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Background and Purpose:Walking in the home and community is an important goal for individuals with incomplete spinal cord injury (iSCI). Walking in the community requires various skills, such as negotiating curbs, doors, and uneven terrain. This case report describes the use of a method to retrain walking overground that is intensive, variable, and relevant to daily walking (skill training). The aims of this case series were to determine the effectiveness of skill training in a small group of people with iSCI and to compare skill training with body-weight–supported treadmill training (BWSTT) in the same individuals.Case Description:Four individuals who were a median of 2.7 years (interquartile range [IQR]=12.8) after iSCI participated in alternating phases of intervention, each 3 months long. All patients started with BWSTT. Two patients subsequently engaged in skill training while the other 2 patients engaged in BWSTT, after which a third phase of intervention (opposite to the second) was repeated.Outcomes:The Modified Emory Functional Ambulation Profile, the 10-Meter Walk Test, the 6-Minute Walk Test, the Berg Balance Scale, and the Activities-specific Balance Confidence Scale were administered before training, monthly throughout training, and 3 months after training.Discussion:Overall improvements in walking speed met or exceeded the minimal clinically important difference for individuals with iSCI (≥0.05 m/s), particularly during the skill training phase (skill training: median=0.09 m/s, IQR=0.13; BWSTT: median=0.01 m/s, IQR=0.07). Walking endurance, obstacle clearance, and stair climbing also improved with both types of intervention. Three of the 4 patients had retained their gains at follow-up (retention of walking speed: median=92%, IQR=63%). Thus, the findings suggest that skill training was effective in this small group of individuals.

Walking ability is a measure of recovery used in many studies that test experimental strategies to treat injuries or diseases of the central nervous system (CNS) in animal models. A common measure in the rat animal model of thoracic spinal cord injury (SCI) is visual inspection and scoring of hind limb activity, which allows the documentation of movements associated with the recovery of locomotor function. In this study, we expand on previously documented visible changes in the locomotor pattern following SCI. The spontaneous recovery of locomotion in rats with thoracic SCIs of variable extent was evaluated using electromyographic (EMG) and kinematic analysis while rats walked on an elevated runway. Comparisons with pre-lesion walking sequences revealed changes in the kinematics and in the muscle activation pattern of various muscles, including enhanced fore limb extensor activity, possibly reflecting an increased contribution to propulsion, altered recruitment of back muscles inserting into the hip (possibly to support stepping movements), and elevated posture during stance, which may compensate for deficits in weight support. These changes were noted in spinal cord injured rats with varying degrees of impairment, including animals with no visually detectable deficit in open-field walking. In summary, the presented results demonstrate that spinal cord injured rats develop alternative locomotor patterns following SCI that cannot be discriminated by the use of qualitative visually based analysis, thus urging the use of quantitative outcome measures in assessing motor function after SCI.

1To quantify the importance of reflexes due to muscle length changes in generating force during walking, we studied high decerebrate cats that walked on a treadmill. One leg was denervated except for the triceps surae and a few other selected muscles. The triceps surae muscles are ankle extensor muscles that attach to the Achilles' tendon which was cut and connected to a muscle puller. In some steps the EMG activity triggered the puller to move the muscle through the pattern of length changes that are normally produced by ankle movements in intact cats walking over ground (simulated walking). In other steps the muscles were held isometrically. The EMG and force produced during the two types of steps were compared. On average about 50% more EMG was generated during the E2 part of the simulated stance phase in the triceps surae muscles, but not in other muscles studied.2Force was increased significantly over the entire stance phase by about 20%, when muscle stretches simulating walking were applied. However, during much of the stance phase the triceps surae muscles are shortening and so would produce less force. The effect of shortening was assessed in control experiments in which these muscles were stimulated at a constant frequency, either isometrically or during simulated walking movements.3By combining data from the walking and control experiments, we estimate that about 35 % of the force produced in the cat ankle extensors during stance is produced by reflexes due to muscle length changes. Other sensory inputs may also contribute to force production, but the total reflex contribution will vary under different conditions of speed, length, loading, task difficulty, etc. Since a substantial percentage of the force in the stance phase of walking is normally produced by muscle reflexes, this force can be continuously adjusted up or down, if the muscles receive extra stretch or unloading during a particular step cycle.

Percussion of the quadriceps tendon was used to test the hypothesis that knee extensor muscle spindle discharge initiates down-regulation of the gain of the soleus H reflex. Seven subjects participated. Soleus H reflex magnitude was observed for up to 15 s, following conditioning tendon taps of 60 N or 80 N force and 10 ms or 100 ms duration, with the knee at 60° or 90° of flexion. The tap elicited quadriceps stretch reflexes in four subjects, with a mean latency of 42 ms. The major component of the conditioning of the soleus H reflex was significant attenuation of magnitude by 30–90% of controls, starting as early as 36 ms post-percussion and lasting as long as 3–8 s. The attenuation of reflex magnitude was evident, whichever combination of duration and force of tap was used. Preceding and/or following this inhibition, there was mild facilitation. Static stretch of quadriceps also significantly reduced soleus H reflex magnitude. These results support the spindle receptor origin for the gain attenuation seen during movement. The time course of the gain attenuation suggests a spinal route, by which the spindle discharge of the heteronymous extensor muscles initiates presynaptic inhibition of transmission through the reflex pathway.

Passive locomotor-like movement induces depression of the gain of a fast conducting spinal sensorimotor path in humans. It was hypothesized that this gain control is mediated through a spinal circuit. In the first experiment, passive pedalling motion was rapidly initiated in eight able bodied subjects. Soleus H-reflexes (used to reveal the gain of the short latency stretch reflex) were recorded over the first 250 ms after the movement started. Significant depression in H-reflex magnitude was observed by 50 ms after the onset of movement. On the basis of the timing, this gain attenuation was likely mediated through a spinal circuit. In a second experiment we tested chronic quadriplegics with clinically complete lesions of the spinal cord. Of five subjects tested, three expressed the reflex and all three showed significant inhibition with passive pedalling movement (mean depression was to 39% of controls). Both the rapid onset of the gain change (Expt. 1) and the presence of movement-induced inhibition in individuals with spinal lesions (Expt. 2) provide evidence that this component of human locomotor control is located in the spinal cord. The initiating source is probably somatosensory receptor discharge due to the movement.

Human soleus H reflexes are attenuated during passive pedalling movements. This depression occurs within 70 ms of movement onset. We hypothesized that the reflex gain would return to control values with a similar brevity following movement. However, H reflexes sampled following a slow (10 rpm) passive pedalling movement of a single leg remained below control values for the duration of a 200 ms collection period, for all four pedal positions tested. The extent of the attenuation after movement was position dependent in a manner similar to that observed during movement. This position effect was more precisely defined by sampling reflexes 200 ms post-movement at 10 pedal crank positions. Also, the full course of reflex recovery was investigated by sampling up to 8 s post-movement at four pedal positions. Reflex gain remained reduced 1–4 s post-movement, in a position dependent manner. There was a subsequent facilitation of the reflex. Thus, following a locomotor-like movement there is sustained attenuation of the soleus H reflex. The early post-movement period is likely the continued expression of movement-induced reflex inhibition while the later period may arise from descending influences consequent to the termination of movement. Presynaptic inhibition is implicated, as reflexes still showed the gain modulation when sampled while soleus was tonically contracted, both following and during the passive movement.

The presumption that the H reflex arises exclusively from la afferent discharge has been challenged. If the reflex is comprised of many afferent responses, then movement-induced H reflex inhibition witnessed at one point in the recruitment curve may be quite different from the inhibition at another point in the curve. H reflex recruitment curves were constructed for three subjects during passive pedalling, isolated knee rotation and isolated hip rotation. Compared to control recruitment curves, these curves were reduced across the full spectrum of stimulus intensities. This suggests one of two possibilities: (1) all afferents contributing to the H reflex are subject to the same source and modality of inhibition; or (2) there is only one afferent type contributing to the reflex.

Misiaszek, John E. and Keir G. Pearson.Stretch of quadriceps inhibits the soleus H reflex during locomotion in decerebrate cats. J. Neurophysiol.78: 2975–2984, 1997. Previously, it has been demonstrated that afferent signals from the quadriceps muscles can suppress H reflexes in humans during passive movements of the leg. To establish whether afferent input from quadriceps contributes to the modulation of the soleus H reflex during locomotion, the soleus H reflex was conditioned with stretches of the quadriceps muscle during bouts of spontaneous treadmill locomotion in decerebrate cats. We hypothesized that 1) in the absence of locomotion such conditioning would lead to suppression of the soleus H reflex and 2) this would be retained during periods of locomotor activity. In the absence of locomotion, slow sinusoidal stretches (0.2 Hz, 8 mm) of quadriceps cyclically modulated the amplitude of the soleus H reflex. The H reflex amplitude was least during the lengthening of the quadriceps and greatest as quadriceps shortened. Further, low-amplitude vibrations (48–78 μm) applied to the patellar tendon suppressed the reflex, indicating that the muscle spindle primaries were the receptor eliciting the effect. During bouts of locomotion, ramp stretches of quadriceps were applied during the extensor phase of the locomotor rhythm. Soleus H reflexes sampled at two points during the stance phase were reduced compared with phase-matched controls. The background level of the soleus electromyographic activity was not influenced by the applied stretches to quadriceps, either during locomotion or in the absence of locomotion. This indicates that the excitability of the soleus motoneuron pool was not influenced by the stretching of quadriceps, and that the inhibition of the soleus H reflex is due to presynaptic inhibition. We conclude that group Ia afferent feedback from quadriceps contributes to the regulation of the soleus H reflex during the stance phase of locomotion in decerebrate cats. This afferent mediated source of regulation of the H reflex, or monosynaptic stretch reflex, would allow for rapid alterations in reflex gain according to the dynamic needs of the animal. During early stance, this source of regulation might suppress the soleus stretch reflex to allow adequate yielding at the ankle and facilitate the movement of the body over the foot.