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BWSTT in Chronic SCI

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Table 9: Studies Using Treadmill Training in Chronic SCI (>1 year post-injury)

Discussion

As shown in Table 9, there have been 19 pre-post studies, 9 RCT (Musselman et al., 2009; Nooijen et al., 2009; Field-Fote et al., 2005; Field-Fote & Roach, 2011; Lucareli et al., 2011; Gorman et al., 2016; Lam et al., 2014; Labruyere et al., 2014) 5 prospective Controlled Trial (Gorassini et al., 2008) and 2 case-control studies (Wernig et al., 1995; Benito Penalva et al., 2010) that altogether studied 812 persons with complete and incomplete SCI, with chronicity ranging from 1 to 28 years post-injury (although years of chronicity was not specified in Field-Fote et al. 2011 study). Treatment intensity ranged from 45 to 300 minutes per week, and treatment duration lasted between 3 and 48 weeks. Based on the stated primary outcome measure of each study where data was available, about 70% of all participants across these studies showed some improvement following treatment (Musselman et al., 2009; Gorassini et al., 2009; Hicks et al., 2005; Yang et al., 2011; Winchester et al., 2009; Protas et al., 2001; Thomas & Gorassini et al., 2005; Effing et al., 2006; Wernig et al., 1995). In the Harkema et al. 2012 study, 88% of patients had responded to locomotor training treatment, but this study included participants that had been injured less than one year.

All studies generally show improvements in overground walking capacity, whether locomotor training was provided with a treadmill or performed over ground, body-weight support, or involved other variations on walk-based therapies (e.g. over ground training with obstacles, robot-applied resistance. Alternative gait retraining therapies or modified approaches to BWSTT for chronic SCI are being introduced (Musselman et al., 2009; Stevens, 2010; Wu et al., 2012; Lam et al., 2014; Yang et al., 2014). Musselman et al. (2009) and Yang et al (2014) compared BWSTT with over ground ‘precision’ skilled walking training. The skilled walking training consisted of task-specific practice (without body weight support) of various gait tasks, such as stair climbing, obstacle crossing, and walking along sloped surfaces. BWSTT was better than precision over ground training in improving walking distance. Surprisingly, both training groups were comparable in improving walking skill. Wu et al. (2012) demonstrated a new cable-driven robotic device to apply resistance against leg movements during BWSTT. Participants were randomized (in a cross-over design) to receive robotic resistance or assistance BWSTT. Although there were no significant differences in outcomes between the two modalities, there was some indication that robotic resistance enabled greater gains in over ground walking speed in people who tended to have better initial ambulatory capacity; conversely, robotic assistance seemed to enable greater gains in walking speed in those who were initially slower walkers. More recently, Lam et al. (2014) showed that training with Lokomat-applied BWSTT with resistance yielded better improvements in skilled walking function that were retained even 6 months post-intervention, vs. Lokomat-assisted BWSTT.

Conclusion

There is level 1b evidence from 1 RCT (Field-Fote & Roach, 2011) that different strategies for implementing body weight support gait retraining all yield improved ambulatory outcomes in people with chronic, incomplete SCI, except for robotic assisted treadmill training which showed little change in walking speed. It is recommended that therapists may choose a body weight support gait retraining strategy based on available resources (Field-Fote & Roach, 2011).

There is level 4 evidence from pre-test/post-test studies (Behrman et al., 2012; Buehner et al., 2012; Harkema et al., 2012; Lorenz et al., 2012; Winchester et al., 2009; Hicks et al., 2005; Wirz et al., 2005; Thomas and Gorassini, 2005; Protas et al., 2001; Wernig et al., 1998) that BWSTT is effective for improving ambulatory function in people with chronic, incomplete SCI.

  • Body weight-support gait training strategies can improve gait outcomes in chronic, incomplete SCI, but most body weight-support strategies (overground, treadmill, with FES) are equally effective at improving walking speed.

    Robotic training was the least effective at improving walking speed, but strategies that provide advanced challenge, such as through practice of skilled walking tasks over-ground or application of resistance against leg movements during walking show promising results.