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Laurance Johnston, Ph.D.

Sponsor: Institute of Spinal Cord Injury, Iceland


  1) Introduction

2) Neuro Institute (USA)

3 Project Walk (USA)

4) Coordination Dynamics Therapy (Estonia, Spain)

5) Activity-Based Restoration (USA)

6) Beyond Therapy (USA)

7) Center SCI Recovery (USA)

8) Centro Giusti (Italy)

1) Introduction: In recent years, aggressive physical rehabilitation programs have emerged that seem to restore significant function in many with SCI, even years after injury. Sophisticated devices and technology have been developed to catalyze such function-restoring rehabilitation, such as GIGER-MD® locomotion system (www.gigermd.com) or the Locomat® robotic treadmill training (photo) (www.hocoma.com).  

Frequently, these programs are used to maximize restored function after an innovative surgical procedure or other intervention. Often videos are created to document the patient’s functional improvement, and given the impressive nature of the physical activities that could be done after but not before treatment, it is assumed that the recovered ability documents efficacy.

However, this assumption may or may not be valid. It is possible that little of the restored function is due to, for example, a $50,000 surgery but rather attributed to the rehabilitation aggressively pursued after the surgery but not before. If functional recovery after a surgical intervention depends upon a slowly regenerating neuron reaching an anatomically distant target site, it will take a relatively long time for new functional improvements to appear. If during that period, the patient has sustained an aggressive physical rehabilitation program, it is not unreasonable to question, as many scientists, indeed, do, what is the true cause of the improvement. Because of this concern, some surgical interventions are now requiring patients to aggressively rehabilitate before the surgical intervention as well as after.

Furthermore, if a patient believes with heart-and-soul conviction that the surgery/intervention will help him recover some function, it will shift his consciousness from the pre-surgical “you-will-never-walk-again” attitude that is often imprinted on patients by medical authorities to a self-fulfilling belief of what may be truly possible if he works hard . The patient’s will propels him to new levels of function, much of which, in fact, may have little to do with the surgery/intervention.

Even considering it alone without any potentially confounding intervention, physical rehabilitation is a complicated area in which observed improvement may be due to a number of causes separately or in combination. First, through a variety of physiological mechanisms, including growth-factor stimulation, aggressive physical rehabilitation in many individuals with SCI probably does trigger some neuronal regeneration.

Second, it may activate dormant but intact neurons that transverse most injury sites, even in injuries clinically classified as complete. Studies suggest that only a small percentage of “turned-on” neurons are needed to regain significant function.

Third, the spinal cord in itself possesses intelligent and not completely subservient to brain oversight. Specifically, the spinal-cord’s “central-pattern generator” can sustain lower-limb repetitive movement, such as walking, independent of direct brain control. With training and appropriately designed leg braces, impressive ambulation may be observed with minimal if any neuronal regeneration.

Fourth, many muscles above the injury site affect ambulatory potential, especially when using appropriately designed leg braces. For example, the latissimus dorsi, a muscle innervated from the spinal-cord’s cervical region, can influence pelvic-area movement and, in turn, ambulatory-associated motions (Anton Wernig, private communication).

Fifth, increasingly, many scientists believe that there are intriguing possibilities about the integration of different neurological systems above and below the injury site, which, although making our understanding of the nervous system more complicated than once assumed, generate rehabilitation opportunities.

Sixth, aggressive physical rehabilitation programs are often initiated relatively soon after injury in a period in which there is already appreciable recovery potential. Once again, it is often difficult to determine how much recovery is due to a specific program and how much would have occurred anyway. Advocates of the status quo and critics of the innovative tend to be skeptical of the results produced by innovative rehabilitation programs as phenomena that may have occurred anyway. The growing base of both scientific and anecdotal evidence suggests that aggressive rehabilitation programs magnify recovery potential.

Finally, confounding understanding even further, in paradigm-expanding speculations, some scientists believe that it is possible for brain-directed function below an anatomically complete injury site. For example, Albert Bohbot, whose laserpuncture work was described previously, believes that there is a sophisticated interaction between our body’s electromagnetic energy channels/systems/fields and our nervous system that can bypass the injury site . Although beyond mainstream biomedical thinking, this is entirely possible under Eastern- and other esoteric-healing philosophies, and, as such, it has been suggested that martial-arts study, which emphasize energy-flow and control, would facilitate this potential.

Summaries are provided below on various private-clinic and university-based rehabilitation programs that may restore some function after SCI. The agendas and priorities of the programs in these two settings often vary greatly. The latter is often research driven with the goal of publishable professional papers and awarded grants, and with the former, research by itself is not the goal but the production of real-world results that economically sustain the program.

2) Neuro Institute: Arnie Fonseca (Arizona, USA) summarized his aggressive physical rehabilitation program at the 2001 Iceland conference in Iceland (see introduction). An exercise physiologist, Fonseca draws upon his former coaching experience to motivate clients with SCI and other neurological disorders to regain surprising function. The author of this report has met Fonseca and was impressed with his drive, can-do spirit, and commitment to his rehabilitation mission, a mission that became personal after his 21-year-old son Brandon sustained a serious head injury from an auto accident.  

Summarized on the Neuro Institute’s website (www.theneuroinstitute.com; also see www.healingtherapies.info), Fonseca describes his program as immersion therapy. Basically, he believes that the best way for a neurologically compromised patient to accrue positive results is to be immersed in goal-oriented rehabilitation therapy for at least three hours a day for three to five days a week. There is no magic technique; the program uses a variety of rehabilitation approaches ranging from state-of-the-art, sophisticated electronic equipment (e.g., FES bikes) to old-fashioned, low-tech weight training. Through his “just-do-it” motivational prowess, Fonesca encourages patients to replace entrenched defeatist attitudes with a new conviction of what is possible if they work hard.

A number of impressive success stories are documented on the Neuro Institute’s website. One of the more notable involves Andrea, whose experience was discussed earlier under the omental therapy section. Her experience represents a good example of how function-restoring surgeries are being combined with aggressive physical rehabilitation. In brief review, an omental/collagen bridge was used to bridge a 4-cm gap in Andrea’s cord that resulted from a skiing accident (Neurological Research 27, 2005). Several years after surgery, Andrea started Fonesca’s program, and has regained considerable function, including some ambulatory ability. Time-sequential MRIs indicate ongoing development of axonal structure through the once huge spinal-cord gap. Although it is difficult to distinguish surgery from rehabilitation contributions, much to the chagrin of scientific purists, this is the sort of synergistic surgical-rehabilitation programs that we are going to see much more of in the future.

3) The Project Walk (California, USA) intensive exercise-based recovery program for SCI was developed by Ted and Tammy Dardzinksi (www.projectwalk.org). Many individuals with SCI who have committed to this program have accrued additional function much beyond what was considered possible after injury. Using the “Dardzinski Method,” the program attempts to re-educate the damaged nervous system through appropriate physical stimulation. Because each injured nervous system is unique and each patient, as a result, has different capabilities, the program is tailored to the client. (Photo: Project Walk Clinic).

Briefly, the program focuses on developing muscle potential below the injury level. The Dardzinksi’s feel that standard rehabilitation programs not only ignore this potential but contribute to its extinction by “tossing-in-the-towel” focusing on non-paralyzed body parts needed for adaptation to wheelchair living instead of ambulation.

They also feel that the extensively administered anti-spasticity and other movement- and sensation-inhibiting medications are the equivalent of pouring water on the flickering embers of regeneration that often still exist after injury. In contrast, Project Walk’s goal is to fan these embers into a phoenix-like re-emergence of functionality. As discussed in the introduction to this section, the program attempts to shift the patient from the all too common “you-will-never-walk-again” belief that is commonly imprinted by medical authorities after injury to a self-fulfilling attitude of what could be truly possible with hard work.

Underscoring their reservations with traditional rehabilitation principles that are based upon the limitations of the past than the promise of the future, the Dardzinksi’s note: “If you were to place an able-bodied person in a reduced gravity environment, tell them they can’t move for a year, heavily medicate them, and give them no hope, what do you think the outcome would be? Bone density, muscle mass, and nervous system activity would begin to shut down and disappear. That able-bodied person would have the same symptoms of a paralyzed person. So, is it just the injury or the treatment that keep some SCI paralyzed?”

Like many other SCI programs that believe that there is a therapeutic window after injury in which the recovery potential is greatest, Project Walk ideally would like to start treating patients relatively soon after injury. The program feels that without proper stimulation and load bearing, a newly injured individual with SCI will soon start losing bone density, muscle mass, and CNS functioning, which will make functional recovery in the future even more difficult. Although the program has treated many after this early therapeutic window, sometimes with dramatic improvements, much more effort is required to accrue the same degree of benefit. Nevertheless, the issue of early treatment represents a bone of contention to many traditional SCI rehabilitation specialists who often dismiss any improvement as something that would have accrued anyway during this period of neuronal plasticity.

Although the training schedule varies depending upon the individual’s function, the average client typically works out three hours every other day.  For people who must return home, individually tailored, home-based programs are designed. Although the program is intensive, it encourages clients not to embrace it exclusively at the expense of overall life balance through career, school, social life, etc.

The program consists of intense one-on-one training that combines strengthening activities for all muscles in the extremities and core (abdominal, back, and pelvic), balance work, and coordination drills. Again, exercise routines are structured to activate paralyzed areas and strengthen weak muscles. Specialists facilitate active and passive motions with participants in various planes of motion to reactivate and reorganize the nervous system. This includes but is not limited to floor exercises, assisted/unassisted work on Total Gyms®, and body weight supported ambulation. The common component of these exercises is weight bearing through the long bones of the body. The program believes that weight bearing is essential to recovery of function because that is what the human body was designed to do.

Functional improvements often include increased muscle mass, CNS activity, health and well being, sensation and function below the injury level, occupational skills, and sweating, as well as decreased drug dependence and pain.

The program encourages the use of a variety of synergistic healing modalities, including acupuncture, hyperbaric oxygen therapy, and the use of standing frames, FES bikes and other external electrical stimulation that helps to maintain muscle mass and circulation. The program also emphasizes good nutrition.

The recently published results of a non-randomized study indicate that Project Walk’s intense-exercise regimen generates substantial functional improvements in individuals with chronic SCI (Harness ET et al, Spinal Cord, 46, 2008). Representing a good example of the much needed cooperation between independent clinics attempting to produce results for patients in real-world settings and academicians with foremost allegiance to the scientific process, Project Walk staff worked with University of California Irvine investigators to document these exercise-generated improvements.

In the study, 21 individuals with chronic SCI (both cervical and thoracic injuries) who underwent six months of Project Walk’s intense exercise (IE) program were compared to eight controls whose program consisted of an unstructured, self-regulated exercise over the same period. IE and control subjects averaged 38 and 34 years old, respectively. On average, 3.3 years had elapsed since injury for IE subjects compared to eight years for controls. Over the study’s six-month exercise period, IE and control subjects averaged 7.3 and 5.2 hours of exercise per week, respectively.

Before the exercise program was initiated, both groups had comparable motor function. Compared to controls, those enrolled in the intense-exercise program improved greatly. Specifically, 71% of IE subjects improved in motor function in contrast to only 25% of controls (25% of controls also decreased in function). Furthermore, in one third of the IE subjects, at least one muscle changed from non-functional to functional after the six months of training.

4) Coordination Dynamics Therapy was developed by Dr. Giselher Schalow, a German scientist with programs in Estonia, Spain, and formerly Switzerland. According to Schalow’s website (http://www.cdt.host.sk/) coordination dynamics therapy (CDT) was introduced by him for “functional and structural repair of the lesioned or malfunctioning human central nervous system (CNS). This mainly movement therapy improves (1) the self-organization of the neuronal networks of the CNS for functional repair by exercising extremely exact coordinated arm and leg movements on a special device and, in turn, the coordinated firing (with respect to time and space) of the many billions of neurons of the human CNS. Structural repair is achieved by training automatisms like creeping, crawling, walking and running and by forcing the ‘adaptive machine’ CNS to adapt by pushing the patient to the limits during exercise.”

Although underscoring that it’s the program and not the equipment per se that makes the difference, the device Schalow emphasizes is a Swiss-manufactured GIGER MD exercise instrument, which has become popular at many rehabilitation centers. The patient powers the instrument in either standing, sitting, or lying-down positions. Arm and leg cycling is phased in a physiologically sequenced and coordinated pattern that promotes the creation and reorganization of function-restoring CNS neuronal networks. Basically, CDT’s gestalt-like approach to muscle movement emphasizes the neuronal plasticity (i.e., adaptability) that is inherent in all. With CDT, it is the rhythm of the exercise patterns not the exercise itself that is most important. Through a wave-like movement, all spinal-cord sections are sequentially affected. (Thumbnail photo of Schalow's clinic: In front a patient with SCI (T-5/6) crawling, supported by a physiotherapist; a patient with an incomplete SCI jumping on springboard; a patient with a complete SCI exercising on GIGER MD device; on the treadmill is a patient with formerly severe brain injury.)

Schalow compares the process to a computer, in which “the CNS neurons and connections represent the computer’s hardware, and the many different self-organizations of neural networks activated by volition and movement-induced input represent the computer’s software.” With this analogy, no matter how powerful your computer, if the software (i.e., neuronal circuits and networks) is not there, you are not going to have significant function. As such, efforts to regenerate neurons without adequate consideration on how they are organized will be inherently limited. 

To reinforce the creation of these nascent, function-restoring neuronal networks requires a substantial effort commitment on the patient’s part; specifically, it is recommended that patients train 20-30 hours per week for at least a half year. Under this regimen, the sequenced movements are repeated many thousand of times.

Schalow published his SCI findings in several professional articles. For example, in 2002, he reported the results of treating 18 patients with at least three months of CDT (Electromyogr Clin Neurophysiol, 42). Patient age ranged from 7-55 years old (averaged 31), and the time since injury averaged five years. In addition to measuring increased ability to creep, crawl, springboard jump, walk, and step climb (which was selectively and not cumulatively reported), Schalow quantified improvements through a “coordination-dynamics” measurement that reflects CNS organization. After three months of CDT, this measurement improved 53%, 32%, and 48% for patients with cervical, thoracic, lumbar injuries, respectively. Given the results, Schalow suggested that cervical and lumbar injuries have greater plasticity potential (i.e., adaptability) than thoracic injuries. Overall, motor function improved in all patients.

In 2003, Schalow reported the results of treating four patients with CDT for longer 6-13-month periods (T12/L1, C4/5 injury, T12, and L3/4 injuries) (Electromyogr Clin Neurophysiol, 43). Three were from the previously reported group. The article concluded: “One patient with an incomplete spinal cord lesion was cured, two patients with clinically complete injuries were partly cured, and one patient with a complete spinal injury L3/4 became incomplete but showed only comparably little progress.”

5) Activity-Based Restoration: Dr. John McDonald, who recently shifted his program from St. Louis’ Washington University to Baltimore’s Johns Hopkins University, has developed an “activity-based restoration” (ABR) program that reinforces patterned neural activity, which, in turn, promotes the creation of function-restoring neuronal networks. ABR is based on the premise that there is often considerable neuronal plasticity (i.e., adaptability) that can be exploited after injury but generally has not been under conventional rehabilitation. In most, even clinically classified complete, injuries, there are substantial numbers of intact neurons that still cross the injury site. Through rigorous physical stimulation, these residual neurons provide the foundation for creating new function-restoring neuronal networks.

It is an “if-you-don’t-use-it-you-lose-it” system, in which paralysis-associated disuse of muscles over time results in a viscous-circle diminution of regeneration potential. In other words, the nervous system requires a certain degree of pattern activity to maintain itself. As such, dormant neurons and nascent neuronal networks somehow must be stimulated, even in the case of paralysis. Like others, McDonald believes that one’s inherent adaptive potential in response to patterned activity is severely compromised by commonly used anti-spasticity medications.

In McDonald’s ABR program, the pattern-activity stimulation is primarily from training on a recumbent functional-electrical-stimulation (FES) bicycle for one hour three times a week. This one-hour effort corresponds to about 3,000 repetitions, which compares to the 12,000 steps the average person takes each day. With this FES device, the computer-controlled, muscle-stimulating electrodes were attached to the skin over the quadricep, hamstring, and gluteal muscles. Supplemental therapies included the corresponding electrical stimulation of other muscle groups, as well as aqua-therapy after some recovery has accrued. Because of the need to maintain a three-session-per- week schedule, to make the program feasible for most individuals, McDonald feels that it ideally should be home based with monitoring over the Internet.

McDonald’s program accrued considerable visibility after the late actor Christopher Reeve regained some astonishing, unexpected function after starting ABR five years after injury, i.e.,  well into the chronic phase of injury in which, from historical rehabilitation perspectives, the probability of significant functional recovery is considered unlikely. Reeve’s improvements were documented by McDonald et al in a 2002 article (J Neurosurg (Spine 2), 97).

Forty-two years old at the time of his injury in 1995, Reeve sustained an ASIA Grade-A complete C-2 injury after being thrown from a horse. Five years later, Reeve started the ABR program and continued it at home. In spite of his clinically classified complete injury, as is the case with so many injuries, magnetic-resonance imaging indicated that Reeve had a doughnut-like rim of tissue (~25% of the normal amount of spinal-cord tissue) surrounding a injury-site cyst. 

After three years of treatment, Reeve improved from ASIA Grade-A classified complete injury, which had been his status for the five years before treatment, to Grade-C incomplete injury (again, as described in appendix, this impairment scale ranges from Grade A,  representing complete injury, to Grade E, representing normal motor and sensory function). Over his three-year treatment period, Reeve’s motor scores improved from 0 on a scale of 0-100 to 20, and sensory scores improved from 5-7 on a scale of 0-112 to 55-77. These improvements correlated with a regained ability to move certain muscles, including most joints in gravity-countering water. Sensation as measured by pinprick and light-touch evaluation improved to 50% and 66% of normal, respectively. This recovery was also associated with a reversal of SCI-associated osteoporosis, increased muscle mass, a greatly reduced incidence of antibiotic-requiring infections and other medical complications, and reduced spasticity.

6) Shepherd Center’s Beyond Therapy Program (Atlanta, GA) is designed to integrate the goals of each client into an individualized program that combines the principles of athletic training along with concepts of traditional physical therapy to promote spinal-cord neural recovery.  Recent research suggests that the central nervous system, once thought to be irreparable, is actually able to functionally reorganize itself with the appropriate training and may allow recovery of lost abilities even in the presence of minimally intact neural tissue. 

The program’s vision is to create an environment of hope and determination for those clients who have sustained a catastrophic neurological injury and provide them with the appropriate assistance to achieve their highest level of sensory and motor recovery.  It is designed to challenge clients to reach a level of physical fitness or function that they had once thought impossible.  The program works to change the focus of the client’s mindset away from the wheelchair and toward rehabilitation and recovery.  Goals include stimulating intact spinal-cord neural tissue that was spared during the initial injury to promote neuromuscular recovery, facilitating neural recovery in individuals who have undergone experimental function-restoring surgeries and therapies throughout the world, and creating an individualized lifelong activity program to help individuals maintain physical readiness for neural recovery.  

Beyond Therapy is a physically rigorous program that combines the expertise of an individualized training team comprised of exercise physiologists, athletic trainers and physical therapists to assist their clients in attaining the highest level of personal strength and restoring function.  Because this program integrates multiple disciplines, there are no boundaries in the variety of experiences and stimuli that clients may receive.  The program extends beyond the range of acute care and predetermined functional goals, and continues the rehabilitation process by administering aggressive treatment of clinically researched protocols to achieve a higher-level of individual achievement.  

Clients are first evaluated by a physical therapist who designs an intense 9-hour/week program that combines state-of-the-art technological advancements in rehabilitative medicine with hard-core physical training.  Each client is evaluated to determine the most appropriate individualized training program which may include the following: Lokomat (Robotic assisted treadmill training), body-weight-support manual treadmill training, Giger training, FES (functional electrical stimulation) bike training, Bioness upper extremity orthotic electrical stimulation, aquatic therapy, standing and gait training with a variety of orthosis/equipment, lower extremity strengthening, upper body and core strengthening in a variety of developmental sequencing techniques. 

Beyond Therapy’s philosophy originates from three primary concepts.  The first is recovery through the use of neural patterned activity.  The client is able to use the most technologically advanced equipment to take their bodies safely through the normal movement patterns and weight bearing that they completed on a daily basis before their injury to remind and re-teach their damaged nervous system how to function appropriately. This may include timed walking on the Lokomat, cycling on an FES Bike, or passive/active cycling with a Giger MD.  The second concept is that of task specificity.  The injured nervous system responds to training and has the ability to modify activity based on the specific training program or inputs that it receives.  This includes teaching the injured nervous system specifically how to crawl and stand again as individual components of their recovery process.  The third concept is that of functional strengthening.  All four limbs and core must be strong enough to support the body’s weight to complete the activity demands being placed upon it by a healing nervous system. 

Beyond Therapy’s experimental protocol was designed to assist clients with navigating through the neurological experimental procedures offered at Shepherd and throughout the world.  This program assists those clients who wish to pursue innovative procedures around the world and need information on how to participate in them.

7) The Rehabilitation Institute of Michigan’s Center for Spinal Cord Injury Recovery (CSCIR) is designed to implement and study the results of innovative treatments that may result in some functional improvement in persons with SCI. To maximize restored function, the program has rehabilitated numerous patients who have undergone various function-restoring cell/tissue-transplantation procedures, including those previously discussed [e.g., Dr. Carlos Lima (Portugal), Dr. Hongyun Huang (China), Dr. Bryukhovetskiy (Russia)].

Basically, CSCIR offers long-term, high-intensity, state-of-the-art, outpatient therapy that focuses on neuromuscular recovery. The program incorporates therapeutic techniques based on the updated information available from emerging research around the globe.  The team works one-on-one with clients to develop creative, individualized therapeutic exercise programs targeted at improving movement and sensation.  The program emphasizes neuromuscular re-education, sensory stimulation, weight-bearing exercise, functional electrical stimulation (FES), aquatic therapy, hand therapy, and massage. The CSCIR program moves beyond traditional rehabilitation techniques and focuses on activating muscles and nerves above and below the level of injury that can develop into  movement, sensation, posture, balance, and coordination improvements.

CSCIR (Rockford), 515 E. Division Street, Rockford, MI 49341


CSCIR (Detroit), 261 Mack Blvd, Detroit, MI 48201



8) Drs. Carlo Alberto Arcangeli and Giovanna Lazzeri at the Centro Giusti Rehabilitation Center (Florence, Italy) have developed an intensive rehabilitation program which has restored function to many individuals with SCI (www.centrogiusti.it). The program has provided follow-up rehabilitation to Dr. Carlos Lima’s patients who have had, as previously discussed, olfactory tissue transplanted back into their injured spinal cord.

The program’s overall philosophy is that post-injury recovery is greatly enhanced by the stimulation provided by ongoing, rigorous physical rehabilitation. The goal is to stimulate every possible improvement, however small it may be, thus validating all physical, mental, and economical efforts. The patient must understand that the work involved is “active” on his part, albeit with the assistance of a therapist and limited aids (too much of such assistance makes the exercises passive and, therefore, lacking stimulation). Given these considerations and having the Russian Rehabilitation School as a background, Drs.Arcangeli and Lazzeri have developed the Intensive Continual Motor Rehabilitation Program R.I.C.

The program has produced functional improvements in numerous patients with SCI. For example, patients with complete cervical injuries have regained a dynamic standing position; many patients with paraplegic, even complete, injuries are now walking with a small orthosis below the knee, simple gait trainer, and therapist assistance; and many with tetraplegic, including complete, injuries after toning up the area above the injury have regained various functions, including walking with orthosis aid, gait trainer and therapist assistance. Numerous patients have reached their goal of virtually abandoning their wheelchairs, challenging their original diagnoses. 

With this program, Dr. Lima’s olfactory-tissue-implantation patients can be compared to patients who have not undergone the procedure, providing new clinical opportunities to be obtained through rehabilitation. They are showing functionality far beyond what could have been expected, e.g., active movements below injury and superior physiological deambulation (i.e., walking about).

The program’s objective is to stimulate the patient to continue to discover improved movement, which, in turn, evolves into functional movements such as deambulation. The program consists of up to 150 exercises (carried out in various postures) that work toward maximizing potential, coordination, balance, posture, and body recognition. Because the exercises are actively carried out, considerable motivation and will are necessary. 

The program is distinguished by its intensity, continuity, and personalization. 1) Intensity: The program consists of 4-6 hours, five-days a week, therapist-assisted sessions. 2) Continuity: Program duration cannot be determined in advance. The first three months are spent in the center, followed by 5-6 months at home, and then three weeks again at the center. At home, the patient must be followed by a program-trained therapist and must have the necessary program apparatus. The patient will then carry on alternating home with center therapy for three-week periods. With this organization, the program evolves over time. 3) Personalization: The program is personalized according to the patients’ capabilities and clinical situation. The patient-therapist relationship is always on a 1-1, or even 1-2, basis. 

Through intense stimulation above and below the injury level, combined with strong motivation, the body’s natural physiological resources are used.  Recovery is due to a variety of events, such as the reactivation and use of various muscle groups above the injury that would not otherwise be used, the activation of the bone-marrow structure below the injury, and numerous other unexplored body resources. The main objective is to regain a physiological deambulation that is as independent from aids as much as possible during which many other secondary goals are reached, such as regaining muscular potential, lost functions, obtaining a standing and dynamic position, some transfer independence, balance, coordination, postural control, and prevention of various immobility-related side effects, such as osteoporosis.  Deambulation is taken into consideration only when the patient is able to maintain good standing-position trunk balance and is not considered an exercise but an end result and reassembling of the exercises. Complete body weight must be put onto the lower limbs while deambulating so that a realistic biofeedback is given (in contrast to in-water training where the patient carries out movements but fails to repeat movements when on ground).

To prevent the “collapsing of the building,” a solid foundation (muscular, articular (i.e., joints), body recognition, and emotional) must be built up before attempting deambulation. From a psychosocial viewpoint, the patient feels sure of himself in his movements; i.e., he feels “alive,” busy, motivated, and stimulated in enjoying a better societal position. When working on the body, program staff believes that they are also working on the psyche.