This post resumes bodyweight supported treadmill training (BWSTT) with Part 3 of 4. If you have not read Part 1 or Part 2 yet, please do so first. In Part 3, we are going to focus on a group of pathologies that have been studied, but not to the same extent as stroke. These include Spinal Cord Injury, Multiple Sclerosis, Traumatic Brain Injury, and Knee Osteoarthritis.
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.
Incomplete Spinal Cord Injury (SCI)
Morawietz and Moffat (2013) conducted a systematic review on patients with incomplete spinal cord injury encompassing 8 studies broken down into 4 acute/subacute and 4 chronic cohorts (1). Within the review based on heterogeneous studies they found no significant improvements in BWSTT, robotic assisted walking, or overground training over one another. The authors also noted that after 1 year post SCI there was a non-statistically significant trend towards greater improvement for overground training. They found that if sensory function was spared, the motor outcomes were greater. The conclusion was made that overground training does require less set up so it may be easier, but recommendations could not be made about optimal intensity, frequency, and timing. A trend was also noted that “different locomotor approaches may play a role at different stages of the rehab process”. This is consistent with rehabilitation for stroke as well. The clinical relevance that may be gleaned is that training at faster speeds, taking more steps, or training longer was associated with best outcomes in neurologic rehabilitation at all stages (follows the principles of motor learning described in Part 1).
Lam et al., 2007 conducted another systematic review based on the literature on BWSTT with incomplete spinal cord injury (2). The authors of this study noted that individuals in the acute and subacute stages of rehab made the largest gains with BWSTT. They reported that individuals greater than one-year post injury can still make progress, but improvements are heterogeneous in nature. The researchers state, “Improvements may be better if patient is classified as ASIA C or D, rather than B”, which follows a logical pattern of reasoning that higher levels of function after disability will allow a patient to achieve training at faster speeds, taking more steps, and/or training longer. This is in accordance with Morawietz & Moffat as described in the paragraph above as well. Finally, on page 8 the investigators noted that “task oriented retraining with bodyweight support…. appears to be more beneficial when applied sooner rather than later after the onset of injury with motor-incomplete lesions”. There seems to be a pattern here. More on this will be discussed in Part 4.
Parkinsons Disease (PD)
Two articles on PD within the inclusion criteria were retrieved from PEDro. The first being an RCT by Miyai et al., 2000 which reported an overall decrease in Unified Parkinson’s Disease Rating Scale score in the BWSTT group compared to ”conventional physical therapy” (3). Broad descriptions (mistakes) such as this are actually fairly common but hopefully becoming less frequent. The issue is that “conventional physical therapy” can never be reproduced. How are we to know if their study results were due to chance if we cannot recreate the study? A good example of this can be seen in O’Briens compression test for the labrum, where the initial paper reported nearly perfect sensitivity and specificity (8). Since then, no studies have been able to recreate their results. This is how we “double-check” research. Ultimately Miyai et al., describe on page 849 that their control group (conventional PT) consisted of “ROM exercise, ADL training, and gait training”. This is not a mortal sin, but the permutations of guesses as to what was actually going on in this control are endless.
The second article chosen was the Treadmill Training for Patients with PD Cochrane Review, 2010 (4). They found that specific to PD, patients could achieve on the treadmill higher training forces to use faster gait cycles and higher velocities. Treadmill training also increased the number of repetitions performed in one session (principles of motor control strike again). The authors’ final conclusion based on 8 trials with a total of 203 participants was that BWSTT may improve specific gait parameters such as gait speed and stride length in PD. With 2 out of 4 cardinal signs of PD being festinating gait and slowness of movements, with BWSTT alone I believe we may be able to improve upon the most severe functional deficits. However, due to heterogeneous results, the Cochrane review did not make conclusive statements such as BWSTT > conventional overground training (COGT). The thought process continues that if you follow the principles of motor control with implementation of BWSTT, you will provide an optimal rehab environment for improving gait.
Multiple Sclerosis (MS)
Swinnen et al. 2012 conducted a systematic review on MS. Due to a limited number of high quality studies, it is unknown what method of gait training is best. The challenge that authors face is the difficulty providing a definitive recommendation because poor studies making up a systematic review creates nothing but a poor systematic review. Most of the current literature is similar to other pathologies studies in that they have heterogeneous inclusion criteria and methodology. Another problem that researchers face is the different types of MS with unknown trajectories response and recovery at the various stages and remittances. Overall, treadmill training, BWSTT, and robotic assisted training all improve walking speed and maximal walking distance in persons with MS (good job physical therapy!).
Chronic Traumatic Brain Injury (TBI)
Brown et al. 2005 recruited subjects post TBI of >/= 7 years. They performed BWSTT twice per week for 14 weeks total. They found that step symmetry improved with COGT however no significant improvements in step symmetry were found with BWSTT. Both BWSTT and COGT provided a narrower step width (closer to normal). Gait velocities did not increase with either group as well. In conclusion, the authors reported BWSTT was NOT more effective than COGT. Are our brains capacities for motor learning reduced once an issue becomes chronic? More will be discussed in Part 4 on this thought.
Knee Osteoarthritis (OA)
During my presentation, this probably got the most attention. We rarely associate knee OA with BWSTT. Watanabe et al., 2013 studied BWSTT and a full weight bearing treadmill-training group (7). The groups performed 20 minutes of walking twice per week for 6 weeks. At 3 weeks (applicable to a typical inpatient rehab timeline) there was:
- 2 seconds off of 10 meter walk time in BWSTT group
- Decreased score visual analogue in BWSTT group
- Significant improvement in – length of stride, speed, and distance walked (6 minute walk test)
No clinically significant difference was found between groups at 6 weeks. My conclusion was that the results of this study might relevant to the patient population in inpatient rehab. If the average patient stay is 14-21 days BWSTT may provide the stimulus required to reduce pain and increase gait speed. I am speculating here, but reduced pain could also be the driving force to minimize need for pain medications such as opioids which also removes the need for a stool softener and so on… The point is that there are many possibilities to be studied and reducing pain and polypharmcy are two secondary effects that may be achieved from proper implementation of BWSTT. What are your thoughts on this? Comment below.
This concludes Part 3 of a 4 Part series on BWSTT. This post attempted to provide literature found on the initial search, which was papers of moderate to high quality of evidence, open access, and within inclusion criteria listed in Part 1. Part 4 will provide summaries of the findings in Parts 2 and 3 and thoughts on clinical relevance.
Thank you for reading,
-Jared Burch, PT, DPT
- Morawietz, C., & Moffat, F. (2013). Effects of locomotor training after incomplete spinal cord injury: a systematic review. Archives of physical medicine and rehabilitation, 94(11), 2297-2308.
- Lam, T., Eng, J., Wolfe, D., Hsieh, J., & Whittaker, M. (2007). A systematic review of the efficacy of gait rehabilitation strategies for spinal cord injury. Topics in spinal cord injury rehabilitation, 13(1), 32-57.
- Miyai, I., Fujimoto, Y., Ueda, Y., Yamamoto, H., Nozaki, S., Saito, T., & Kang, J. (2000). Treadmill training with body weight support: its effect on Parkinson’s disease. Archives of physical medicine and rehabilitation, 81(7), 849-852.
- Mehrholz, J., Friis, R., Kugler, J., Twork, S., Storch, A., & Pohl, M. (2010). Treadmill training for patients with Parkinson’s disease. The Cochrane Library.
- Swinnen, E., Beckwée, D., Pinte, D., Meeusen, R., Baeyens, J. P., & Kerckhofs, E. (2012). Treadmill training in multiple sclerosis: can body weight support or robot assistance provide added value? A systematic review. Multiple sclerosis international, 2012.
- Brown, T. H., Mount, J., Rouland, B. L., Kautz, K. A., Barnes, R. M., & Kim, J. (2005). Body Weight‐Supported Treadmill Training Versus Conventional Gait Training for People With Chronic Traumatic Brain Injury. The Journal of head trauma rehabilitation, 20(5), 402-415.
- Watanabe, S., & Someya, F. (2013). Effect of body weight-supported walking on exercise capacity and walking speed in patients with knee osteoarthritis: a randomized controlled trial. Journal of the Japanese Physical Therapy Association, 16(1), 28-35.
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