Chapter 12: Ambulation

Chapter 12 presents information that will support clinicians in navigating the complex considerations around walking recovery after spinal cord injury.

INTRODUCTION

Ambulation is a priority concern for many people following spinal cord injury. Walking can be an emotionally charged issue, with significance far beyond the pragmatic consideration of independent mobility. For many, walking symbolizes power, competence, and potency. Conversely, the inability to walk may be experienced as inadequacy, failure, and incompetence. Rehabilitation professionals should be sensitive to patients’ perspectives, while at the same time recognizing that these views spring from negative societal attitudes about disability. We should also remain vigilant about our own biases, striving to eliminate their impact on clinical judgment and interactions.^a This chapter will explore the complex issues related to walking when working with individuals who have experienced spinal cord injury as they navigate their journeys in new physical bodies.

The medical community has substantial responsibility when engaging in dialogue about walking including, but not limited to, education that surrounds interventions for improving walking abilities. We must be aware of the inherent biases and subtle microaggressions^b against disability that can emerge when we discuss walking, and take care to avoid negative messages that we may inadvertently send. Do we express failure when an individual is unable to restore walking abilities? Do we celebrate when a former patient returns to the clinic walking as compared to using wheeled mobility? Inability to restore walking abilities is not a “failure” of the patient or the rehabilitation team. We must be cautious of our messaging and steadfast in our support of individuals who live with disabilities.

AMBULATION AFTER INJURY: TO WALK OR NOT TO WALK?

In recent decades, restoration of walking after spinal cord injury has been an area of debate among rehabilitation professionals.^1,2 On the one hand, walking is often a priority for patients, and advances in our understanding of neuroplasticity have led to greater focus on restorative interventions. On the other hand, walking is not always the best option in terms of functional independence and participation. Ambulation with assistive devices and orthoses is a good deal slower and profoundly more energy-consuming than walking without this equipment.^3-14 In contrast, the speed and energy costs of wheelchair propulsion^c are similar to those of normal walking.⁹ As a result, people with complete spinal cord injuries, and many who have incomplete injuries, are likely to abandon their ambulation skills after rehabilitation.^9,15-19

Devoting significant time to walking training, then ultimately using a wheelchair for mobility instead of walking, is not without ...