Title: Is Partial Body Weight Supported Gait / Treadmill Training (BWSTT) Effective Following CNS Lesion
1Is Partial Body Weight Supported Gait / Treadmill
Training (BWSTT) Effective Following CNS Lesion
- Sean Knight
- Lisa Forster
- Shelby Kantar
2Learning Objectives
- Students will be able to
- Describe the history and facts of BWSTT
- Describe the populations best suited for BWSTT
- Describe the outcomes of Robotic BWSTT in pts
with SCI, CVA, MS - Describe the pros/cons of robotic-BWSTT (Locomat
or DGO) - Describe and differentiate aspects of
conventional BWSTT and Robotic BWSTT - Describe the outcomes of Conventional BWSTT in
pts with SCI and CVA - Describe the pros/cons of Conventional BWSTT
- Summarize differences between conventional BWSTT
and Robotic BWSTT and how it will affect your
decision making as a physical therapist.
3Introduction
- 3 months post stroke
- 25 of stroke survivors are wheelchair dependent
- 60 have reduced gait velocity and endurance
- (Hesse, S. 2008)
- Restoration of gait is major functional goal for
both patients and therapists in rehab - At this point an optimal Rx for gait has yet
- to be identified
- BWSTT is a task-oriented
- intervention that targets gait
- (Fulk, G. 2004)
4Why Choose BWSTT?
- Greater number of steps can be performed within a
single training session - Higher repetition up to 1000s steps/20 min on
treadmill vs. 50-100 steps/20 min conventional PT
- Most appropriate training intensity
- Adjust the speed
- Adjust amount of body weight support
- Adjust amount of PT assistance
- (Roy, M. 2009)
5History
- Animal research in 1960s
- Cats with transected spinal cords could produce
stepping patterns after several weeks of BWSTT - Partially supported in a sling and hind legs were
manually assisted on a treadmill - (Cardenas, D. 2003)
- First used in clinical settings in1980s
6Costs
- Treadmills range from 100s - 1000s
- Body weight support harness system 15,500
- 2 PTs manually assist pts gait deviations
- Labor intensive
- Min. time 20 min/treatment session
- (Roy, 2009)
7Research
8Populations Best Suited for BWSTT
- Stroke
- Traumatic Brain Injury
- Spinal Cord Injury
- Cerebral Palsy
- Down Syndrome
- Parkinsons Disease
- Amputees
- Multiple Sclerosis
9Robotic-BWSTT
- Literatures used term also
- DGO (Driven Gait Orthosis)
- Lokomat (manufacturers company)
- RAGT (Robot Assisted Gait Training)
- A motorized exoskeleton computer-controlled
device that generates passively guided,
symmetrical lower-extremity trajectories that are
consistent with a normal physiological gait
pattern.
10Robotics may help in BWSTT in incomplete SCI
- Subjects
- 2 males and 1 female with incomplete motor SCI
- Purpose
- Effectiveness of Robotic BWSTT
- Results
- Improvements in
- Time Up Go
- Functional Reach Test
- 6 Walk Test
- Sum of Modified MMT
- Over-ground ambulation
- Authors Conclusion
- Lack of control condition
- Too many confounding factors
- Only used 3 subjects
- Hornby, G., et al, Physical Therapy Journal
2005
11Robotics vs. PT Intervention
- Subjects
- Twelve ambulatory subjects with motor incomplete
spinal cord injury - Purpose
- To investigate differences in metabolic costs and
lower-limb muscle activity patterns during
robotic- and therapist-assisted treadmill
walking. - Results
- EMGs were lower in subjects using robotics
- Metabolic costs were higher in subjects using
robotics - Authors Conclusion
- When compared to PT assisted treadmill training
- Robotics use passive assistance which teaches
dependence - Robotics reduces subsequent motor performance and
retention - Robotics reduces voluntary muscle activity and
neuroplastic changes in the CNS - Jeffrey F Israel, et al, Physical Therapy
2006
12Title Robot-assisted gait training in multiple
sclerosis a pilot randomized trial
- Subjects 35 stable MS patients
- Purpose To compare Robotic Assisted Gait
Training (RAGT) with Conventional Gait Training
with PT. - Results
- Walking velocity, distance, and knee-extensor
strength increased more with RAGT than
conventional PT - Conventional PT gait training only improved
velocity - Authors Conclusion
- RAGT may be helpful in decreasing impairment in
MS patients - RAGT can be especially helpful with patients who
are severely impaired or patients where weight
may be an issue - Beer, S., et al, Multiple Sclerosis 2008
13Who does Robotic BWSTT REALLY help?
Title Prospective, Blinded, Randomized Crossover
Study of Gait Rehabilitation in Stroke Patients
Using the Lokomat Gait Orthosis.
- Subjects
- 16 stroke patients
- Purpose To compare Robotic BWSTT with
Conventional BWSTT with PT. - Results
- Significant improvement in Robotic-BWSTT in
- Rivermead Motor Assessment Scale
- 6 minute test - distance
- Ashworth scale
- Authors Conclusion
- Lokomat training eliminates prolonged repetitive
movements of non-ergonomic position on physical
therapists. -
- May, A., et al, Neurorehabilitation and
Neural Repair 2007
14People, not robots, prove to be better walking
assistants
- Subjects
- 48 stroke patients, 6 months post stroke
- Purpose To compare Robotic BWSTT using Lokomat
with Conventional BWSTT with PT. - Results
- Robotic passive swing assistance may have reduced
volitional drive necessary for motor memory
consolidation. - Lokomat was unable to increase intensity enough
to match conventional BWSTT intensity levels. - Authors Conclusion
- If robotic devices are altered to provide
compliant assistance or assistance as needed for
all biomechanical tasks associated with walking
in the same way therapists can, then they may
become equal or even superior. - Kristen J. Light., BioMechanics Magazine 2008
15Pros/Cons of Robotic BWSTT
- Pros
- Reduces manual labor of PT
- More repetition
- More consistent force
- Cons
- Cannot alter force as needed
- Once programmed for session, cant change
- Decreased specificity
- Expensive
- Too much afferent input
16Conventional BWSTT
17When looking at the points of contact, what would
be a disadvantage to robotic training?
- Robotic training places much more contact on the
patient generating an excess of sensory input,
which is not typical of ambulation. This is not
the case with PT assisted BWSTT.
VS
Physical Therapy Journal Vol. 85, No. 1, January
2005, pp. 52-66
18Title Walking training of patients with
hemiparesis at an early stage after stroke a
comparison of walking training on a treadmill
with body weight support and walking training on
the ground
Clinical Rehabilitation, Vol 15, No. 5, 515-527
(2001)
- 73 first acute stroke hemiparetic patients RCT
- BWSTT vs. On-Ground Training
- No significant difference
- Fugl-Meyer Stroke Assessment
- FIM score
- Berg Balance Assessment
- Walking Velocity
- Conclusion
- BWSTT was no better than ground training
- BWSTT rehabilitation in early stages of stroke is
a comparable choice to ground walking. -
- (Nilsson, L. 2001)
19Title A New Approach to Retrain Gait in
Stroke Patients through BWSTT stimulation.
Stroke. 1998 29 1122-1128.
- 100 chronic stroke patients
- With BWS vs. Without BWS
- Significant difference in BWSTT
- Berg Balance Score
- St.Re.A.M. score (also post 3 months)
- Ground walking
- Speed (also post 3 months)
- Endurance.
- Conclusion
- Retraining of gait in stroke population with
BWSTT resulted in better walking abilities than
without-BWSTT. - BWS allows for more symmetrical gait by not
allowing for compensatory mechanisms to develop - (Visintin, B. 1998)
20Title Effects of Task-Specific Locomotor and
Strength Training in Adults Who Were Ambulatory
After Stroke Results of the STEPS Randomized
Clinical Trial
- 80 chronic stroke patients
- 4 Groups
- BWSTT/LE-Ex
- BWSTT/UE-Ex
- BWSTT/Cycling
- Cycling/UE-Ex
- Significant increases in
- walking speed for BWSTT/UE-Ex compared to
Cycling/UE-Ex - No difference for walking distance for any groups
- Conclusion
- BWSTT is more effective in improving walking
speed and maintaining these gains at 6 months. - (Sullivan, K. J. et al. 2007)
21Title Gait Training Induced Changes in
Corticomotor Excitability in Patients With
Chronic Stroke
Neurorehabilitation and Neural Repair, Vol. 22,
No. 1, 22-30 (2008)
- 14 chronic stroke patients
- Ground Training alone vs. Ground Training BWSTT
- Significant changes in GT BWSTT
- Berg Balance Scale
- Walking speed and Step Length
- Decreased threshold for TA in unaffected side
- AH in affected hemisphere only
- General increases in Map Size for
- TA in both hemispheres.
- Correlation was found between corticomotor
excitability and functional improvement. - Conclusion
- GT BWSTT may
- Induce changes in corticomotor excitability.
- Improve balance and gait performance.
- (Yen, C. 2008)
22Cochrane Corner
Stroke. 2003343006
- 11 trials
- 458 participants
- There was NO statistically significant
differences between BWSTT and other interventions
for walking dependence for participants who were
dependent walkers at the start of the treatment.
23Title Spinal Cord Injury Locomotor Trial Group.
Weight-supported treadmill vs over-ground
training for walking after acute incomplete SCI.
Neurology. 2006 66 352 - 356
- 146 subjects within 8 weeks of incomplete SCI.
- ASIA Scale B, C, D only
- BWSTT vs. Over-ground mobility therapy
- No significant difference in
- FIM-L scores (functional tests)
- Walking speeds (functional tests)
- Conclusion
- Physical therapy strategies of BWSTT and over
ground training did not produce different
outcomes - This finding was partly due to the unexpectedly
high percentage of American Spinal Injury
Association C subjects who achieved functional
walking speeds, irrespective of treatment - (Dobkin, B. 2006)
24Title Efficacy of partial body weight-supported
treadmill training compared with overground
walking practice for children with cerebral
palsy a Randomized Controlled Trial
- 26 children with CP classified level III or IV
- PBWSTT vs. Over-Ground Walking
- No Significant Difference
- 10-meter walk test (self-selected walking speed)
- 10-minute walk (walking endurance)
- Conclusion
- safe and feasible to implement, however, it may
be no more effective than over-ground walking for
improving walking speed and endurance for
children with CP -
- (Willoughby, K. Arch Phys Med Rehabil. 2010)
25Pros/Cons of Conventional BWSTT
- Pros
- More repetition
- Safety
- of pts BW is supported
- Risk of falling during training
decreased/eliminated - PT can control speed, inclination, percent
un-weighted - PT can control movement aspects of leg
- Can decrease likelihood of developing
compensatory mechanisms in abnormal gait - Cons
- Cost
- Manual labor of 2 PTs
26Summary of Conventional BWSTT and Robotic BWSTT
- Robotic BWSTT
- Pros
- Does not require manual labor of 2 pts
- More consistent force
- Cons
- Robots are expensive
- Force cannot be readily altered
- Too much afferent input, which is unlike normal
gait
- Conventional BWSTT
- Pros
- Less Expensive
- Control Speed
- Control angle of inclination
- Control weighted
- Control sensory input the patient will feel and
closer replicates normal gait
- BOTH
- Pros
- Repetition
- Safety
- Cons
- Not task specific
- Does not mimic real life situations
- Does not require normal balance in gait
27Considerations of BWSTT
- Supraspinal input is necessary in order to
restore gait. - Thus, BWSTT can complement, but NOT replace task
oriented over ground gait training. Hubertus
Hedel, Ph.D., P.T. - Maintenance of equilibrium is NOT trained due to
body weight unloading. - Lack of specificity to patients functional goal
- Can alter only inclination
28Review of Learning Objectives
- Students should be able to
- Describe the history and facts of BWSTT
- Describe the populations best suited for BWSTT
- Describe the outcomes of Robotic BWSTT in pts
with SCI, CVA, MS - Describe the pros/cons of robotic-BWSTT (Locomat
or DGO) - Describe and differentiate aspects of
conventional BWSTT and Robotic BWSTT - Describe the outcomes of Conventional BWSTT in
pts with SCI and CVA - Describe the pros/cons of Conventional BWSTT
- Summarize differences between conventional BWSTT
and Robotic BWSTT and how it will affect your
decision making as a physical therapist.
29References
- Beer, S., Aschbacher, B., Manoglou, D., Gamper,
E., Kool, J., Kesselring, J. Robot-assisted gait
training in multiple sclerosis a pilot
randomized trial. Multiple Scleorsis Journal
2008 Vol. 14, No. 2, 231-236 - Biodex System. http//www.biodex.com/rehab/unweigh
ing/unweighing_470feat.htm - Cardenas, Diana. Body-weight-supported treadmill
training for SCI. University of Washington School
of Medicine Department of Rehabilitation
Medicine. 2003 12(1) - Fulk, George. Locomotor training with body weight
support after stroke the effect of different
training parameters. Journal of Neurolgic
Physical Therapy. March 2004 - Hesse, Stefan. Treadmill training with partial
body weight support after stroke a review.
NeuroRehabilitation 2008 23 5565. - Hornby, G., Zemon, D., Campbell, D.
Robotic-sssisted, body-weightsupported treadmill
training in individuals following motor
incomplete spinal cord injury. Physical Therapy
Journal 2005, pp 52-66 - Jeffrey F Israel, Donielte D Campbetl, Jennifer H
Kahn T George Hornby. Metabolic Costs and Muscle
Activity Patterns During Robotic- and
Therapist-Assisted Treadmill Walking in
Individuals With Incomplete Spinal Cord Injury.
Physical Therapy November 2006. Volume 86, Number
11. - Kristen J. Light. People, not robots, prove to be
better walking assistants. BioMechanics Magazine
Sep2008, Vol. 15 Issue 9, p17-18 2p. - May, A., Kofler, M., Quirback, E., Matzak, H.,
Frohlinch, K., Saltuari, L. Prospective, blinded,
randomized crossover study of gait rehabilitation
in stroke patients using the lokomat gait
orthosis. Neural Repair 2007 21 307 - Mosely, A. M., Stark, A., Cameron, I. D.,
Pollock, A. Treadmill training and body weight
support for walking after stroke. Journal of the
American Heart Association. 2003 34 3006 - Neville Hogan, PhD, et al. Motions or muscles?
Some behavioral factors underlying robotic
assistance of motor recovery. Journal of
Rehabilitation Research Development
August/September 2006. Volume 43, Number 5, Pages
605618. - Nilsson, L., Carlsson, J., Danielsson, A.,
Fugl-Meyer, A., Hellstrom, K., Kristensen, L.,
Sjolund, B., Sunnerhagen, K. S., Grimby, G.
Walking training of patients with hemiparesis at
an early stage after stroke a comparison of
walking training on a treadmill with body weight
support and walking training on the ground.
Clinical Rehabilitation. 2001 15 515-527 - Nuberwalker. http//www.nciia.org/WebObjects/Nciia
Resources.woa/wa/View/GrantProfile?n1000460 - Roy, Marc-Andre. Body Weight Supported Treadmill
Training for Stroke Family/Patient.
Information. http//strokengine.ca/ - Sullivan, K. J., Brown, D. A., Klassen, T.,
Mulroy, S., Ge, T., Azen, S. P., Winstein, C. J.
Effects of task-specific locomotor and strength
training in adults who were ambulatory after
stroke Results of the STEPS randomized clinical
trial. Physical therapy. 2007 87 1580-1602. - Visintin, M., Barbeau, H., Korner-Bitensky, N.,
Mayo, N. E. A new approach to retain gait in
stroke patients through body weight support and
treadmill stimulation. Journal of the American
Heart Association. 1998 29 1122-1128. - Dobkin, B., Apple, D., Barbeau, H., Basso, M.,
Behrman, A., Deforge, D., Ditunno, J., Dudley,
G., Elashoff, R., Fugate, L., Harkema, S.,
Saulino, M., Scott, M. Weight-supported treadmill
training vs. over-ground training for walking
after acute incomplete SCI. Neurology. 2006
66(4) 484-93 - Yen, C., Wang, R., Liao, K., Huang, C., Yang, Y.
Gait training induced change in corticomotor
excitability in patients with chronic stroke.
Neurorehabilitation and Neural Repair. 2008.
22 22-30. - Willoughby, K , Dodd, K, Shields, N., Foley, S..
Arch Phys Med Rehabil. 2010 Jan91(1)115-22.