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Sitting, Standing and Balance Training

Most individuals with incomplete SCI have the potential to recover some degree of mobility and many functional activities of daily living (ADL) through rehabilitation (McKinley et al., 1999). Proper balance control is important not only for mobility and ambulation, but in fact underlies daily home and community-based functional activities in sitting and standing (Huxham et al., 2001).

SCI is accompanied by changes in sensation, loss of muscle strength, decreased cognitive reserve and spasticity amongst a host of other pathological changes that may lead to balance and gait impairments. Balance and gait impairments in turn, may lead to falls. The incidence of falls in people with SCI has been reported to be as high as 75% with loss of balance being the primary perceived factor contributing to falls in incomplete SCI (Brotherton et al., 2006). Moreover, falls are a major contributor of SCI with falls being the most common cause of SCI in individuals > 60 years old (Dohle and Reding, 2011). It is not currently known the extent to which deficits in balance may affect people with SCI.

The central nervous system (CNS) maintains balance by integrating information from visual, vestibular and sensorimotor systems (Horak and Macpherson, 2006). Greater understanding of the principles underlying the neural control of movement and functional recovery following neurological injury has resulted in increased efforts to design rehabilitation strategies based on task-specific training (Wolpaw and Tennisen, 2001; Behrman and Harkema, 2007; Fouad and Telzaff, 2012). This concept has been translated to various rehabilitation interventions, such as those targeting walking outcomes (e.g. body-weight supported treadmill training) (Mehrholz et al., 2008; Van Hedel and Dietz, 2010; Wessels et al., 2010; Harkema et al., 2012) or arm and hand function (e.g. constraint-induced movement therapy) (Taub et al., 1999; Wolf et al., 2002). For balance, task specific rehabilitation similarly focuses on the achievement of the three main functional goals encompassing balance: 1) maintaining an antigravity posture such as sitting and standing, 2) anticipatory postural control during voluntary self-initiated movements and 3) reactive postural control during an unexpected perturbation (Berg, 1989).

There has been a great deal of focus on the effectiveness of gait training in SCI rehabilitation research (Mehrholz et al., 2008; Van Hedel and Dietz, 2010; Wessels et al., 2010; Harkema et al., 2012), but there has been relatively little attention on the impact of interventions specifically targeting balance outcomes. In other neurologic populations, there is some evidence that task-specific balance training can be effective for improving functional outcomes. A systematic review in people with stroke found moderate evidence that balance could be improved with exercises such as challenging static/dynamic balance ability and practice of balance in different functional tasks, including sitting, standing, walking, and stair climbing (Lubetzky-Vilnai and Kartin, 2010). In recent years, and with the rapid development in technology (e.g., exoskeletons, virtual-reality), there has been more data available about balance outcomes following gait training (Dobkin et al., 2006; Wu et al., 2012; Harkema et al., 2012), as well as specific sitting (Boswell-Ruys et al., 2010; Harvey et al., 2011) or standing (Alexeeva et al., 2011) balance interventions in people with SCI.

Table 2: Sitting Balance

Author Year
Research Design
Total Sample Size







Sitting Balance-Acute






Harvey et al. 2011







Population: 32 individuals- 30 males and 2 females; chronic SCI; motor level T1 – L1; 29 AIS A, 2 AIS B, 1 AIS C; age range= 24-31y; years post injury= 8-17 weeks


Treatment: In the control group, individuals received 6 weeks standard in patient rehabilitation. In the experimental group, participants received 6 weeks standard in patient rehabilitation + 3 additional 30-minute sessions/wk of 84 task specific exercises with 3 levels of difficulty (252 exercises) in unsupported sitting.


Outcome Measures: Maximal Lean Test (Maximal Balance Range), Maximal Sideward Reach Test.

1.     The mean between-group differences for the Maximal Lean Test, Maximal Sideward Reach Test and the Performance Item of the COPM were –20 mm, 5% arm length, and 0.5 points respectively.

Sitting Balance-Chronic (> 1 year SCI)






Boswell-Ruys et al. 2010






Population: 30 participants- 25 males and 5 females; 25 AIS A, 15 AIS B; level of injury: T1-12; mean age=45y; mean years post injury= 14.5y


Treatment: Participants in the experimental group receieved 1hr of 84 task specific exercises with 3 grades of difficulty in an unsupported sitting 3 times a week for 6 weeks. The control group did not receive any intervention.


Outcome Measures: Primary measures were: Upper Body Sway Test, Maximal Balance Range Test; Secondary measures were: Alternating Reach test (supported and unsupported), Seated Reach Test 45°to right, Coordinated Stability Test (Version A), Upper Body Sway Test (lateral and antero-posterior components).

1.     The between-group mean difference for the maximal balance range was 64mm.




Kim et al. 2010


Prospective Controlled Trial

Level 2



Population: 12 individuals- 9 males and 3 females; 11 AIS A, 1 AIS B; level of injury: T6-12. mean age= 40.86y


Treatment: The control group received conventional PT. The experimental group received conventional PT and goal-oriented training on a rocker board. The patients sat on a stable surface with their legs straight on the floor. Reach forwarrd, left and right, were all measured. Sessions were 5 sets of 10 reps 5 times a week for 4 weeks.


Outcome Measures: Modified Functional Reach Test, sway area and sway velocity using the Balance Performance Monitor

1.     There was an increase in the MFRT distance in the experimental group.

2.     The experimental group showed a decrease in sway area with both opened and closed eyes after training.

3.     The experimental group showed a significant difference before and after training compared to the control, as shown by MFRT distance and swaying area.


Bjerkefors et al. 2006



Level 4



Population: 10 individuals- 7 males and 3 females; 7 AIS A, 2 AIS B, 1 AIS C; level of injury between T3-12; mean age= 37.6 ± 12y; median years post-injury= 11.5y


Treatment: Participants paddled a modified kayak ergometer for 60 minutes 3 times a week for 10 weeks.


Outcome Measures: sit and reach tests

1.     Sit and reach tests significantly increased from 3.5cm at baseline to 5.8cm at the end of 10 weeks.






Bjerkefors et al. 2007



Level 4



Population: 10 individuals- 7 males and 3 females; 7 AIS A, 2 AIS B, 1 AIS C; level of injury between T3-12; mean age= 37.6 ± 12y; median years post-injury= 11.5y


Treatment: Participants paddled a modified kayak ergometer for 60 minutes 3 times a week for 10 weeks.


Outcome Measures: anterior-posterior (A/P), medio-lateral (M/L) angular and linear and twisting (TW) displacements on support surface translations – forward (FWD), backward (BWD) and lateral (LAT); Kinematic Responses include: I-onset of acceleration (unpredictable), II-constant velocity, III-deceleration (predictable), IV-end of deceleration

1.     A/P angular and linear and TW angular during LAT translations for all kinematic responses were significantly decreased except II for A/P angular

2.     M/L angular displacements during LAT translations-significant decrease for kinematic response IV.

3.     M/L linear displacement during LAT translations-no significant effects for all kinematic responses.

[why not in the same format as the ones above? I like how you did those – they are much clearer to get through in table format]






Grigorenko et al. 2004



Level 4



Population: Experimental group: 12 individuals- 9 males and 3 females; chronic SCI; 6 AIS A, 5 AIS B, 1 AIS C; level of injury: T2-11; mean age=40y; median years post-injury= 17y;

Control group: 12 able bodied participants who did not train


Treatment: Participants were involved in 2-3 modified kayak sessions on open water per week for 8 weeks.


Outcome Measures: sitting quietly on a force plate-standard deviation (SD), median velocity, median frequency

1.     Small effects in all 3 variables except on the median frequency in the sagittal plane (opposite to becoming normal)

2.     Before training and comparing to the control group, all variables differed.

3.     Small effects on balance variables-no significant effect.