Pain points in gait training for spinal cord injury patients

For many spinal cord injury (SCI) patients, gait training isn't just a therapy—it's a lifeline. It's the promise of regaining independence, of walking their child to school, of strolling through a park without assistance. But behind the hopeful smiles in rehab centers lies a reality far more complex than the simple phrase "relearning to walk." John, a 32-year-old former teacher who suffered a T10 injury in a car accident, puts it bluntly: "They tell you it's about strength, but no one warns you about the days you'll cry because your legs won't even lift an inch, or the nights you'll lie awake wondering if you'll ever feel the ground beneath your feet again."

Gait training, whether through traditional therapist-assisted exercises or cutting-edge technology like robotic gait trainers, is physically grueling. But the pain points extend far beyond sore muscles. They're emotional, financial, logistical, and even technical—barriers that can chip away at a patient's resolve, even when their spirit remains unbroken. In this article, we'll pull back the curtain on these hidden struggles, exploring why gait training often feels like an uphill battle, and what needs to change to make the journey less isolating.

When someone with an SCI steps into a gait training session, their body is often fighting against years of disuse. Muscle atrophy sets in quickly after injury; even a few weeks of immobility can leave legs that once ran marathons feeling like dead weight. But the physical challenges go deeper than weakness alone.

Spasticity, a common side effect of SCI, turns muscles into rigid, uncooperative opponents. Imagine trying to straighten your knee, only to have it jerk back into a bent position—over and over—during a single session. "It's like my leg has a mind of its own," says Maria, a 45-year-old who injured her spine in a fall. "One minute, I'm focused on shifting my weight; the next, my calf is spasming so hard it feels like it's going to snap. By the end of the hour, I'm sweating more from fighting my own body than from the actual exercise."

Joint contractures, another hurdle, occur when muscles and tendons shorten from prolonged immobility, leaving limbs stuck in fixed positions. A patient with a contracture in their hip might struggle to even stand upright in a gait trainer, let alone take a step. These issues aren't just inconvenient—they can derail progress for weeks, as therapists first work to stretch tight tissues before addressing walking itself.

And then there's fatigue. SCI patients often experience "neurogenic fatigue," a bone-deep exhaustion caused by the brain's struggle to send signals through damaged spinal pathways. "I'll start a session feeling okay, but after 10 minutes of trying to engage my quads, I'm ready to collapse," John explains. "It's not just tiredness—it's like my nervous system hits a wall and shuts down. My therapist says it's normal, but it still makes me feel like I'm failing."

Physical pain fades with rest, but the emotional toll of gait training lingers. For many patients, the biggest pain point isn't the effort—it's the uncertainty. "They told me I'd see improvement in 6 months," says Raj, a 28-year-old SCI patient. "Eight months in, I can lift my foot 2 inches instead of 1. Is that progress? My therapist says yes, but all I see is how far I am from walking my dog again."

This sense of stagnation breeds frustration, and frustration often spirals into self-doubt. Social media doesn't help; patients scroll through posts of others with similar injuries "miraculously" walking after a few months, never seeing the outtakes—the countless failed attempts, the tears, the sessions cut short. "I follow this SCI influencer who posts videos of herself dancing in a robotic exoskeleton," Maria admits. "I know she's trying to inspire, but some days, it just makes me feel worse. Why can't I do that? What's wrong with me?"

Hopelessness can creep in, too. When every step requires Herculean effort and setbacks are common (a spasm flare-up, a minor infection that halts training), even the most determined patients can start to question if the fight is worth it. "There was a week where I skipped three sessions," John recalls. "I told myself I was 'resting,' but really, I was scared. What if this is as good as it gets? What if I'm never going to walk again?"

Therapists often prioritize physical goals, but mental health support is rarely integrated into gait training programs. "My rehab center has a psychologist, but you have to schedule an appointment weeks in advance," Raj notes. "By then, the moment has passed. I needed someone to talk to that day I cried in the locker room, not a month later."

Robotic gait training has revolutionized rehab for SCI patients. Devices like the Lokomat or Ekso Bionics exoskeletons promise consistent, repetitive movement—critical for rewiring neural pathways—without straining therapists. But for many, this "high-tech hope" comes with a steep price tag that's impossible to ignore.

Traditional gait training, which relies on manual assistance from therapists, is already costly, with sessions ranging from $100 to $300 an hour. Robotic gait training? Add $50–$100 more per session, and many insurance plans cap coverage or refuse to pay altogether. "My insurance covers 12 sessions of robotic gait training a year," Maria says. "Twelve. That's one month. After that, it's $250 out of pocket per session. I can't afford that—my medical bills are already drowning me."

Even for patients who can access robotic gait trainers in rehab, the transition to home use is another financial nightmare. A basic lower limb exoskeleton for home therapy can cost $50,000 or more—far beyond the means of most families. "My therapist suggested a home unit to keep practicing between sessions," Raj explains. "I laughed and said, 'Do I look like I own a mansion?' Even used models are $20k. It's not an option."

The cost barrier isn't just about money; it's about equity. Patients with private insurance or financial savings can afford extra sessions, while those on Medicaid or with limited resources are left with traditional therapy alone. "It's a two-tiered system," John says. "If you're rich, you get the robot that might help you walk. If you're not, you get a therapist who's spread thin, helping three patients at once. It feels like my recovery is being decided by my bank account, not my potential."

Even if cost weren't an issue, many SCI patients face another hurdle: access. Robotic gait trainers and specialized gait training programs aren't available in every city, let alone every town. "I live in a rural area," says Sarah, a 40-year-old SCI patient from the Midwest. "The nearest rehab center with a robotic gait trainer is 3 hours away. That means waking up at 5 a.m., driving 6 hours round trip, and paying for gas and a hotel if sessions run late. It's exhausting—mentally and physically."

For patients with limited mobility, transportation itself is a nightmare. Wheelchair-accessible vans are expensive, and public transit often isn't reliable. "I tried taking the bus once," Sarah adds. "It broke down, and I missed my session. Now I pay $80 a week for a ride service. That's money I could be using for therapy."

Urban patients aren't immune, either. Top-tier rehab centers in cities like New York or Los Angeles have long waitlists—sometimes 6 months or more—to access robotic gait training. "I called 10 centers before I found one with an opening," Maria says. "By the time I started, I'd already lost months of potential progress. Every day that passes, my muscles get stiffer, my hope dims a little more."

And even when patients do get in, session times are often rushed. With therapists juggling multiple patients and insurance companies limiting session lengths, there's little time for personalized attention. "My robotic gait training sessions are 45 minutes, but 15 of those are spent strapping me into the machine," John says. "Then the therapist is checking her watch, making sure we hit the 'reps' the insurance company requires. It feels like I'm a number, not a person."

Robotic gait trainers and lower limb exoskeletons are marketed as "intelligent" tools that adapt to each patient's needs. But the reality is often clunkier. "The exoskeleton is supposed to sense when I want to take a step," Raj explains. "But half the time, it moves too fast, jerking my leg and causing spasms. Other times, it doesn't move at all, like it's ignoring me. My therapist has to hit 'reset' so many times, we lose valuable minutes."

Many devices are designed with "average" body types in mind, leaving patients with unique builds struggling to fit. "I'm 5'10", but my legs are longer than average," Sarah says. "The exoskeleton straps dig into my hips, and the knee joints don't align with mine. After 20 minutes, I'm in pain—not from the exercise, but from the machine itself. It's supposed to help, not hurt."

Software glitches are another frustration. "One session, the robot suddenly shut down mid-step," Maria recalls. "I was stuck standing, suspended in the harness, for 10 minutes while they rebooted it. By then, my legs were shaking so bad, I couldn't finish the session. It's not the therapist's fault, but it makes you wonder: If this is 'state-of-the-art,' how far are we really from reliable technology?"

Even when devices work perfectly, they lack the nuance of human touch. A therapist can adjust their approach in real time—slowing down when a patient grimaces, encouraging when they falter. A robot? It's programmed to hit metrics, not read emotions. "My therapist knows when I'm about to give up," John says. "She'll say, 'Remember when you couldn't lift your foot at all? Look at you now, taking three steps.' The robot just beeps and says, 'Complete 10 more reps.' It's cold. Impersonal."

To better understand the trade-offs patients face, let's compare the pain points of traditional therapist-assisted gait training and robotic gait training:

Gait training for SCI patients is a journey fraught with invisible struggles. It's the physical pain of spasticity and fatigue, the emotional weight of slow progress, the financial burden of high-tech tools, the frustration of inaccessible care, and the limitations of technology that promises more than it can deliver. These pain points don't just hinder recovery—they chip away at a patient's sense of self, turning "relearning to walk" into a battle for dignity.

But there's hope. As researchers develop more affordable, adaptable lower limb exoskeletons, as insurance companies begin to recognize the long-term value of comprehensive gait training coverage, and as rehab centers integrate mental health support into their programs, the path forward is becoming clearer. Most importantly, there's a growing movement to center patients' voices—to listen when they say, "This hurts," and to build solutions that address their whole selves, not just their legs.

John, now 14 months into his recovery, sums it up best: "Gait training isn't just about walking. It's about feeling seen. It's about someone asking, 'How are you doing today?' and actually caring about the answer. If we can fix that—if we can make patients feel supported, not just treated—then maybe 'one step at a time' won't feel so impossible."

For SCI patients, every step forward is a victory. But until we address the pain points that make those steps feel like defeats, we're only seeing half the story.