Is Partial Body Weight Supported Gait / Treadmill Training (BWSTT) Effective Following CNS Lesion

1. Sean Knight Lisa Forster Shelby Kantar Is Partial Body Weight Supported Gait / Treadmill Training (BWSTT) Effective Following CNS Lesion

2. Learning 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.

3. Introduction • 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)

4. Why 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)

5. History • 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

6. Costs • Treadmills: range from $100s - $1000s • Body weight support harness system $15,500 • 2 PTs manually assist pt’s gait deviations • Labor intensive • Min. time: 20 min/treatment session (Roy, 2009)

7. Research

8. Populations Best Suited for BWSTT • Stroke • Traumatic Brain Injury • Spinal Cord Injury • Cerebral Palsy • Down Syndrome • Parkinson’s Disease • Amputees • Multiple Sclerosis

9. Robotic-BWSTT • Literatures used term also: • DGO (Driven Gait Orthosis) • Lokomat (manufacturer’s 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.

10. Robotics 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

11. Robotics 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

12. Title: 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 • Author’s 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

13. Who 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

14. People, 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

15. Pros/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, can’t change • Decreased specificity • Expensive • Too much afferent input

16. Conventional BWSTT

17. When 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

18. Title: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)

19. Title: 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)

20. Title: Effects of Task-SpecificLocomotor 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)

21. Title: 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)

22. Cochrane Corner Stroke.2003;34:3006 • 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.”

23. Title: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)

24. Title: 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)

25. Pros/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

26. Summary 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

27. Considerations 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 patient’s functional goal • Can alter only inclination

28. Review 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.

29. References • 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/unweighing/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: 55–65. • Hornby, G., Zemon, D., Campbell, D. Robotic-sssisted, body-weight–supported 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 605–618. • 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/NciiaResources.woa/wa/View/GrantProfile?n=1000460 • 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 Jan;91(1):115-22. • www.costhelper.com