Bodyweight Supported Treadmill Training: Current Evidence (Part 2)

Part 2

This begins Part 2 of a series on bodyweight supported treadmill training (BWSTT). If you have not read Part 1 yet, please do so now. The purpose of future posts will be to delve into the results of the literature search on specific pathologies, with the current post being devoted to cerebrovascular accident (stroke). This will have very little commentary on the papers themselves because we will return to clinical summaries in Part 4.

For the purpose of this series, acute was defined as 1-2 months, subacute 2-4 months, and chronic > 3-4 months post neurological insult. 

Acute Stroke

In McCain et al., the investigators provided BWSTT prior to initiating an overground training protocol (COGT)(1). In this study COGT was initiated when the patient could walk for 3 minutes with no more than 10% bodyweight support. The control group performed COGT from start of the study. All kinematic features were measured via motion capture analysis. By the end of the study, the BWSTT group had significantly higher improvements in gait kinematics including velocity, stride symmetry, and endurance. The conclusion to be taken from this paper is that the restoration of “typical” gait with BWSTT as early as possible may reduce kinematic asymmetries commonly seen in later phases of neurological rehab.

Stroke
Image Credit: WebMD

SubAcute Stroke

In the Subacute stroke literature, DePaul et al (2015) reported no clinically meaningful difference between BWSTT and overground training within 1 year post stroke with a median time since onset of 18 weeks (2). Although these results were not statistically significant, BWSTT provided higher self selected walking speeds and maximum gait speed. A limitation noted in this study include 15 sessions all precisely 1 hour in duration. Because of setup time, BWSTT spent 30 minutes of gait training, whereas COGT received an average of 40 minutes of work time.

Barbeau and Vistintin (2003) showed significant improvements in BWS > COGT in persons with lower baseline measures and of older age (3). The authors hypothesized that slowly loading the limbs would gradually improve the core musculature supporting posture and locomotion. Finally, the overall training effects were also higher in the high-functioning group receiving BWS but did not meet statistical significance. This may be hypothesized to be due to greater walking speeds on the treadmill carrying over to overground walking.

Beabeau
Age effects – Barbeau & Vistintin, 2003

In the graph above, conclusions were made that BWSTT may provide reduced load on the cardiovascular system initially. This is contrary to the benefits of BWSTT listed in Part 1, and can be categorized as (paradoxically) another benefit when applied in the appropriate context. Walking with BWS provided 30% less oxygen consumption in both post-stroke and age matched healthy subjects. This may allow for higher speeds with reduced loading to improve the factors described earlier such as reduced compensatory kinematics. Some examples of this include cerebrovascular accident post hypertensive crisis and general medical patients with comorbidities such as atrial fibrillation, hypertension, and congestive heart failure.

Mao et al., (2015) reported improved spatiotemporal parameters in the BWS group in ALL measures post training (average age of 60 and 50 days post injury) (4).

Mao

Statistically superior outcomes were noted in cadence and gait speed. These are arguably two of the most important factors for future household and community ambulators. Gait speed alone may also allow for future implications including functional abilities and duration of life. You can review this open access paper which denotes gait speed as important as a vital sign.

Chronic Stroke

Chronic stroke was found to have relatively poorer outcomes when comparing BWSTT to COGT. I will include the conclusions of three papers from the literature search for the sake of brevity. This will begin what seems to be a fairly consistent trend among chronic neurological injury. Please feel free to review the papers as they are listed in the references below. For now, you can take my word for it that they are of acceptable methodology without any serious flaws to nullify the conclusion.

  • “Body Weight–Supported Treadmill Training Is No Better Than Overground Training for Individuals with Chronic Stroke: A Randomized Controlled Trial” (5)
  • “Conclusion: BWSTT offers improvement in gait but has no significant advantage over conventional gait- training strategies for chronic stroke survivors.“ (6)
  • “…task-specific training during treadmill walking with body-weight support is more effective in improving walking speed and maintaining these gains at 6 months than resisted leg cycling alone.” (7)
    • Walking was more effective than cycling to improve walking
      speed, this meets face validity as we would expect from the principles of motor learning e.g. performing the activity is optimal for skill acquisition.

As a reminder, Part 3 will continue our series with results based on different pathologies.

Thanks for reading,

-Jared Burch, PT, DPT


References

  1. McCain, K. J., Pollo, F. E., Baum, B. S., Coleman, S. C., Baker, S., & Smith, P. S. (2008). Locomotor treadmill training with partial body-weight support before overground gait in adults with acute stroke: a pilot study. Archives of physical medicine and rehabilitation89(4), 684-691.
  2. DePaul, V. G., Wishart, L. R., Richardson, J., Thabane, L., Ma, J., & Lee, T. D. (2015). Varied Overground Walking Training Versus Body-Weight-Supported Treadmill Training in Adults Within 1 Year of Stroke A Randomized Controlled Trial. Neurorehabilitation and neural repair29(4), 329-340.
  3. Barbeau, H., & Visintin, M. (2003). Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Archives of physical medicine and rehabilitation, 84(10), 1458-1465.
  4. Mao, Y. R., Lo, W. L., Lin, Q., Li, L., Xiao, X., Raghavan, P., & Huang, D. F. (2015). The effect of body weight support treadmill training on gait recovery, proximal lower limb motor pattern, and balance in patients with subacute stroke. BioMed research international2015.
  5. Middleton, A., Merlo-Rains, A., Peters, D. M., Greene, J. V., Blanck, E. L., Moran, R., & Fritz, S. L. (2014). Body Weight–Supported Treadmill Training Is No Better Than Overground Training for Individuals with Chronic Stroke: A Randomized Controlled Trial. Topics in stroke rehabilitation21(6), 462-476.
  6. Srivastava, A., Taly, A. B., Gupta, A., Kumar, S., & Murali, T. (2016). Bodyweight-supported treadmill training for retraining gait among chronic stroke survivors: A randomized controlled study. Annals of physical and rehabilitation medicine59(4), 235-241.
  7. Sullivan, K. J., Brown, D. A., Klassen, T., Mulroy, S., Ge, T., Azen, S. P., & Winstein, C. J. (2007). Effects of task-specific locomotor and strength training in adults who were ambulatory after stroke: results of the STEPS randomized clinical trial. Physical therapy87(12), 1580.

Featured Imaged Credit: I, Science Magazine

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