This is Part 4 of 4, if you have not read Parts 1, 2, or 3 yet, please do so now. We have now discussed theory and rationale for bodyweight supported treadmill training (BWSTT). We have also discussed some of the literature regarding BWSTT use in different pathologies. The purpose of this final post is to summarize the literature and provide clinical implications for use.
∗ To the best of my knowledge this is the first open access presentation based on BWSTT with categorization of pathology and time since onset ∗
The results show that BWSTT has different outcomes based on time since neurological insult. This was an effect seen throughout multiple neurological pathologies. Because of this, it may be possible that there is a limit to our capacity for motor learning once compensations have set in.
As an anecdotal example, in inpatient rehab I attempted BWSTT with a patient who was in the chronic stage post CVA (approximately 1 year). I hoped that with proper facilitation, we could reduce his vaulting and increase step length to regain walking distances >10 feet. He had been referred from his home health therapist due to lack of progress. Despite multiple sessions of facilitation, pre-gait strategies, and full stepping with bodyweight support, he was unable to make significant improvements. The end result was an orthosis to provide a new compensation so that he was able to independently transfer and walk short distances with contact guard assist. Sadly, BWSTT had not provided much (if any) value to our outcomes. Using BWSTT in the right context, for the right persons, and within a complete plan of care is required to optimize results. This will be talked about more at length towards the end of this post.
-In acute stroke, a conclusion may be made based on current evidence that using BWSTT can provide improvements in gait kinematics, velocity, stride symmetry, and endurance.
-In subacute stroke, BWSTT may provide improved gait kinematics, speed/cadence, and reduced cardiovascular loading
-In chronic stroke, one is not currently superior to the other, but in my opinion it may be best to provide overground training and other functional activities as it is more time efficient (less set up).
Recommendation: use BWSTT in patients in the acute and subacute stages to improve gait parameters with ultimate goal of transition to 0% bodyweight and transfer to overground training.
Incomplete Spinal Cord Injury (SCI)
Because of the heterogeneous results in patients at the chronic stage post SCI, no results are conclusive. Again we meet the issue of chronicity and set compensations.
The results of Lam et al., 2007 bring up an interesting idea that patients with sensory sparing may achieve best improvements post SCI. This may be integrated with the supraspinal mechanisms hypothesis, which was postulated by Yagura et al., 2006. My take on this is that the more input into the brain we can receive, the better a patient may recover post SCI. Either way, it will be difficult to prove this idea, and it may be more likely that we rule in the theory of supraspinal mechanisms by exclusion of the central pattern generator.
Overall, there are many more papers on complete and incomplete SCI which were not included in this search. No recommendation can be provided based on these 2 studies reviewed. It is likely, however, that the earlier BWSTT is implemented in the rehabilitation process the better the outcomes will be. This follows Principles 1 and 2 of motor control: “Use it or lose it ” & “Use it and improve it”.
Parkinson’s Disease (PD)
BWSTT may provide improvement in specific gait parameters such as stride length and gait speed. This was talked about briefly in Part 3 , but it will be reiterated that these are arguably two of the most important factors in gait with PD. Secondary to lack of dopamine release, many struggle with gait due to bradykinesia and festinating gait. If we can improve these components of gait, we may be able to maximize quality of life. This is especially true when patients are in their “off” phase between doses of their respective pharmacological routine. As physical therapists, we can play a very important role within the interdisciplinary team by implementing interventions such as BWSTT appropriately as well as educating our patients and other medical professionals about our value.
Multiple Sclerosis (MS)
We found (again) heterogeneous results, which stated BWSTT was not superior to overground training. I do not believe there will be any conclusive statements for a fairly long period of time (> 5 years). These research studies are challenging to set up and time consuming to conduct due to the different types of MS and variability of physical presentation.
Knee Osteoarthritis (OA)
I was fairly surprised with these results personally. Patients with knee OA saw significant results at 3 weeks with reduction in pain and improved time off of the 10 meter walk test. However, there was no difference between BWSTT and full bodyweight treadmill training at 6 weeks. I took some time to try to make sense of this. My conclusion was that BWSTT provides a period of less strenuous movement to allow calming of the area but a certain level of exercise induced hypoalgesia. There is then progressive loading and building back up of the musculature, improving strength and resiliency of the connective tissue/bones (this is a mantra of Greg Lehman). If this reduction in pain at 3 weeks was not by chance, it could be beneficial to the overall plan of care in a complex patient case. This is especially true to those limited due to pain in inpatient rehab, who frequently have a plethora of comorbidities. There may also be more literature with other similar modalities such as Alter-G, but that was not within the inclusion criteria of this lit review.
Overarching Ideas of BWSTT
- Physical therapy needs to be progressive and intensive.
This is not a new concept and has been a major push in geriatric rehab as part of the American Physical Therapy Association Choosing Wisely Campaign. Therapists frequently see persons of older age as weak or fragile, when we should see them as capable of high function activities with proper loading and guidance by a therapist. In the case of BWSTT, we need to get repetitions and intensity as high as reasonably possible.
- Listen to your patient’s response.
Following the principles of motor control, take into account patient saliency. Explain to them the purpose of BWSTT, the results of previous studies listed in this 4 Part series, and how it is relevant to them.
- Time since onset is a key factor to implementation
With stroke, spinal cord injury, and traumatic brain injury – acute neurological insults will be your most rapid responders to BWSTT. Chronic stages of neurological disease may not benefit more than overground training. There was no effect noted in cohorts with diagnoses of PD, MS, or knee OA.
- Every patient is different
The best example of this is the literature on MS. Due to a high variability of functional presentations, we must take all factors into account when choosing the optimal rehab protocol for our patients.
- Repetition is key
This is straightforward for all motor skills. The more we purposefully practice a skill, the better we will get at it. Author Malcolm Gladwell even proposed that he had found the ultimate key to becoming an expert at a skill by performing it for 10,000 hours in his book Outliers.
This concludes the 4 Part series on BWSTT. This was encompassing of the literature found on a basic literature search of open access papers. It does not include all literature, and was fairly brief in regards to prior research on spinal cord injury. If you are interested in this topic, you can read further on the evidence based on SCI by searching the trial listed here. There are also the STEPS and VIEWS trials which are not included in this series.
I look forward to future studies on ALL pathologies so we can use the results to continue to improve upon our knowledge and critical thinking skills when formulating a patient plan of care.
Thank you for reading,
-Jared Burch, PT, DPT
References (for all 4 Parts):
1.Yagura, H., Hatakenaka, M., & Miyai, I. (2006). Does Therapeutic Facilitation Add to Locomotor Outcome of Body Weight− Supported Treadmill Training in Nonambulatory Patients With Stroke? A Randomized Controlled Trial. Archives of physical medicine and rehabilitation, 87(4), 529-535.
2.Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. Journal of speech, language, and hearing research, 51(1), S225-S239.
3.Van Hedel, H. J. A., Tomatis, L., & Müller, R. (2006). Modulation of leg muscle activity and gait kinematics by walking speed and bodyweight unloading. Gait & posture, 24(1), 35-45.
4.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 rehabilitation, 89(4), 684-691.
5.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 repair, 29(4), 329-340.
6.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.
7.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 international, 2015.
8. 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 rehabilitation, 21(6), 462-476.
9. 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 medicine, 59(4), 235-241.
10. 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 therapy, 87(12), 1580.
11.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.
12.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.
13.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.
14.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.
15.Mehrholz, J., Friis, R., Kugler, J., Twork, S., Storch, A., & Pohl, M. (2010). Treadmill training for patients with Parkinson’s disease. The Cochrane Library.
16.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.
17.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.
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