Incomplete SCI Research Articles

Comparison of the effects of complete and incomplete spinal cord injury on lower urinary tract function as evaluated in unanesthetized rats

In rats, phasic external urethral sphincter (EUS) activity (bursting) is postulated to be crucial for efficient voiding. This has been reported to be lost after spinal cord transection (txSCI), contributing to impaired function. However, anesthesia may confound evaluating EUS activity. We therefore evaluated urodynamic parameters in unanesthetized, restrained rats and compared the effects of txSCI to that of a clinically relevant, incomplete, contusive injury (iSCI) on lower urinary tract function. Adult female rats were subjected to txSCI or standardized iSCI at the T8 vertebral level. As expected, all injured rats were initially unable to void but developed a reflex bladder with time, with iSCI rats recovering more rapidly than txSCI rats. LUT function was evaluated urodynamically at 2 and 6 weeks after injury. In response to infusion of saline into the bladder, controls consistently exhibited coordinated contraction of the bladder and activation of the EUS in a phasic pattern and had a high voiding efficiency (86.4 ± 2.5%). Voiding efficiency of iSCI rats was reduced to approximately 57% and txSCI rats to approximately 32%. However, two different patterns of EUS activity during voiding were present in both txSCI and iSCI groups at both time points: (1) rats with phasic EUS activity, similar to controls and (2) those that only exhibited tonic EUS activity during voiding. The former had more normal voiding efficiencies. Thus, phasic EUS activity and the improved voiding efficiency associated with it can occur and can be detected in unanesthetized rats after both incomplete and complete SCI.

The amplitude of lower leg motor evoked potentials is a reliable measure when controlled for torque and motor task

Motor evoked potential (MEP) amplitudes have the disadvantage of a high variability when repeatedly assessed. This affects the reliability of MEP amplitude measurements taken during the course of motor incomplete spinal cord injury (iSCI). The study investigated the reliability of anterior tibial (TA) MEP measures controlled for dorsal flexion torque and motor task. TA MEPs were recorded at 10, 20, 40 and 60% of maximal voluntary contraction (MVC) during a static and dynamic (isometric increase of dorsal flexion torque) motor task. To determine reliability, 20 healthy and five chronic iSCI subjects were tested twice (> or =7 days) by the same investigator. Intraclass correlation coefficients (ICCs) were calculated. MEP amplitudes and latencies were compared between 20 healthy and 29 iSCI subjects. The reliability of MEP amplitude was in general good (ICC > or = 0.52) and was highest during the static task at 40% MVC (ICC = 0.77). The increased facilitation by the dynamic motor task showed the best reliability at 20% MVC (ICC = 0.48). The reliability was good to excellent for MEP latency (0.46 < or = ICC < or = 0.81), MVC (ICC > or = 0.90) and for the TMS threshold required to evoke a MEP response (ICC > or = 0.77). The torque generated by the MEP response ()0.02 < or = ICC < or = 0.55) and the duration of the silent period (0.07 < or = ICC < or = 0.50) were not reliable. Both MEP amplitudes and latencies differed significantly between healthy and iSCI subjects. Controlling for torque generation and motor task establishes a reliability of TA MEP amplitudes that is sufficient for longitudinal assessments in motor incomplete SCI.

The Evolution of Walking-Related Outcomes Over the First 12 Weeks of Rehabilitation for Incomplete Traumatic Spinal Cord Injury: The Multicenter Randomized Spinal Cord Injury Locomotor Trial

Background. The Spinal Cord Injury Locomotor Trial (SCILT) compared 12 weeks of step training with body weight support on a treadmill (BWSTT) that included overground practice to a defined but more conventional overground mobility intervention (CONT) in patients with incomplete traumatic SCI within 8 weeks of onset. No previous studies have reported walking-related outcomes during rehabilitation. Methods. This single-blinded, randomized trial entered 107 American Spinal Injury Association (ASIA) C and D patients and 38 ASIA B patients with lesions between C5 and L3 who were unable to walk on admission for rehabilitation. The Functional Independence Measure (FIM-L) for walking, 15-m walking speed, and lower extremity motor score (LEMS) were collected every 2 weeks. Results. No significant differences were found at entry and during the treatment phase (12-week mean FIM-L = 5, velocity = 0.8 m/s, LEMS = 35, distance walked in 6 min = 250 m). Combining the 2 arms, a FIM-L ≥ 4 was achieved in < 10% of ASIA B patients, 92% of ASIA C patients, and all of ASIA D patients. Walking speed of ≥ 0.6 m/s correlated with a LEMS near 40 or higher. Conclusions. Few ASIA B and most ASIA C and D patients achieved functional walking ability by the end of 12 weeks of BWSTT and CONT, consistent with the primary outcome data at 6 months. Walking-related measures assessed at 2-week intervals reveal that time after SCI is an important variable for entering patients into a trial with mobility outcomes. By about 6 weeks after entry, most patients who will recover have improved their FIM-L to >3 and are improving in walking speed. Future trials may reduce the number needed to treat by entering patients with FIM-L < 4 at > 8 weeks after onset if still graded ASIA B and at > 12 weeks if still ASIA C.

PR_266: Nephrogenic Fibrosing Dermopathy in a Patient With T6-Level Incomplete Spinal Cord Injury due to Epidural Abscess: A Case Report

Setting: University-affiliated, freestanding rehabilitation hospital. Patient: Patient with T6 incomplete SCI due to epidural abscess. Case Description: A 63-year-old white man had severe low back pain, lower-extremity weakness, and dysuria. Magnetic resonance imaging revealed an epidural abscess that was drained via T9-L2 laminectomy. Complications included acute renal failure requiring hemodialysis, re-exploration of his laminectomy site, and development of swelling and stiffness of all limbs, rendering him totally dependent.

Up-regulation of 5-HT 2 receptors is involved in the increased H-reflex amplitude after contusive spinal cord injury

The amplitude of the H-reflex increases chronically after incomplete SCI and is associated with the development of exaggerated hindlimb reflexes. Although the mechanism for this increased H-reflex is not clear, previous studies have shown that pharmacological activation of the 5-HT 2 receptors (5-HT 2R) can potentiate the monosynaptic reflex. This study tested the hypothesis that increased expression of 5-HT 2R on motoneurons is involved in increased H-reflex amplitude after a standardized clinically relevant contusive SCI. Adult female rats were subjected to contusion, complete surgical transection, or a T8 laminectomy only. At 4 weeks after surgery, H-reflex recordings from the hindpaw plantar muscles of contused rats showed twice the amplitude of that in laminectomy controls or transected rats. To probe the role of 5-HT 2R in this increased amplitude, dose–response studies were done with the selective antagonists mianserin or LY53857 and the 5-HT 2R agonist (±)-1-(2,5-Dimethoxy-4-iodophenyl)-2-aminopropane hydrochloride (DOI). The drugs were intrathecally infused into the lumbar cord while recording the H-reflex. Mianserin did not have any significant effects on the H-reflex after transection, consistent with the loss of distal serotonergic innervation. After contusion, both 5-HT 2R antagonists reduced the H-reflex reflex amplitude with a significantly higher ID 50 compared to the uninjured controls. The 5-HT 2R agonist DOI significantly increased reflex amplitude in contused but not control rats. Furthermore, while 5-HT immunoreactivity was similar, contused rats displayed increased 5-HT 2AR immunoreactivity in plantar muscle motoneurons compared to uninjured controls. We conclude that increased expression of 5-HT 2R is likely to be involved in the enhanced H-reflex that develops after contusive SCI.

Impaired scaling of responses to vestibular stimulation in incomplete SCI

Patients with incomplete spinal cord injury (iSCI) have impaired postural control leading to a high danger of falling. Clinically, it is impossible to assess the extent to which postural instability due to sensorimotor deficit is influenced by a disturbance in the vestibulospinal pathways. Galvanic vestibular stimulation (GVS) was applied to investigate changes in the vestibular spinal responses and their potential influence on postural stability in iSCI patients. Six chronic iSCI patients and age-matched controls were stimulated with a bipolar binaural stimulus. The centre of pressure (CoP) and soleus EMG responses during free standing with closed eyes on firm and compliant ground were measured. The impairment in postural stability was assessed by the mean amplitude of CoP deflections during two minutes undisturbed standing. Although iSCI patients were significantly less stable than controls, direct GVS responses of the soleus EMG and postural sways tended to be increased on firm ground. The GVS responses increased when changing from firm to compliant ground, showing a close correlation between the extent of postural instability and the response amplitudes. Therefore, challenging proprioceptive feedback induced a significant up-modulation of the GVS responses. However, when we took the postural instability in iSCI patients into account, the EMG and CoP responses to GVS were reduced compared to controls. The combined assessment of EMG and CoP responses to GVS complements the clinical examination and permits evaluation of the preservation and modulation of vestibulospinal responses in iSCI.

Diagnosis and treatment for the injury of cervical disc and longitudinal ligament

To study the diagnosis and treatment for the injury of cervical disc and longitudinal ligament. From 2001 to 2005, the clinical data of sixty-three patients with cervical disc and longitudinal ligament injury were studied. Early treatment was done based on spinal cord injuries and spinal stabilities by X rays and MRI. Early operation was done in fifty-four cases and early non-operation in nine cases. The follow-up time was six to forty-one months in all patients. The neurological recovery was found in two of eight complete SCI post-operation, thirty-one in thirty-nine incomplete SCI. Cervical collar or plaster orthotic were used in nine cases with four to six weeks. Evidence of instability was noted in four patients, who were operated with anterior decompression fusion. Neck chronic pain was found in two patients, anterior decompression and fusion was done in one with cervical spinal cord compression. MRI examination is the most value measure for the diagnosis of cervical disc and longitudinal ligament injury. Early anterior decompression and fusion was an important approach for cervical disc and longitudinal ligament injury.

Skeletal Muscle Morphology after Incomplete Spinal Cord Injury

PURPOSE: The purpose of this study was to 1) quantify skeletal muscle size in lower extremity muscles in persons after incomplete spinal cord injury (i-SCI) 2) assess differences in muscle size between involved lower limbs, 3) determine the impact of ambulatory status (using wheelchair (W/C group) versus not using wheelchair for mobility) on muscle size after i-SCI, 4) determine if differential atrophy occurs among individual muscles after i-SCI. METHODS: Seventeen persons with i-SCI and 17 age, gender, weight and height matched non-injured controls participated in the study. Three-dimensional trans-axial images of the more lower limb were collected in a 1.5T magnet using an extremity or body coil. Maximal cross sectional area (CSA) of the lower extremity muscles [soleus (SOL), medial gastrocnemius (MG), lateral gastrocnemius (LG), tibialis anterior (TA), quadriceps femoris (QF) and hamstrings (HAMS)] were calculated using custom designed software. Independent t-tests were used to compare CSA values of the i-SCI and control groups. Paired t-tests were used to compare the more and less involved limbs of the i-SCI group. Non-parametric tests were used to compare CSAs of the W/C and non-W/C groups. RESULTS: Persons with incomplete SCI had significantly lower muscle CSA values in all muscles tested [range = 24% – 31%]. Significantly lower muscle CSA values were also observed in both the W/C [range = 21% – 39%] and non-W/C groups [range = 24% – 38%] compared to controls. The TA and HAMS muscles in the W/C group and MG in non-W/C group did not show any differences compared to controls. The W/C group exhibited significantly greater plantar flexor atrophy than the non-W/C group [p<0.05], with maximum atrophy in the MG [39%, p<0.05]. CONCLUSIONS: Our results suggest marked and differential atrophic response of the affected lower extremity muscles that is seemingly impacted by ambulatory status in persons with incomplete-SCI.

Lower Urinary Tract Dysfunction in Ambulatory Patients With Incomplete Spinal Cord Injury

We evaluated urinary tract dysfunction in individuals with spinal injury who remained able to ambulate. We observed changes with time in urological management. All patients attending outpatient clinics with traumatic, incomplete (American Spinal Injury Association grades D and E) spinal cord injury during a 2-year period were identified. All patients had their hospital notes reviewed retrospectively and salient urological data extracted. A total of 43 men and 21 women were identified during this period. Mean age was 46 years (range 18 to 70). Mean followup was 7 years (range 1 to 18). At the time of inpatient discharge 40 of the 64 patients (62.5%) could void spontaneously, 20 required CSIC and 4 had a suprapubic catheter. In 19 of these 40 patients (47.5%) who had been initially assessed as having a bladder that was safe to void spontaneously the condition deteriorated, such that CSIC was required. Conversely 5 of 20 patients (25%) who initially required CSIC improved, such that it became redundant. At last followup 68.7% of the patients had abnormal urodynamics and 24 of the 64 (37.5%) required a change in urological management despite no appreciably detectable neurological change. Despite relatively near total neurological recovery patients with incomplete SCI have neuropathic bladder unless proved otherwise. Salient deterioration in bladder dysfunction is not uncommon. Regular urological monitoring and appropriate treatment changes are required in the long term.

Pathologic Extremity Fracture Care in Spinal Cord Injury

Fracture management in chronic SCI can be summarized by the following principles. Fractures in the upper extremity and in incomplete SCI are treated by standard orthopedic guidelines. Nondisplaced femoral neck fractures require cannulated screw fixation, whereas displaced fractures require an endoprosthesis. Nondisplaced intertrochanteric and subtrochanteric hip fractures may be treated nonoperatively in the elderly or medically ill, but those who require mobilization and a predictable outcome require intramedullary hip screw (IMHS) fixation. Femoral shaft and displaced tibia shaft fractures require intramedullary locked nails. Most periarticular knee fractures may be managed by nonoperative splinting. Nondisplaced fractures of the tibia and below are treated by nonoperative means.

Analysis of sEMG during voluntary movement-part II: voluntary response index sensitivity

In this paper, a method for analyzing surface electromyographic (sEMG) data recorded from the lower-limb muscles of incomplete spinal-cord injured (iSCI) subjects is evaluated. sEMG was recorded bilaterally from quadriceps, adductor, hamstring, tibialis anterior, and triceps surae muscles during voluntary ankle dorsiflexion performed in the supine position as part of a comprehensive motor control assessment protocol. Analysis of the sEMG centered on two features, the magnitude of activation and the degree of similarity [similarity index (SI)] of the sEMG distribution to that of healthy subjects performing the same maneuver (n = 10). The analysis calculations resulted in response vectors (RV) that were compared to healthy-subject-derived prototype response vectors resulting in a voluntary response index (VRI). Incomplete SCI subjects (n = 9) were used to test the sensitivity of this analysis method. They were given supported-weight treadmill ambulation training, which is expected to improve or at least not cause a deterioration of voluntary motor control. The VRI provided evidence that the quantitative sEMG analysis method used was able to differentiate between healthy subjects and those with iSCI, characterize individual differences among iSCI subjects, and track motor control changes occurring over time.

Specific aspects of erectile dysfunction in spinal cord injury

According to preliminary studies, the overall incidence of spinal cord injury (SCI; traumatic and medical) in Spain is estimated to be between 12 and 20 per million inhabitants, and almost 80% of these injuries occur in young men. SCI causes organic changes in men leading to erectile dysfunction (ED), impaired ejaculation, and changes in genital orgasmic perception. A vast majority of men with both complete and incomplete SCI will require treatment for ED, and the therapeutic options should include sexual counseling so that the patient can be informed about his disorder and can adjust his sexual behavior accordingly. The first-line treatment of choice is oral drugs, such as phosphodiesterase inhibitors (sildenafil, tadalafil, and vardenafil). Sildenafil has been shown to be highly effective and well tolerated in men with ED of various etiologies, including SCI. Data are also presented on sublingual apomorphine, which has limited indications for the treatment of ED in SCI, and on constrictive rings and vacuum systems. Second-line treatments include intracavernous injections of prostaglandin E(1), papaverine, and phentolamine, alone or in combination, which have been shown to be highly effective in the treatment of ED in men with SCI. Finally, for third-line treatments, the indications for surgical methods are given, including penile prostheses and neuroprosthesis of anterior sacral roots. These devices should be reserved for the cases when the above-mentioned methods have repeatedly failed. Historically, the treatment of ED among patients with SCI has been managed by clinicians in physical medicine and rehabilitation. Thus, the criteria for referral and the competencies of these specialists are established, and they should be included as an integral part of the rehabilitation program.

Transcutaneous functional electrical stimulation for grasping in subjects with cervical spinal cord injury

Case series. To evaluate the benefit, shortcomings and acceptance of a new transcutaneous functional electrical stimulation (FES) technology aimed at improving the grasp function in tetraplegic subjects in acute and postacute rehabilitation. Spinal cord injury (SCI) centre, university hospital. : Subjects (N=11) with complete or incomplete SCI at C4/5-C7 who started FES 1-67 months after their accident were included. Hand function tests, analysis of video recordings and of written documentation of FES sessions, status of muscle strength, and follow-up query were used as outcome measures. Nine subjects used FES as a neuroprosthesis. Eight demonstrated improved grasp function and performance in activities of daily living. In one subject, no benefit from FES was observed. Two other subjects showed improvements in muscle strength and facilitation of active movement with FES. Four subjects successfully integrated FES as neuroprosthesis in everyday life within the rehabilitation centre. Three received the system for home use. The most relevant reasons for stopping the FES application were: (i) improvement of voluntary grasp function, (ii) physical and psychological problems, (iii) no available stimulator for home use, and (iv) insufficient assistance for electrode placement at home. Shortcomings related to the transcutaneous surface technology (eg pain or coactivation of neighbouring muscles) could usually be reduced, or did not limit the efficiency or acceptance of FES. Individually designed digital or analogue control devices were preferred. Tetraplegic subjects in acute and postacute rehabilitation can profit from a new transcutaneous FES system with respect to functional use and independence. It can be implemented in the rehabilitation programme for muscle strengthening and facilitation of voluntary activity. For a successful application of FES, there is a need for individual electrode placement, stimulation programmes, and FES control devices.

Case for gait analysis as part of the management of incomplete spinal cord injury.

Incomplete spinal cord injury at ASIA (D) level often leads to major gait re-education attempts for patients and staff. Walking prognosis usually depends upon muscle power loss, degree of spasticity present, type of lower limb joint deformity developing and availability of treatment. As an adjunct to physical examination and observation, instrumented gait analysis can inform treatment, since three-dimensional dynamic joint range motion (kinematics) and estimation of joint forces occurring at the hip, knee and especially ankle/foot (kinetics) can be combined with walking EMG and energy cost tests to understand fully a gait deficit. This should then assist the clinical decision-making process. Knowledge of the effects of any dynamic contracture on the available redundancy within ipsilateral limb joints, and information about muscle actions obtained by calculating joint forces (including moments and powers) improves overall knowledge of gait cycle abnormality. Such gait analysis has revolutionised the management of spasticity in walking cerebral palsy children by guiding surgical and other treatments. Similar improvements could be looked for in incomplete SCI patients whose gait pattern is not ideal. Dynamic energy cost estimations could also be used as an outcome measure to study improvements after treatment: whether this is orthotic, pharmacological or following physiotherapy or surgical techniques.

A pilot study of myoelectrically controlled FES of upper extremity.

Functional electrical stimulation (FES) of upper limbs can be used for the recovery of some hand functions on patients with CNS lesions. This study deals with the control of FES by means of myoelectrical activity detected from voluntarily activated paretic muscles. The specific aim of this paper is to evaluate the accuracy of myoelectrical control in terms of produced force and movement. For this purpose, a specific device called myoelectrical controlled functional electrical stimulator (MeCFES) has been developed and applied to six tetraplegic patients with a spinal cord lesion and one stroke hemiplegic patient. Residual myoelectric signals from the paretic wrist extensor (m. extensor carpi radialis, ECR) have been used to control stimulation of either the wrist extension (i.e., the same muscle) or thumb flexion. A tracking test based on a visual feedback of the produced force or movement compared to a reference target trajectory was used to quantify control accuracy. A comparison was made between the tracking performances of each subject with and without the MeCFES and the learning process for two of the subjects were observed during consecutive sessions. Results showed that the wrist extension was improved in three out of five C5 SCI patients and the thumb flexion was largely increased in one incomplete C3 SCI patient. The hemiplegic patient showed limited thumb control with the MeCFES but indicated the possibility of a carry over effect. It was found that a low residual natural force resulted in a less accurate movement but also with a large increase (up to ten times) of the muscle output. On the contrary, persons with a medium residual force obtained a smaller amplification of muscle force with a higher tracking accuracy.

Neural Injury and Recovery of the Thoracolumbar Spine Fractures

For evaluation of neural injury from the thoracolumbar spine fracture, we should know the type and extent of injury. In case of the complete Spinal Cord Injury( SCI Frankel classification A), they will not only lose the spinal cord function permanently distal to the injury site, but also show the probability 0~9% from Frankel A to D or E. But in case of the incomplete SCI, they will show sacral sparing and some kind of function will be recovered. The anticipation of recovery from the SCI depend on the results of neurologic examination after the spinal shock. If they have motor sparing, 86% of patients show the recovery of motor function during the first 6 month. The factor that influence to neurologic recovery are the initial kyphosis angle and canal compromising pattern, and do not influenced by treatmet methods.

Inter-rater reliability of the 1992 international standards for neurological and functional classification of incomplete spinal cord injury.

To determine the inter-rater reliability in scoring sensory and motor function and in defining sensory and motor levels in incomplete spinal cord injury, using the revised 1992 International Standards for Neurological and Functional Classification of Spinal Cord Injury (ISCSCI-92) and to determine the effect on raters agreement of one standardising assessment. Two physicians and two physiotherapists at the Spinal Cord Injury Unit, Karolinska Hospital, classified 23 patients according to the ISCSCI-92. Kappa values were calculated. Kappa values varied from 0 to 0.83 (poor to very good) for the pin-prick scores, from 0 to 1 for the light touch scores and from 0 to 0.89 for motor function after the standardising assessment. Kappa values for sensory and motor levels were fair to poor after the standardising assessment. The results showed improvement in degree of agreement in 35/46 dermatomes for scoring pin-prick, in 15/42 for light touch, in 14/19 segments for motor function and for three out of four sensory and motor levels. This study indicates a weak inter-rater reliability for scoring incomplete SCI lesions using the ISCSCI-92.

球海綿体反射を用いた横紋筋性尿道括約筋の筋電図学的研究

The change of sacral reflex activity of the striated urethral sphincter in the urine storage phase is investigated using evoked potential reaction of the bulbocavernosus reflex (BCR). Eleven normal male subjects and 13 male patients with neurogenic bladder due to suprasacral (C3-C7) spinal cord injury (SCI patients) were investigated. Within the SCI patients, five were complete SCI and 8 were incomplete SCI. BCR was elicited by electrical stimulation of dorsal nerve of the penis, and the evoked potential of the BCR was recorded with a concentric needle electrode from the periurethral striated muscle. BCR was performed both at empty and at filled bladder respectively, and changes of the amplitudes (AMP) were examined. Moreover, the changes of AMP affected by bladder filling were compared between the normal subjects and the SCI patients. In both the normal subjects and the SCI patients, AMP increased at the filled bladder as compared with that of the empty bladder. In addition, the change of AMP was statistically bigger in the SCI patients (a ratio of amplitude at filled bladder/amplitude at empty bladder: 4.73 +/- 3.90) than in the normal subjects (the ratio: 1.32 +/- 0.44). Sacral reflex activity was accelerated by bladder filling in both the normal subjects and SCI patients. And the acceleration in the SCI patients was more remarkable than that in the normal subjects. In addition to the conventional evaluation of the integrity of sacral reflex arc by BCR examination, the observation of changes of BCR affected by bladder filling may provide the information for the continuity of sacral segment and supraspinal micturition center.

The effect of treadmill gait training on low-frequency depression of the soleus H-reflex: comparison of a spinal cord injured man to normal subjects

H-Reflex recruitment curves were obtained at 0.1 and 1 Hz in the right soleus of an incomplete SCI man before and after training and on 12 neurologically normal individuals. Low frequency depression (LFD) was calculated by the formula: 1−(H-wave amplitude at 1 Hz/0.1 Hz)×100. Training consisted of treadmill walking at the speed matching his overground fast walking. The subject trained for 30 min every other day for 10 days under supervision and then continued three times a week for 4 months at a health club. Maximum H/M ratio of the right soleus (78%) was greater than that of the normals (67%) and did not change following training (79%). The mean LFD of the SCI subject was 24% prior to training compared to 42% for the normal subjects. Following training, LFD increased to 35%. In addition, the reflex threshold appears to have increased following training. This was accompanied by 47 and 45% increases in the subject's self selected and fast gait velocities, respectively. We conclude that training adaptations enabled the SCI subject to increase his gait velocity due to an improved ability to gate peripheral afferent feedback during gait.

Significance of FES-assisted plantarflexion during walking of incomplete SCI subjects

Abstract The significance of electrically stimulated ankle plantarflexors during functional-electrical-stimulation-assisted walking was evaluated. The dynamic (floor reaction forces) and kinematic (ankle and hip joint trajectories) data were assessed in incomplete spinal cord injury patients. The interplay of kinematic and dynamic parameters was described by mathematical modelling. An improved hand-control module providing voluntary control over functional-electrical-stimulation-restored walking pattern was developed. A specially designed two-step hand push-button enabled the division of the stride time into three distinct phases: midstance, push-off, and swing phase. Noticeable effects of functional electrical stimulation during the push-off phase were particularly evident in the vertical ground reaction force and horizontal hip joint displacement.