The Importance of Gait Analysis in

Incomplete Spinal Cord Injury Patients

in Field of Neurorehabilitation*
Soraya Prez-Nombela1,**, Antonio Jos del Ama-Espinosa1,
Ana de los Reyes-Guzmn1, ngel Gil-Agudo1,
Francisco Molina-Rueda2, and Diego Torricelli3
1

Biomechanics and Technical Aids Department National Hospital for

Spinal Cord Injury, Toledo, Spain
sperezn@sescam.jccm.es
2
University Rey Juan Carlos, Alcorcn, Spain
3
Bioengineering Group, CSIC, Arganda, Spain

Abstract. The most important aspect in rehabilitation of incomplete spinal cord

injury (SCI) is the possibility to recover walking ability. Lower limbs
exoesqueletons are of increasing importance in neurorehabilitation of SCI patients to
achieve gait with this type of robotic device. The objective of this study was to
analyze the gait from biomechanical point of view to help in describe theoretical and
experimental biomechanicals models for kinematics compatibility with neurorobots
(NR). An experimental protocol was carried out in 9 patients with SCI and 10
control subjects (CG). Data were obtained using a three-dimensional motion
analysis system, two force plates and surface electromyography system. The most
relevant findings involved the knee and ankle, specially in the sagittal plane. This
information is found important for the development of neurorobotic and
neuroprosthetic devices, aimed to design better and tailored neurorehabilitation
strategies.

1 Introduction
The consequence a spinal cord injury is a partial or complete loss of motor,
sensory and autonomic functions below the level of lesion [1]. Trauma to the
spinal cord and interruption of the spinal interneuronal circuits connecting the
brainstem and the supraspinal motor center interfere with several aspects of
normal gait [2]. The physicians who treat acutely injured spinal cord injury
patients have noted that most ask whether they will walk again. It is important,
therefore, to know the probability that an acutely injured patient with incomplete
*

This research is part of the HYPER project funded by CONSOLIDER-INGENIO 2010

CSD2009-00067, Spanish Ministry for Science and Innovation.
**
Corresponding author.
J.L. Pons et al. (Eds.): Converging Clinical & Engi. Research on NR, BIOSYSROB 1, pp. 673677.
DOI: 10.1007/978-3-642-34546-3_109
Springer-Verlag Berlin Heidelberg 2013

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S. Prez-Nombela et al.

tetraplegia will become ambulatory [3]. So, the percentage of subjects who regain
some walking capacity depends strongly on the extent of spinal cord lesion. On
the other way, a number of new therapeutic interventions, such as body-weight
supported locomotor training and robotic technologies aim to improve walking
function and reduce co-morbidities [4].
Gait rehabilitation robots are of increasing importance in neurorehabilitation.
Conventional devices are often criticized because they are limited to reproducing
predefined movement patterns of gait. Robots should support patients only as
much as needed and stimulate them to produce maximal voluntary efforts [5]
Main targets of the HYPER proyect (Hybrid Neuroprosthetic and Neurorobotic
devices for Functional Compensation and Rehabilitation of Motor Disorders) are,
on one hand to speed up the rehabilitation procedures and on the other to improve
the outcome of the therapy using new paradigm and technology [6].
One of work packages of this complex research in neurorehabilitation is
biomechanics. The hybrid development of Neurorobots (NRs) and Neuroprotheses
(NPs) will require biomechanical scientific support to overcome critical issues for
efficiency, safety and dependability. This new concept poses new challenges that
can be answered with Biomechanics assessment. Therefore, the aim of this study is
to assess gait, both healthy and pathological, to identify specific deficits and
movement models to be used for designing new rehabilitation strategies with
hybrid neurorobots.

2 Material Y Methods
Nine patients with incomplete spinal cord injury (SCI) participated at the
experiment and their data were compared with a control group (CG) of 10 subjects
with similar demographic and anthropometric characteristics. The clinical
characteristics are shown in the Table 1.
Table 1 Clinical characteristics of the SCI group
VARIABLE
Sex (men, %)
Age (years)
Level of injury at cervical (%)
Level of injury at dorsal (%)
Level of injury at lumbar (%)

SCI Group (n=9)

5 (56.00)
39.32 (12.76)
5 (56.00)
3 (33.00)
1 (11.00)

We certify that all the participants provided informed consent prior to be

included in this study and the experimental protocol desing was approved by local
ethics committee. The research was carried out in the Biomechanical and
Technical Aids Department of the National Hospital for Spinal Cord Injury
(Toledo, Spain).

The Importance of Gait Analysis in Incomplete SCI Patients

675

Kinematic data were obtained using a three-dimensional motion analysis system

with two scanner units (CODA System.6, Charnwood Dynamics, Ltd, UK). Eleven
active markers were positioned and attached to anatomic landmarks as described
previously [7]. Kinetic data were obtained synchronously using two force platforms
(Kistler Instrument AG, Switzerland) with a sampling frequency of 1000 Hz.
Finally, the electromyography data (EMG) were recorded using 14 channels of
surface electromyography system (Noraxon) with a sampling frequency of 1500
Hz; and the electrodes were positioned as described Cram et al. [8].
All patients with SCI walked with their usual footwear along a 10m walkway at
self-selected speed, while temporal-spatial, kinematics, kinetis and EMG data
were recorded. The controls were registered walking at three different speeds. As
the patients range of speed varied between 0.51 and 0.88 m/s, medium speed
trials of the CG were used to make the comparison. Five valid trials were obtained
for each subject to reduce intrasubject variability. Subjects rested for one minute
between trials to avoid fatigue.
The distribution of samples was analyzed with Kolmogorov-Smirnov test, and
the samples dont shown normal distribution. So we analyzed the differences
between SCI and CG at medium speed using a non-parametric test, U-Mann
Whitney. The differences were considered significant for P less tan 0.05. SPSS for
Windows (v.12.0) were used for the statistical analysis.

3 Results
The kinematics results for the pelvis and hip indicated that statistically significant
differences were not found. But in the more distal joints, there are some
differences between groups.
Figure 1 (a) shows that the knee flexion at the initial contact was significantly
greater (p<0.05) in the SCI group (7.72 3.25) than in the CG at medium speed
(3.77 5.50). It must be noted that the CG showed higher knee range of motion in
the sagittal plane (61.96 4.44) than in SCI group (53.78 14.30).
The ankle dorsalflexion at the initial contact was smaller (p<0.05) in the SCI
group (2.21 5.69) than in the CG at medium speed (8.96 7.38). However, the
maximal plantar-flexion value was greater (p<0.05) in CG (-6.24 9.34 in SCI
group and -12.10 9.62 in CG) and the plantar-flexion was smaller in SCI group
at the instant of the toe-off (-1.95 12.14 in SCI group and -11.56 7.92 in CG).
See Figure 2 (a).
In the same way, the kinetic parameters begin to appear differences in the distal
joints of the lower limbs. It was found that the maximal external rotation moment
of the knee was lower (p<0.05) in the SCI group (0.10 0.06) than in CG (0.15
0.07) at medium speed (Figure 1(b)).
In the ankle joint, it was obtained that all the moments of the sagittal plane
were greater in the CG at medium speed. (Figure 2(b)) These findings of the ankle
joint could be due to the ankle power generation was also lower in the SCI group
(p<0.05) (Figure 2(c)).

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S. Prez-Nombela et al.

(b

(a)

Fig. 1 (a) Kinematic curve in the sagittal plane for the Knee. Positive values indicated
flexion. Grey line shows CG at medium speed and black line the SCI group. (b) Kinetic
rotation moment. Positive values indicated external rotation mment.
(a)

(b)

(c)

Fig. 2 (a) Kinematic curve in sagittal plane for the ankle. Positive values indicated
dorsiflexion. Grey line represents CG at medium speed and black line the SCI group. (b)
Ankle plantarflexor moment. Positive values indicated plantarflexion moment. (c) Sagittal
plane of power of the ankle joint. Positive values indicated power generation.

EMG outcomes vary greatly between subjects; probably, due to this variability,
only we found statistically significant differences in the zero crossing variable, in
the medial and lateral hamstrings and tibialis anterior muscles was greater in SCI
group (p<0.05). This parameter is related to muscle strength, so this fact indicate
that SCI group have to do slightly more strength with these muscles.

4 Conclusions
The most remarkable walking differences between patients with incomplete SCI
and CG were found in the knee and ankle joints. Reduced knee flexion during
swing phase combined with a peak of plantarflexion after toe-off can lead to a
insufficient toe-clearance. Furthermore, ankle joint moment and power at toe-off

The Importance of Gait Analysis in Incomplete SCI Patients

677

are greatly reduced compared to healthy subjects, which also impairs walking
progression, affecting step length and walking velocity. Regarding hip actuation,
this population does not apparently need intervention.
Therefore neurorehabilitation therapies for this population must be targeted
towards a functional compensation or re-education of the maximal flexion of the
knee during swing phase combined with a reduction of ankle plantarflexion after
the toe-off. Another objective of the neurorehabilitation must be increase user
ability to generate ankle plantarflexion moment, either by reducing dorsalflexion
muscle spasticity or potentiating plantarflexion muscle force.
In conclusion design of future neurorobotic devices for rehabilitation of
incomplete SCI patients should provide motor control in cuadriceps, triceps surae
and pretibialis muscles in order to provide knee stability during stand phase of
gait, reduce plantarflexion after toe-off, and increase knee flexion during swing
phase.
This article has shown how biomechanical gait analysis can be used to assess
the specific functional deficits within a population of SCI patients, directed to
design better and tailored neurorehabilitation strategies with neuroprosthesis and
neurorobots.

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