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Sean Knight Lisa Forster Shelby Kantar

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

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) Reference (first 2 bullets): Hesse, Stefan. Treadmill training with partial body weight support after stroke: A review. NeuroRehabilitation 2008; 23: 55–65. Reference (last bullets): Fulk, George. Locomotor Training with Body Weight Support after Stroke: The Effect of Different Training Parameters. Journal of Neurolgic Physical Therapy. March 2004

4 Why Choose BWSTT? (Roy, M. 2009)
Greater number of steps can be performed within a single training session Higher repetition: up to 1000s steps/20 min on treadmill vs 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) Reference: Roy, Marc-Andre. Body Weight Supported Treadmill Training for Stroke - Family/Patient Information.

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 Reference (first bullet): Cardenas, Diana. Body-Weight-SupportedTreadmill Training for SCI. University of Washington School of Medicine: Department of Rehabilitation Medicine. 2003; Volume 12, Issue 1 IN adult laboratory animals whose spinal cords were surgically transected at the low thoracic level, the ability to step or stand is a function of whether these motor tasks are PRACTICED. If adult spinalized cats are trained daily to step with full load bearing on a treadmill over a period of 3 to 12 weeks, their stepping ability improves. If they were trained to stand, their standing will improve. It is all about specificity of training. You cannot train someone to stand and expect their stepping to get better.

6 Costs (Roy, 2009) 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) Reference (1st bullet): costhelper.com Reference (2nd bullet): Nuerwalker -- Reference (3rd bullet): Roy, Marc-Andre. Body Weight Supported Treadmill Training for Stroke - Family/Patient Information.

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 Reference:

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. So just to bring everyone to the pace - in literatures robotic- BWSTT is also referred to as DGO or by the manufacturer's company named, Locomat By definition it is…a motorized exoskeleton…

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 So, moving on back to literature reviews, Published in PT Journal 2005, this article focuses on Robotic-BWSTT in a rather small population. They took 2 males and 1 female with incomplete SCI and Simply studied the effectiveness of robotic BWSTT What they found is improvements in time up and go, functional reach test, 6’ walk test, Sum of modified MMT, and Over-ground ambulation Finally, the author concludes that a confident causal relationship could not be drawn because 2 of the px were on anti-spasticity medication and 2 were within the post 2 month period of spontaneous neurological recovery. Methods: Robot 3/wk Speed 1.2 – 1.6mph at patient tolerated. Total distance walked per session limited to 1000meters. BWS was minimized to allow max LE loading. ASIA – American Spinal Injury Association SNR – spontaneous neurological recovery of motor function

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 This study Published in Neurorehab and repair 2008, focuses on robotic-BWSTT in MS population They took 13 subjects and Compared the effects of the traditional manual BWSTT .vs. the newly evolved robotic-BWSTT What they found is that there was no significant difference between the two groups, but there were general improvement within group consisted of 25 foot time, 6’ walk test’s distance, and double limb support time and step length ratio, i.e. symmetry In the end the authors concluded that both BWSTT types have the potential to reduce gait impairments in MS population. Method: 2/wk x 3wk total of 6 sessions, time = 40 minutes % BWS. Speed of 1.5km/h; once the px got to 2.5, the BWS was decreased

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 Published in MS Journal last year, this study focuses on MS population They took 35 MS patients and Compared the effects of robotic-BWSTT and conventional walking training What they found is that there was no significant difference in velocity, 6 minute walk test’s distance and knee extensor strength. However general improvements were found in all those variables up there in robotic-BWSTT group but conventional walking training only velocity improved. In the end, the author concludes that higher benefits are noted with robotic-BWSTT and robot-BWSTT was better Method: 30 minutes/day x 5 days/wk for 5 weeks; Robotic: 40-80%BWS, starting at low speed 1.0 – 1.5 kmh Conventional WT: PT walking by side of px for 30minutes.

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 Published in Neruo Rehab and Repair Journal 2007, this study focuses mostly on acute stroke population. They took 16 stroke patients and Compared the effects of robotic-BWSTT .vs. Conventional Physical Therapy on Gait What they found is significant improvement with robotic BWSTT in rivermead motor assessment scale, 6’ test’s distance, and Ashworth Scale In the end, one of the author’s conclusion was that lokomat training reduces repetitive stresses that are placed on PT during manual-BWSTT Method: conventional physical therapy (bobath (antispastic exercise), balance exercise, ground walking) locomat

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
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

18 73 first acute stroke hemiparetic patients; RCT
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, (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) Published in Clinical Rehab Journal 2001, this study focuses on BWSTT and On-Ground Training. They took 73 first acute stroke hemiparetic patients and Compared the effects of BWSTT and On-Ground Training on Ground Walking What they found was no significant difference in Fugl-Meyer Stroke Assessment, FIM, Berg Balance Assessment, and Walking Velocity scores In the end, the author concludes that BWSTT was better and is a considerable choice for ground walking.

19 Title: A New Approach to Retrain Gait in Stroke Patients through BWSTT stimulation.
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) Published in 1998, this study focuses on two types Treadmill Training They took 100 subjects with stroke and Compared the effects of Treadmill Training with Body Weight Support and Without Body Weight Support on Gait What they found is that there WAS significant difference of improvement With BWSTT in berg balance score, Stream scores, and over ground walking speed and endurance. In the end the author concludes that BWSTT resulted in “better walking abilities” than without BWS STREAM - can be roughly defined as voluntary movement recovery of both UE and LE based on 25 item scale. It stands for Stroke Rehabilitation Assessment of Movement

20 Title: 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) This next study published in PT Journal 2007, focuses on task specificity training for functional walking They took 80 post stroke ambulatory adults and Compared the effects of BWSTT, cycle, and LE strength training interventions on ground walking What they found is that BWSTT had significantly greater increases in walking speed than cycling alone. In the end the authors conclude that BWSTT is more effective in improving walking speed and maintaining these gains at 6 months, while Endurace improvement was evident in cycling and BWSTT.

21 Title: Gait Training – Induced Changes in Corticomotor Excitability in Patients With Chronic Stroke
Neurorehabilitation and Neural Repair, Vol. 22, No. 1, (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) Published in 2008, this my favorite article that focuses on Corticomotor Excitability associated with BWSTT They took 14 chronic stroke patients and Compared the effects of ground training and ground training + BWSTT on Motor Performance and Corticomotor Excitability What they found is that significant changes in the group that received Ground Training + BWSTT in berg balance score, walking speed, step length, and decreased threshold for TA in unaffected hemiparesis. Further, general increases were noted in map size for Tibialis Anterior and Abductor Hallucis in affected hemisphere only. Interestingly for the same group, a correlation was found between corticomotor excitability and functional improvement. In the end authors concluded that gait training + BWSTT may bring about changes in cortiocomotor excitability, improve balance and gait performance. TA – tibialis anterior AH – abductor hallucis This one is BWSTT + Ground Training .vs. Ground Training Only Note: significant differences were not found within the group that did not receive BWSTT significant difference were found within and between the groups that received BWSTT

22 Cochrane Corner 11 trials 458 participants
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.” Last but not the least, published in 2003 this cochrane review consisted of 11 trials and a total of 458 participants. What they found is there was NO…. The message is it is OUR job to decide who is appropriate for BWSTT. (usual indication being safety) Also, the same article mentioned to be careful with BWSTT because adverse effects can occur, but significant difference was not found. Cochrane Review PDF

23 Title: Spinal Cord Injury Locomotor Trial Group
Title: Spinal Cord Injury Locomotor Trial Group. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. 2006; 66: 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) Published in Neurology Journal 2006, this study focuses on BWSTT and regular over-ground training They took 146 sub-acute SCI patients and Compared the effects of BWSTT and ground mobility therapy on walking What they found is that there was no significant difference between the two in velocity and distance; and FIM scores 6 months post intervention In the end the author concludes that PT intervention via BWSTT or Ground training made no difference. FIM – functional independence measure Downfall of study – learning curve is greatest in the first three months.

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
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
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 Supraspinal input – stimulation of sensory receptors located in supra-spinal muscles Finally, one of the authors indicates that BWSTT will soon be commercial and physical therapist’s job will be to decided which intervention is appropriate for patient. i.e. robotic-bwstt, regular bwstt, or ground training.

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, Biodex System. 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 Volume 86, Number 11. Kristen J. Light. People, not robots, prove to be better walking assistants. BioMechanics Magazine Sep2008, Vol. 15 Issue 9, p p. 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 ; 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 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 ; 15: Nuberwalker. Roy, Marc-Andre. Body Weight Supported Treadmill Training for Stroke: Family/Patient. Information. 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 ; 87: 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: 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 ; 66(4): 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 ; 22: Willoughby, K , Dodd, K, Shields, N., Foley, S.. Arch Phys Med Rehabil Jan;91(1):


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