Developmental research in paraplegic walking.

An injured London policeman's fight to stand and walk again, despite the handicap ofcomplete paraplegia at thoracic level from a gunshot wound, captured the public imagination last year. British journalists hailed as an important breakthrough his treatment-firstly, with an electrical stimulation system (functional electrical stimulation) for the paralysed lower limb musculature, then using a splint to support his trunk and legs while continuing functional electrical stimulation to important propelling muscle groups. This media interest was, unfortunately, concentrated on work in the United States-to the dismay of many other groups working on the same problem in Britain and Europe. Treatment centres for patients with spinal cord injuries and the self help agencies (for example, the Spinal Injuries Association) have been aware of these research efforts but have rightly and responsibly treated all claims with some scepticism based on their knowledge that rehabilitation to a life in a wheelchair is still a vitally necessary part of successful recovery from paraplegia or tetraplegia. Indeed, the problems of the acute injury quickly become superseded by intense efforts to educate these patients in how to care for themselves safely after hospital discharge. Splints are used as part of rehabilitation but are often heavy and difficult to put on and off, and standing often requires help. Athletic adult paraplegics with incomplete or cauda equina lesions may walk with the so called "swing through" or paraplegic gait using crutches. Those with complete paraplegia at thoracic level find this tiring since the whole weight of the body has to be lifted upwards and then swung forwards using the arms. Gordon and Vandervalde showed that this motion consumed six to eight times more energy than normal walking.' Developments in splinting techniques have eased this burden. The use of lightweight materials is not a complete answer, but an analysis of the principles of handicapped and normal walking by Rose et al has led to an orthosis (or splint) that provides low energy cost reciprocal ambulation (that is, one leg follows another in swing).23 This provides independent walking for patients with thoracic paraplegia of any cause-and it is available in Britain. Similarly a less rigid splint, or brace, has undergone development by Douglas (an orthotist) in the United States. Dias and colleagues have shown this to work,4 but some extravagant claims have been made by others and have led to uncertainty about prescription criteria. Functional electrical stimulation systems alone are said …