Lower Limb Table 4: Locomotor Training Studies Examining Strength Measures

Author Year; Country
Score
Research Design
Sample Size

Methods

Outcomes

Field-Fote & Roach 2011;

USA

PEDro = 8

RCT

N=64

Population: Patients with chronic SCI at least 1 year post-injury, mean ages between 38 and 45; TM group (14 males, 3 females), TS group (14 males, 4 females), OG group (11 males, 4 females), LR group (12 males, 2 females)

Treatment: Training 5 days/week for 12 weeks with: treadmill-based training with manual assistance (TM), treadmill-based training with stimulation (TS), overground training with stimulation (OG), or treadmill-based training with robotic assistance (LR)

Outcome Measures: Walking speed (over 10m), distance walked in 2 minutes, lower LEMS

  1. There was a significant time effect of training on the LEMS scores of the right and left leg: LEMS scores of all participants increased 8-13%, with no significant between-group differences.

Tester et al. 2011;

USA

Observational

N=30

Population: 22 males, 8 females; mean(SD) age 40(14), 23(18) months post-injury; AIS score C or D

Treatment: 21 participants underwent a 9-week manual-assisted locomotor training (LT) with 5 sessions/week; each session entailed 20-30 minutes of partial BWS treadmill stepping with manual assistance as needed

Outcome Measures: presence of arm swing in relation to LEMS, WISCI II presence of arm swing

 

  1. Arm swing was absent during treadmill stepping for 18/30 (60%) of individuals
  2. There was no significant difference between arm-swing vs. no arm-swing groups in the level of injury or UEMS but there was a significant difference in LEMS

 

Benito Penalva et al. 2010;

Spain

Case control

N=42

Population: 29 motor incomplete SCI patients (24 males, 5 females, mean age 47; Group A < 3 months post-injury (n=16), Group B > 3 months post-injury (n = 13)

and 13 healthy volunteers (10 males, 3 females, mean age 32) with pre-test only

Treatment: Gait training using either the Lokomat or Gait Trainer GT1 (based on availability of the system), 20-45 minutes per sessions (5 days a week for 8 weeks).

Outcome Measures: the LEMS, WISCI II, 10MWT, H reflex modulation by TMS

  1. After gait training, there was a significant improvement in LEMS for both groups

Jayaraman et al. 2008;

USA

Pre-Post

N = 5

Population: 5 subjects with chronic SCI, age 21-58, level of injury C4-T4.

Treatment: 45 30-min sessions of locomotor training (LT) with partial BWS spread over 9-11 weeks.

Outcome Measures: Voluntary contractile torque; voluntary activation deficits (using twitch interpolation), muscle cross-sectional area (CSA) using MRI.

  1. All subjects demonstrated improved ability to generate peak isometric torque, especially in the more involved plantar flexor (PF, +43.9 + 20.0%) and knee extensor (KE,+21.1+12.3%) muscles
  2. Significant improvements of activation deficit in both KE and PF muscles
  3. All subjects demonstrated increased muscle CSA ranging from 6.8% –21.8%

Gregory et al. 2007;

USA

Case series

N=3

Population: 3 males; all subjects were diagnosed asAIS D; 17-27 mos post-injury.

Treatment: 12 weeks, 2-3 sessions/week of lower extremity resistance training combined with plyometric training (RPT). Resistance exercises included unilateral leg press, knee extension/flexion, hip extension/flexion and ankle plantar flexion exercises on adjustable load weight machines. Subjects performed 2-3 sets of 6-12 repetitions at an intensity of ~70-85% of predicted 1 RM. Unilateral plyometric jump-training exercises were performed in both limbs on a ballistic jump-training device (ShuttlePro MVP ®). Subjects completed a total of 20 unilateral ground contacts with each limb at a resistance of ~25% of body mass. Upon successful completion of at least 20 ground contacts, resistance was increased in increments of 10 lbs.

Outcome Measures: Maximal cross-sectional area of muscle groups, dynamometry, maximum and self-selected overground gait speed.

  1. RPT resulted in an improved peak torque production in the knee extensors (KE) and ankle plantar flexors (PF).
  2. Time to peak tension decreased from mean (SD) 470.8(82.2) ms to 312.0(65.7) ms in the PF and from 324.5(35.4) ms to 254.2(34.5) ms in the KE.
  3. Average rate of torque development and the absolute amount of torque generated during the initial 220 ms during a maximal voluntary contraction improved; more pronounced improvements in the PF than the KE.
  4. On average, training resulted in a mean (SD) 14.2(3.8) and 8.3(1.9)% increase in max-CSA for the PF and KE, respectively.
  5. RPT resulted in reductions in activation deficits in both the PF and KE muscle groups.
  6. Average 36.1% increase in maximum gait speed and 34.7% increase in self-selected gait speed after training.

Hornby et al. 2005b;

USA
Pre-post
N=3

Population: 2 males, 1 female; AIS C; 5 weeks/ 6 weeks/ 18 months post-injury.

Treatment: Therapist and Robotic-assisted, body-weight-supported treadmill training (parameters varied between subjects).

Outcome Measures: LEMS, functional mobility outcomes.

  1. No group statistics
  2. Increase in AIS lower limb motor scores in 2/3 subjects in acute phase (5 & 6 weeks) which cannot be separated from natural recovery. No changes seen in 3rd person initiated at 18 months.

Field-Fote 2001;

USA
Pre-post

N=19

Population: 13 males and 6 females; mean age 31.7 yrs; all subjects were diagnosed as AIS C; >1 yr post-injury.

Treatment: Body weight-supported treadmill walking with peroneal nerve FES of the weaker limb for 1.5 hours, 3X/week, 3 months.

Outcome Measures: LEMS, Gait outcomes.

  1. LEMS had median increases of 3 points in both the FES-assisted leg and the non-stimulated leg
  2. Increase in AIS lower limb motor scores in 15 of 19 incomplete SCI (AIS C).

Petrofsky 2001;

USA
Prospective Controlled Trial
N=10

Population: 10 males; age 22-30 yrs; incomplete, T3-T12 lesion level

Treatment: The control group (n=5) had 2-hour daily conventional physical therapy, including 30 min biofeedback of more affected gluteus medius for 2 months. Experimental treatment (n=5) had same program and used a portable home biofeedback device.

Outcome Measures: Muscle strength (isometric strain gauge transducer) and gait analysis.

  1. Gains in strength (in quadriceps, gluteus medius and hamstring) were seen for both groups but were greater for the experimental group than controls.
  2. After 2 months of therapy the reduction in Trendelenburg gait was greater for the experimental group than for the control group and the experimental group showed almost normal gait.

 

Wernig et al. 1998; Germany
Pre-post
N=76

Population: Strength data reported for 25 chronic subjects only

Treatment: BWSTT (Laufband therapy). 1-2X/day for 30 minutes, 5 days/week for 8-20 weeks.

Outcome Measures: Voluntary muscle scores and walking function.

  1. No group statistics.
  2. All subjects showed increases in cumulative muscle scores (i.e. 8 muscles summed) indicative of increased strength.

Wernig et al. 1995; Germany
Case Control
N=153

Population: 153 subjects; locomotor training group: n=89 (44 chronic, 45 acute); control group: n=64 (24 chronic, 40 acute)

Treatment: BWSTT (Laufband therapy) vs conventional rehabilitation. Specific parameters for each were not described or appeared to vary within and between groups.

Outcome Measures: Manual muscle testing, walking function and neurological examination pre and post training.

  1. 6 /20 chronic individuals initially “nearly paralysed” gained bilateral muscle strength (increased manual muscle testing)
  2. For acute patients, no differences in strength gains between BWSTT and conventional rehab.
  3. Authors noted that locomotor gains had little correlation with strength gains.

Granat et al. 1993;

UK
Pre-post
N=6

Population: 3 males and 3 females; age 20-40 yrs; all subjects were diagnosed as Frankel C or D; C4-L1 lesion level; 2-18 yrs post-injury.

Treatment: FES-assisted locomotor training to quadriceps, hip abductors, hamstrings, erector spinae, common peroneal nerve, minimum 30 min, 5 days/week.

Outcome Measures: Manual muscle tests, maximum voluntary contraction (MVC), upright motor control, spasticity, balance and gait outcomes.

  1. Significant increase in strength (increase in hip flexors and knee extensor manual muscle test).
  2. Increased strength as indicated by increased quadriceps torque with MVC.
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