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Overground Training for Gait Rehabilitation

Table 3: Prevention of AD during Bladder Procedures

Author Year; Country
Score
Research Design
Sample Size
MethodsOutcomes
 

Senthilvelkumar et al. 2015

India

RCT

PEDro=7

Level 1

N= 16

 

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).

1.     There was no statistically significant between group differences in the Walking Index for Spinal Cord Injury [mean difference=0.3points; 95% CI (-4.8 to 5.4); p=0.748].

2.     No statistically significant between group differences in the Lower Extremity Muscle Score either [mean difference=0.2 points; 95% CI (-3.8 to 5.1); p=0.749].

 

 

 

 

 

Pramodhyakul et al. 2016

Thailand

RCT

Level 1

PEDro=5

N= 32

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

1.     The participants demonstrated significant improvement in all functional tests after the 5 days of training. The improvement in the group trained using the visuotemporal cue was significantly better than that trained without using the cue.
 

 

 

 

 

Jones et al. 2014

USA
RCT

PEDro=5

Level 2

N= 38

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).

1.     ABT had a positive effect on neurologic function (International Standards for Neurological Classification of Spinal Cord Injury total motor score and lower extremity motor score.)

2.     ABT had a positive effect on 10-meter walk test speed and 6-minute walk test total distance.

 

 

 

 

 

Jones et al. 2014

USA

Secondary analysis of results from a randomized controlled trial

PEDro=5

N= 38

 

 

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).

1.     On the basis of the most conservative estimate, 18%, 26%, and 32% of the participants demonstrated clinically significant improvements on the TUG test, the 10MWT, and the 6MWT, respectively.

2.     This secondary analysis identified likely responders to ABT on the basis of injury characteristics: AIS classification, time since injury, and initial walking ability.

3.     Training effects were the most clinically significant in AIS grade D participants with injuries <3 years in duration.

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data

 

Oh & Park 2013

Korea

Pre-post

Level 4

N=4

 

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.

1.   All outcome measures indicated an improvement in lower limb function from baseline to 4-wk follow-up, as well as from baseline to the 1-yr follow-up:

* values are median (interquartile range)

10MWT: walking speed was 0.58 (0.48-0.78) at baseline; increased to 0.85 (0.66-1.12) at 4-wk follow-up and 0.97 (0.83-1.02) at 1-yr follow-up

6MWT: walking distance was 172.5 (169-198) m at baseline; increased to 259.5 (208.5-337.5) at 4-wk follow-up, 280 (250-323.5) at 1-yr follow-up

CWT: minutes taken to finish the test decreased from 11.86 (9.13-14.24) at baseline to 8.47 (5.98-11.4) at 4-wk follow-up and 7.55 (6.88-8.89) at 1-yr follow-up

WAQ score increased from 38 (27.5-46.5)

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.

  • Community-based ambulation training that is progressively challenged may result in long-lasting benefits in incomplete SCI.