Overground Training for Gait Rehabilitation
Overground training is usually implemented when there is improved neuromuscular capacity and the person with SCI is ready to learn overground skills to utilize in the home and community. Though overground training is often used as a control group for other types of treatment (e.g., treadmill training) and are described in those respective sections, there is one study that assessed a progressive approach to overground training.
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Author Year; Country |
Methods |
Outcomes |
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Senthilvelkumar et al. 2015; India |
Population: 16 individuals; motor incomplete tetraplegia; 0-2yrs post-injury. Treatment: Participants were randomized to one of two groups: body weight-supported overground training on level ground and body weight-supported treadmill training. Both groups received 30 minutes of gait training per day, five days a week for eight weeks. In addition, both groups received regular rehabilitation which included flexibility, strength, balance, self-care, and functional training. Outcome Measures: The primary outcome measure was the Walking Index for Spinal Cord Injury (/20 points) and the secondary outcome was the Lower Extremity Muscle Score (/50 points). |
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Pramodhyakul et al. 2016; Thailand |
Population: 32 individuals- 26 males and 10 females; incomplete SCI; 26 AIS D and 10 AIS C; mean age= 41.69 ± 10.90y; months post injury= 35.00 ± 24.40 months Treatment: Participants were randomly assigned to the experimental or control groups using stage of injury, severity of SCI, and baseline walking ability as criteria for group arrangement (16 participants per group). The participants were trained to walk over level ground at their fastest safe speed with or without a visuotemporal cue, 30 minutes/day, for 5 consecutive days. Outcome Measures: 10 MWT, 6 MWT, Timed up and Go Test (TUG), 5 times sit to stand test. |
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Jones et al. 2014; USA |
Population: 38 individuals- 27 males and 11 females; chronic, motor incomplete SCI; AIS C or D; age range= 22-63y; years post injury= >12 months. Treatment: A total of 9h/wk of Activity-based Therapy (ABT) for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. Outcome Measures: Neurologic function (International Standards for Neurological Classification of Spinal Cord Injury), 10-MWT, 6-MWT, and Timed Up and Go test, community participation (Spinal Cord Independence Measure, version III, and Reintegration to Normal Living Index), metabolic function (weight, body mass index, and Quantitative Insulin Sensitivity Check). |
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Jones et al. 2014; USA |
Population: 38 individuals- 27 males and 11 females; chronic, motor incomplete SCI; AIS C or D; age range= 22-63y; years post injury= >12 months. Treatment: A total of 9h/wk of Activity-based Therapy (ABT) for 24 weeks including developmental sequencing; resistance training; repetitive, patterned motor activity; and task-specific locomotor training. Algorithms were used to guide group allocation, functional electrical stimulation utilization, and locomotor training progression. Outcome Measures: Walking speed and endurance (10-meter walk test and 6-minute walk test) and functional ambulation (timed Up and Go test). |
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Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data |
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Oh & Park 2013; Korea |
Population: 4 participants with incomplete SCI (3M, 1F); 33-63 yrs old; 2 AIS C, 2 AIS D. Treatment: 4-week training program consisting of 4 stages with different community situations. In each stage, patients underwent 1 hr sessions of community-based ambulation training; 6 times/wk for a 4 week period. During the training period, the level of difficulty was increased weekly with progressive changes in environmental demands. Outcome Measures: 10MWT; 6MWT; CWT; WAQ; ABC. |
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Discussion
Overground training can only be undertaken with higher functioning people with incomplete SCI, although the emergence in recent years of robotic exoskeletons has facilitated the opportunity for overground gait training in motor-complete SCI. However, overground training provides an important mode of exercise for improving walking function, and likely other physical and mental functions (e.g., muscle strength, balance, bone health, cardiovascular function, or depression symptoms) shown to be positively affected by exercise in the general population. In people with motor-incomplete SCI, several studies have indicated the benefits of overground training on functional walking capacity (Forrest et al. 2014; Oh & Park 2013). Overground training has also been integrated with wider variety of other exercises to provide more comprehensive therapy (Jones et al. 2014) and others have suggested the additive benefits of providing visuotemporal cues during walk training (Pramodhyakul et al. 2016). One Level 1 RCT (Senthilvelkumar et al. 2015) shows no differences between overground vs treadmill-based training. Oh and Park (2013) found that an intensive 6x/week, 4-week training program resulted in effects at 1-year follow-up and demonstrate the positive benefits of exercise.
Conclusion
There is Level 1 evidence (Senthilvelkumar et al. 2015) that overground and treadmill-based training are comparable.
There is level 4 evidence (Oh & Park 2013) that community-based ambulation training that is progressively challenging may result in long-lasting benefits in incomplete SCI.
