Key Points
Sitting Balance
Sitting balance is a significant component of independent daily living for people with SCI, especially those with cervical level injuries or those with complete injuries at the thoracic/lumbar level (Lei et al. 2023). It may be especially important to consider sitting balance in people with SCI as they may have limited trunk control, and otherwise simple daily tasks, like reaching for something, moves the person’s center of gravity, and they may lose their balance, and put them at risk for falls. Dressing, wheelchair handling, transfers, sitting on the edge of or across surfaces, and toileting all require a combination of static and dynamic postural control involving the trunk (Lee & Lee 2021; Tak et al. 2015). Therefore, the rehabilitation of sitting balance is beneficial for enhancing quality of life after SCI.
Evidence of Virtual Reality (VR)
Virtual reality (VR) balance training produces improvements in sitting balance in people with both acute and chronic SCI.
Evidence of Exercise and Activity-Based Therapy (ABT)
Various exercise interventions (i.e., wheelchair skills training program, unsupported sitting, seated Tai Chi, arm crank or kayak ergometry, Spinal Mobility, and activity-based therapy [ABT]) can be used to improve sitting balance in people with subacute and chronic SCI.
Evidence is lacking about the optimal dosage and length of intervention for improving sitting balance in people with acute or chronic SCI.
Evidence of Body-Weight Supported Locomotor Training (BWSLT)
Studies with strong evidence show that different body-weight supported locomotor training (BWSLT) methods do not improve sitting balance in people with chronic SCI.
Only preliminary recommendations can be made from the results of lower-quality and smaller studies assessing exoskeleton training methods for sitting balance in people with chronic SCI.
Evidence of Electrical Stimulation
Electrical stimulation plus balance training can be used to facilitate trunk stability for seated dynamic postural control in people with spinal cord injury (SCI), though a virtual reality program plus balance training provided superior results.
In people with acute SCI, electrical stimulation can improve dynamic trunk stability more so in motor incomplete tetraplegia than motor complete tetraplegia.
In people with chronic SCI, a combination of electrical stimulation and therapeutic exercise can improve sitting balance outcomes.
Standing Balance
Up to 75 % of individuals with incomplete SCI experience falls while standing and frequent losses of balance post-rehabilitation (Arora et al. 2020; Brotherton et al. 2007). Moreover, falls are among the most common cause of SCI in persons > 60 years old (Dohle & Reding 2011), so standing balance training may be particularly important for the safety of older people and people with incomplete SCI.
Evidence of Virtual Reality (VR)
VR training is an effective strategy to improve walking and standing balance performance in patients with incomplete SCI, and may afford further benefits compared with the same training interventions without the VR biofeedback.
Electromyography (EMG) Biofeedback, visual feedback, or visuotemporal cue feedback adding to standing, stepping or body-weight supported treadmill training (BWSTT) protocols may improve gait, balance, and lower limb muscle strength in incomplete SCI and chronic SCI.
Evidence of Non-Body-Weight Supported Training
A number of balance training interventions can improve standing balance in people with SCI. Perturbation-based balance training, conventional intensive balance training, task-specific (stepping) and impairment-based training, walking training over different surfaces, rebound therapy, overground multi-modal locomotor training, or community-based ambulation training may result in improvements, mainly in standing balance and balance confidence.
High-intensity locomotor (70%-85% HRmax) and resistance (isometric contractions of maximum volitional effort) training programs seem to be safe in patients with SCI; however, the effectiveness for improving standing balance is contradictory. Larger randomized controlled trials (RCTs) are necessary.
Studies assessing non-body-weight supported treadmill training or overground training programs in people with acute and/or complete SCI have been inconclusive or trials were of lower quality.
Evidence of Body-Weight Supported Treadmill Training (BWSTT)
Though typically body-weight support treadmill training improves walking safety, and does not effectively test standing balance, many studies assessing walking have also included secondary outcomes measuring standing balance (e.g., the Timed Up and Go test).
Evidence to date shows that BWSTT has similar effects on standing balance and functional independence outcomes as overground mobility training of similar intensity.
Evidence of Wearable Powered Exoskeletons
Even though wearable exoskeleton-assisted gait training has been studied to improve gait performance, some studies have measured standing balance in patients with SCI, though there is little consensus regarding training regimens and exoskeleton models used. There is insufficient evidence regarding whether wearable exoskeleton-assisted training provides better walking function, balance performance, or energy expenditure outcomes, compared with other approaches (such as robotic-assisted gait training [RAGT] with Lokomat or knee ankle foot orthoses [KAFOs]) in patients with SCI.
Powered Exoskeleton use may be cumbersome, not available for home use, have a high cost, and participants may experience adverse events.
Evidence of Neuromodulation
Evidence of Functional Electrical Stimulation (FES)
Some RCTs involving BWSTT coupled with functional electrical stimulation (FES) or FES-cycling have shown improvements in standing balance outcomes or functional independence, and some have not.
Evidence of Transcranial Direct Current Stimulation (tDCS)
Concurrent application of transcranial direct current stimulation (tDCS) did not further enhance the effects on walking, balance, and strength outcomes of motor skill training, overground walking training, or BWSTT in patients with motor-incomplete SCI.
Evidence of Repetitive Transcranial Magnetic Stimulation (rTMS) (and Other Approaches)
Repetitive transcranial magnetic stimulation (rTMS) and non-invasive brain stimulation (NIBS) combined with locomotor or exercise training do not seem to provide more benefits in standing balance and walking function than exercise alone in patients with SCI; however, they may provide positive effects on lower limb strength.
Gaps in the Literature
- Many studies we found tested balance as a secondary outcome with walking as the primary outcome; specifically, studying balance function as a primary outcome in SCI should improve data available, and in turn, clinical recommendations.
- Most studies we found testing balance in SCI, even high-quality RCTs, have fewer than 20 people per condition; authors of recent systematic reviews have stated that more well-designed and appropriately powered RCTs testing balance function are needed (Benn et al. 2025; Walia et al. 2023).
- Most studies on balance in people with SCI include people with incomplete injuries and at the chronic phase of SCI; more studies including people at the acute phase of injury and/or complete SCI would provide results more representative of the general SCI population.
