim into Microsoft Word documents and then verified. Word documents, in turn, were converted to text-formatted data files and imported into N6 qualitative software29 for coding. The coding process involved reviewing text/data, line by line, to identify prominent themes. Using N6, we systematically selected/highlighted segments of the text file, defined the theme of the segment, and then assigned the text segment a representative code. Through the coding process, we generated a coding framework reflective of the participant’s LT experiences. As coding progressed, if an existing code was representative of a subsequent data segment, the segment was coded accordingly. Conversely, if the data segment represented a new theme, a new code was defined, added to the framework, and assigned to the segment.

Consistent with the constant, comparative method30 commonly used in qualitative analysis, we commenced data analysis during the coding process. For example, as we reviewed data for coding, we carefully compared them with text/data previously categorized at specific codes to identify similarities, differences, and/or relationships. By continually comparing data within and across the various codes, we were able to refine our coding framework and define recurrent themes and patterns.

Consultation with Care Providers

The training team conducted an informal assessment of the need for the participant’s care provider to be informed about new skills acquired during training. Consultation with patient care providers at the nursing facility was conducted by the training team, the VA SCI clinical care coordinator, and the VA social worker. The goals of this consultation were to enable the participant to practice new skills safely in his residential environment as well as to create ways in which the care provider could assist the patient in practicing skills throughout his daily activities.


Assessments of Body Structure and Functions

ASIA Motor Scores

Posttraining evaluation demonstrated an increase in the UEMS from 36/50 to 39/50 and an LEMS increase from 35/50 to 41/50.

Assessments of Activity

Gait Speed and Temporal and Spatial Characteristics

Self-selected walking speed did not show substantial improvement pretraining vs posttraining changing only marginally from 0.12 m/sec to 0.15 m/sec. The fastest comfortable walking speed demonstrated similar marginal changes from 0.26 m/sec pretraining to 0.29 m/sec post-intervention. Changes at each speed failed to reach the MDC of 0.08 and 0.30 reported in other populations. The step length ratio progressed toward 1.0 post-training, changing from 0.76 pre-training to 0.88. The ratio of stability (ie, single-limb stability) increased bilaterally post-training on the left and right sides (toward the normal value of 4.0), from 1.3 to 2.4 and 0.91 to 1.71, respectively. Stride length improved from 0.50 to 0.57 m bilaterally, and cadence values remained consistent from pre- to post-training.

Gait Kinematics and Functional Activity

Observationally, the participant improved his posture and qualitatively normalized movement kinematics of his legs (Fig. 2). At initial evaluation, the participant could only stand when supported by the platform walker with assistance to place his arm in the device, and he required assistance to go from sitting to standing. Basic transfers required minimal assistance. He walked with a flexed trunk, relying heavily on weight support through his upper extremities onto the walker’s platform attachments. The excessive trunk flexion prevented the lower extremities from achieving an extended position at the hip, even during terminal stance, whereas the knees were in a flexed position throughout the gait cycle. The kinematics seen at pre-evaluation were not because of orthopedic limitations as the participant had range of motion at bilateral hips, knees, and ankles at least to neutral. At completion of the training, the participant walked with more erect posture with his head up and directed forward. The weight-bearing on his upper extremities was limited through his hands rather than through the elbows, and he was able to stand for brief periods of time with no upper extremity support. Freeing of his hands for functional use directly translated to independence in basic and instrumental activities of daily living such as sitting to standing from the wheelchair, toilet transfers, bowel and bladder management, meal preparation, and home maintenance. Lower extremity kinematics were normalized with knee extension observed bilaterally in midstance and both legs extending past neutral in terminal stance.

Figure 2.:
Pre- and post-training gait kinematics and assistive devices. a. The phases of the gait cycle during pretesting overground assessment. b. The same gait phases examined at posttesting overground assessment. Note the improved posture and increased extension at the trunk, hips, and knees. This improved posture facilitated a transition to a standard rolling walker, freeing his upper extremities for other functional activities.

Level of Walking Independence

The participant’s level of independence (Fig. 2) for walking improved from a WISCI II score of 8 (using a rolling platform walker) to 13 (use of rolling walker). The participant did not use any type of orthotic device either pre- or post-training.


Walking Activity in the Home and Community

On average, the participant increased his stepping activity from 26 steps per day before training to 1273 steps per day after training, exceeding the MDC of 223 established in the SCI population. Pre- and post-training, his most productive hour was evaluated further and was thought to demonstrate his best capacity to step. Analysis of this hour demonstrated that he was capable of taking 1470 steps in 1 hour post-training and only 84 steps per hour pre-training (Fig. 3). Community cadence increased from a maximum of 20 steps per minute (average of 6.4 steps per minute during walking bouts) to a maximum of 72 steps per minute (average of 32.7 steps per minute during walking bouts).

Figure 3.:
Pretraining (A) and posttraining (B) amount of self-elected walking activity in the home and community for a 24-hour period. C and D. Graphs represent the most productive hour of walking shown in A and B, respectively, demonstrating the greatest capacity of the patient for walking activity. Community cadence increased from a maximum of 20 steps per minute (average of 6.4 steps/min during walking bouts) to a maximum of 72 steps per minute (average of 32.66 steps/min during walking bouts).

Contributions to Health Status: Personal and Environmental Influences

Participant Perspectives

Three primary themes were identified from the qualitative data: (1) physical benefits and changes due to LT, (2) emotional benefits and changes due to LT, and (3) the role of the therapy team. Through data analysis, the relationships among these themes became evident, as did their impact on the participant’s LT experiences. Findings were used to develop a conceptual framework illustrative of the participant’s self-reported LT outcomes (Fig. 4). Each theme is described separately and is supported with representative data in the form of participant quotes and the investigator’s interpretation of meaning.

Figure 4.:
Participant perspectives of locomotor training and walking recovery.

To provide readers with an optimal context for understanding the themes/findings, we first briefly address the participant’s mental health status. No records of the participant’s psychological status were available to the therapy team. However, during interviews, he made several mental health-related references. For example, he shared that he experienced [emotional] “pain” throughout his life and that he experiences emotional “ups and downs” as part of his personality. Early in treatment, the participant expressed frustration over his disability and negativity toward his need for mobility devices—a power wheelchair and a platform walker. He also admitted to having very high expectations of LT—stating that he felt angry “when I found out that I wouldn’t leave here walkin’ on my own” (without the assistance of a mobility device). These comments are consistent with disability adjustment-related challenges, and likely represent an early “personal influence” on the participant’s progress. Disability adjustment challenges likely were tied to the participant’s high expectations for LT and his subsequent frustration on realizing that he would continue to require a mobility device.

Physical Benefits and Changes Due to LT

The participant identified improved mobility as a highly valued LT outcome. Data suggest that a combination of factors challenged the participant’s negative beliefs or bias31 held toward his disability early in treatment. These factors altered his negative bias and resulted in a change in perspective that enabled him to acknowledge his accomplishments, draw positive meaning from his LT experiences, and, ultimately, improve his motivation for recovery. This change in perspective is evident in the following passage, in which the participant describes his satisfaction with his physical improvements:

… I can’t ask for no more. I came here (pause) like I say, on a platform walker. Uh, I couldn’t lift my arm like this [lifting arm to demonstrate]. I got it [arm] up and uh. I’m standing really, really good—very, very good. My legs, uh, are in much better shape.

Thus, even though the participant required the assistance of a rolling walker on completing LT, he was pleased that the training resulted in improved posture, increased strength in his legs, and the ability to use a less restrictive walker without platform attachments. This change in mobility device also resulted in greater freedom of arm movement. In addition to physical improvements, the participant also identified a decrease in pain. He stated “I know the therapy helps, so. My pain level, on a scale of 1 to 10? I’d say is about a 3. Like I say I don’t even, I can’t even remember the last time I took the Tylenol.”

Emotional Benefits and Changes Due to LT

Data indicated that improvements in the participant’s function and mobility had a strong influence on his sense of emotional well-being. For example, when asked about what changes he noticed as a result of LT, the participant stated, “Yeah I, I’m feelin’ better, mentally. Just have strength to get up outta the wheelchair; be able to go places without the chair, makes me feel better.” In these statements, the participant directly attributes his emotional well-being to his mobility improvements. Given his negative feelings toward his wheelchair, the mobility independence that he gained with his walker was particularly rewarding and seemed to enhance his self-esteem.

Data from the participant’s second interview (eight weeks into the therapy protocol) indicated another noteworthy emotional change. The participant relayed a conversation with a member of the therapy team that appeared to hold special significance for him. The participant relayed that he made a comment to the therapist that he (the participant) was not “independent” if he used a walker. The participant explained how the therapist clarified that a walker did not represent dependence and that if he (the participant) was using the walker by himself, he was independent. This different perspective seemed to alter the participant’s negative bias. By challenging the participant’s perceptions, the therapist enabled him to view the walker as a facilitator rather than a barrier to his independence. Subsequently, the participant reported that his motivation to use his walker greatly increased. As evident in Figure 4, data also suggest that the participant viewed the therapy team’s role in coordinating arrangements for him to practice using his walker in his home environment as a strong sign of social support. In the following passage, the participant relates how the therapy team’s support (challenging his beliefs about his walker and facilitating his practice with his walker) led to an increased sense of motivation:

Umm, the people—they told me that uh (pause) I was free to walk on my own with the walker. It changes, you know it changed, my uh, attitude. Motivated me. My attitude changed. Right now um, I’m ready to challenge myself.

Role of the Therapy Team

Data indicate that the participant highly valued his therapy team for their contributions to his positive LT outcomes. In fact, he identified the “people” as one of the benefits of LT that he valued the most. As already indicated, the therapy team’s role in facilitating the participant’s walking practice, both during LT and in his home environment, was viewed by the participant as altruistic and a sign of social support. In the following interview excerpt, the participant describes his feelings regarding the therapy team:

They uh, they were uh, BORN [spoken with emphasis] for this job, you know. They take a lot of, uh, hard work and love and motivation for uh, the people that they tryin’ to help, you know. They really do, you know. And uh, I could see AND feel it. And like I say, I wouldn’t (pause) trade them for the world, you know.

Our findings indicate that therapy team was a critical “environmental factor” that influenced the participant’s LT outcomes. They created an environment that was both challenging and supportive, and, in turn, empowered the patient to confront and change the “personal factors” (physical and emotional status) to maximize his LT outcomes.

Consultation with Care Providers

As the participant’s home environment during the study was a nursing home care unit, the care providers in his case were the nursing home staff responsible for his care. During the intervention, as the participant acquired new skills, the research team became aware that the nursing home staff was prohibiting the participant from walking in the home with his assistive devices due to concern for his ability to achieve this task safely. Consultation with the nursing home staff, informing them of the new abilities that he had demonstrated in training sessions, encouraged the staff to support his walking program within the home environment. As a result, the nursing home staff included walking behavior in their management plan as one of his personal goals and the participant was able to increase walking practice in his home/community environment.


After completing LT, with the help of the VA social worker and clinical care coordinator, the participant was discharged to an apartment in the community, and at the time of this writing, the participant is continuing to live independently. He had also begun volunteering at his local VA Medical Center and with Voter Registration Campaigns. Although these outcomes were identified after the study, they are included in Figure 4 because they represent how the physical benefits, emotional benefits, and the role of the therapy team merged to empower the participant to become actively engaged in his home and community.


This case report illustrates the importance of a broad-based evaluation examining the multiple contributors to functional recovery after a therapeutic intervention. Gait speed, a critical component of functional walking recovery, is often used as a primary outcome measure, but in this case would not have illustrated this individual’s functional capacity. Although gait speed changed only marginally, self-elected stepping activity increased and posture and kinematics improved, and he progressed to a less restrictive assistive device allowing for more functional use of the upper extremities. The temporal and spatial characteristics also improved, particularly the ratio of stability, but these changes do not likely account for the functional improvements and independence. Most important was his change in disposition from requiring assistance in a skilled nursing facility to living independently in the community. Critical in this transition was his psychosocial adaptation and the personal contributions to his overall health status, as demonstrated in the outcomes reported. Capturing all the factors contributing to the ultimate outcome of independent living is imperative, as is assessing how therapies may capitalize on patients’ potential by using the knowledge of the multidimensional construct of their recovery.

One of the critical features of the ICF model is the addition of the environmental contributions to an individual’s health status, without which there would be no framework to assess how a modification of the environment affects an individual’s status. In this case study, a crucial junction in the overall case management was the involvement of the nursing home staff with his personal goals and improved capacity of walking. The nursing home staff was able, in essence, to modify the individual’s environment, creating one in which walking behavior was more supported and even expected within the context of mandating safety and building confidence. This modification of the environment corresponded with observed improvements in training performance as improved functional capacity became realized through opportunity to practice throughout the day.

Environmental changes were consistent with the participant’s attitudinal changes as gleaned from qualitative interviews. Increased walking behavior, goal-setting with therapists and case management, realization of potential, and a renewed sense of hope all contributed to the outcomes represented in the participant’s model for recovery (Fig. 4). Assessing these components of rehabilitation will inform therapists how best to engage individuals throughout the therapeutic process, not only in goal setting, but also as contributors to their own emotional well-being.

This case report is a retrospective analysis of an individual who experienced dramatic increases in function with only marginal increases in clinical measures such a gait speed. The qualitative analysis of the participant’s personal factors, however, was a prospective study as a component of a doctoral dissertation. This methodology was undertaken because it was thought that existing quantitative measures of participation such as the Craig Handicap Assessment and Reporting Technique and a 36-item short-form social functioning health survey did not delineate the participants’ personal factors as they contributed to rehabilitation.32,33 Although we realize this component of the case report is not necessarily reproducible in the clinic, it is hoped that qualitative findings from individuals undergoing LT may lead to future quantitative assessments that can capture personal contributions to the rehabilitation process. Efforts are currently underway to adapt this type of information into outcome measurement.34,35 The concept of therapeutic process has been defined as “all the meaningful activity that mediates [therapeutic] procedure and [therapeutic] outcomes.”36 In the context of our study, the LT therapeutic process refers to the interactive process among (1) the physical interventions used during the treatment, (2) the respective roles of the therapists and participant and their resulting interpersonal interactions, and (3) the training environment created through these activities and interactions. The qualitative interviews enabled the research team to investigate this process and its potential effect on the behavioral outcome measures in a way that previously has been unreported in locomotor rehabilitation. Studies examining the psychological effects of LT have incorporated quantitative assessments37 and focused interviews,38 but none allows for the illumination of participant-specific therapeutic processes that may frame the broad spectrum of recovery.

The case report format used to discuss the multifaceted evaluation has limited external validity but allows for a detailed evaluation of a single individual. Other participants have shown improvements in the area of walking speed,4 but the individual presented here represents another portion of the heterogeneous population of incomplete SCI that have substantial functional recovery in the absence of quantifiable changes in walking speed. Furthermore, the case study design allowed us to present a detailed model of the factors contributing to his functional improvement. Although this model is specific to this research participant, it presents a detailed analysis of the personal and environmental factors contributing to an individual’s ability to function independently that are often omitted in quantitative research.

The ultimate outcome of independent disposition in the community is cost-effective to the healthcare system through decreased institutionalization and potential reduction in side effects related to extended periods of sitting such as exacerbated heterotopic ossification, recurrent pressure sores, and decreased functional capacity. An organized, collaborative, and expansive research/treatment network is required, incorporating case management, collaborative therapies, and other healthcare providers in order to assist in maximizing a participant’s healthcare status via an understanding the contributing factors as outlined in the ICF rehabilitation model.


This work was supported by Department of Veterans Affairs Rehabilitation Research and Development grant VA RR&D F2182C establishing the Brain Rehabilitation Research Center of Excellence, Malcom Randall VA Medical Center, Gainesville, FL, and NIH/NCMRR grant K01 HD 01348-01.

This material is the result of work supported in part by the Office or Research and Development, Rehabilitation R&D Service, Department of Veterans Affairs, and the Malcom Randall VA Medical Center, Gainesville, FL.


1. National Spinal Cord Injury Statistical Center. Department of Education [Spinal cord injury information network-fact sheet]. Available at: Accessed May 20, 2008.
2. Edgerton VR, Tillakaratne NJ, Bigbee AJ, et al. Plasticity of the spinal neural circuitry after injury. Annu Rev Neurosci. 2004;27:145–167.
3. Behrman AL, Harkema SJ. Locomotor training after human spinal cord injury: a series of case studies. Phys Ther. 2000;80:688–700.
4. Behrman AL, Lawless-Dixon AR, Davis SB, et al. Locomotor training progression and outcomes after incomplete spinal cord injury. Phys Ther. 2005;85:1356–1371.
5. Dobkin B, Apple D, Barbeau H, et al. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. 2006;66:484–493.
6. Barbeau H. Locomotor training in neurorehabilitation: emerging rehabilitation concepts. Neurorehabil Neural Repair. 2003;17:3–11.
7. Dietz V, Harkema SJ. Locomotor activity in spinal cord-injured persons. J Appl Physiol. 2004;96:1954–1960.
8. Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J. Neurol Phys Ther. 2005;29:127–137.
9. Gardner MB, Holden MK, Leikauskas JM, et al. Partial body weight support with treadmill locomotion to improve gait after incomplete spinal cord injury: a single-subject experimental design. Phys Ther. 1998;78:361–374.
10. Protas EJ, Holmes SA, Qureshy H, et al. Supported treadmill ambulation training after spinal cord injury: a pilot study. Arch Phys Med Rehabil. 2001;82:825–831.
11. Perry J, Garrett M, Gronley JK, et al. Classification of walking handicap in the stroke population. Stroke. 1995;26:982–989.
12. Nagi SZ. A study in the evaluation of disability and rehabilitation potential: concepts, methods, and procedures. Am J Public Health Nations Health. 1964;54:1568–1579.
13. International Classification of Functioning, Disability, and Health. Geneva: World Health Organization; 2001.
14. Jette AM. Toward a common language for function, disability, and health. Phys Ther. 2006;86:726–734.
15. Maynard FM Jr, Bracken MB, Creasey G, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord. 1997;35:266–274.
16. VHA Directive 1176-Spinal Cord Injury and Disorders System of Care: Department of Veterans Affairs, May 2, 2005.
17. Edgerton VR, Roy RR, Hodgson JA, et al. A physiological basis for the development of rehabilitative strategies for spinally injured patients. J Am Paraplegia Soc. 1991;14:150–157.
18. Edgerton VR, Leon RD, Harkema SJ, et al. Retraining the injured spinal cord. J Physiol. 2001;533:15–22.
19. Dittuno PL, Dittuno JF Jr. Walking index for spinal cord injury (WISCI II): scale revision. Spinal Cord. 2001;39:654–656.
20. Coleman KL, Smith DG, Boone DA, et al. Step activity monitor: long-term, continuous recording of ambulatory function. J Rehabil Res Dev. 1999;36:8–18.
21. Palombaro KM, Craik RL, Mangione KK, et al. Determining meaningful changes in gait speed after hip fracture. Phys Ther. 2006;86:809–816.
22. Fulk GD, Echternach JL. Test-retest reliability and minimal detectable change of gait speed in individuals undergoing rehabilitation after stroke. J Neurol Phys Ther. 2008;32:8–13.
23. Visintin M, Barbeau H. The effects of body weight support on the locomotor pattern of spastic paretic patients. Can J Neurol Sci. 1989;16:315–325.
24. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992.
25. Perry J. The mechanics of walking in hemiplegia. Clin Orthop Relat Res. 1969;63:23–31.
26. Professional Staff Association of Rancho Los Amigos Medical Center. Observational Gait Analysis Handbook. Downey, CA: Professional Staff Association of Rancho Los Amigos Medical Center; 1989.
27. Silva M, Shepherd EF, Jackson WO, et al. Average patient walking activity approaches 2 million cycles per year: pedometers under-record walking activity. J Arthroplasty. 2002;17:693–697.
28. Bowden MG, Behrman AL. Step activity monitor: accuracy and test-retest reliability in persons with incomplete spinal cord injury. J Rehabil Res Dev. 2007;44:355–362.
29. N6 (Non-numerical unstructured data indexing searching & therorizing) qualitative data analysis program, Version 6.0 [computer program]. Version 6.0. Melbourne, Australia: QSR International Pty Ltd.; 2002.
30. Glaser BG, Strauss AL. The Discovery of Grounded Theory. Strategies for Qualitative Research. Vol 7. New York: Aldine DeGruyter; 1967.
31. Beck AT, Weishaar ME. Cognitive therapy. In: Corsini RJ, Wedding D, eds. Current Psychotherapies. Itsaca: F.E. Peacock; 2005, 238–268.
32. Whiteneck G, Meade MA, Dijkers M, et al. Environmental factors and their role in participation and life satisfaction after spinal cord injury. Arch Phys Med Rehabil. 2004;85:1793–1803.
33. Lidal IB, Veenstra M, Hjeltnes N, et al. Health-related quality of life in persons with long-standing spinal cord injury. Spinal Cord. 2008.
34. Patient-Reported Outcomes Measurement Information System: Dynamic tools to measure health outcomes from the patient perspective. Available at: Accessed May 20, 2008.
35. Patient-Reported Outcomes Measurement Information System: Dynamic tools to measure health outcomes from the patient perspective. Available at: Accessed May 20, 2008.
36. Csordas TJ, Kleinman A. The therapeutic process. In: Sargent CF, Johnson TM, eds. Medical Anthropology: Contemporary Theory and Method (Rev. Ed.). Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc.; 1996:3–20.
37. Hicks AL, Adams MM, Martin Ginis K, et al. Long-term body-weight-supported treadmill training and subsequent follow-up in persons with chronic SCI: effects on functional walking ability and measures of subjective well-being. Spinal Cord. 2005;43:291–298.
38. Nymark J, Deforge D, Barbeau H, et al. Body weight support treadmill gait training in the subacute recovery phase of incomplete spinal cord injury. J Neurol Rehabil. 1998;12:119–138.

ambulation; outcomes; spinal cord injury

© 2008 Neurology Section, APTA