1. Body-Weight- Supported Gait Training
Mary Bernardo, Katie Blow, Lauren Bussian, Kaylea Kirven, Sarah Nockengost
Alternative Intervention Presentation
Lifespan
Virginia Commonwealth University

2. Body-Weight-Supported Treadmill Training (BWSTT)
Used in a variety of practice settings
Targets strength, endurance, and task-specific gait training
Body weight is unloaded by a harness or adult assistance
Active movements with therapist guidance/assistance when necessary
Generally followed by a period of overground gait training with body-weight support as needed
Body-weight supported gait training usually starts with body-weight-supported treadmill training. The child body weight is fully or partially unloaded by a harness or manual assistance allowing he or she to walk on the treadmill.
This is a task specific gait exercise that also targets strength and endurance. It is used in a variety of settings including outpatient clinics, schools, and inpatient rehabilitation facilities.
Skills can be progressed to overground gait training with body-weight support as child masters the treadmill, manual guidance from a therapist as needed.
Body-Weight Supported Treadmill Training, Colorado Physical Therapy Specialists

3. Video
:20-1:10

4. Background
1960’s - Animal research proved that cats with transected spinal cords could actively step after a period of BWSTT
1992 – Wernig and Muller reported improved walking patterns following BWSTT in patients with SCI
Systematic Review of pediatric studies in 2006
Only 7 articles from
peer-reviewed sources
Still preliminary in pediatric population
Lots of studies in the adult population post-stroke, TBI, or SCI resulting in positive outcomes

5. Rationale
Motor Learning principles support the use of repetitive, task-specific practice over time
Current evidence demonstrates the neuroplasticity of the central nervous system, indicating its ability to learn
Body-Weight-Supported Gait Training provides the appropriate intensity and specificity needed to promote neuroplastic changes.
Facilitates step training
Reduces postural requirements
Encourages more appropriate motor patterns
The rationale behind body-weight supported gait training relies on the evidence stating that the central nervous system is neuroplastic and demonstrates an ability to relearn or habituate, and the idea that motor learning requires task-specific practice
Supporters of this intervention believe that BWSTT provides the appropriate intensity and task-specificity to promote neuroplastic changes, and that is facilitates step training by reducing postural requirements and encouraging more appropriate motor patterns.

6. APTA Guidelines for Use of Body-Weight-Supported Treadmill Training
(APTA’s Section on Pediatrics, 2010)
Frequency
2-5 days/week
Session Length
5-30 minutes/session
Treadmill Speed
.05-3 mph
Percent Body-Weight Support
Load stance limb
Use the least amount of body-weight support to maintain erect postural alignment
Manual Assistance
Least amount required for stepping
Assist intra- and inter-limb coordination if necessary
Support Using arms/hands
Fading use of handrails
Episode of Treatment
2-16 weeks
Session - does not include setting up or getting child off of equipment
Speed - generally as high as the child can tolerate while maintaining appropriate gait pattern

7. Equipment Various equipment used for BWSTT Examples: LiteGait System:
May require manual assistance requiring 2-4 trained providers
Lokomat:
Provides robotic assistance during body-weight- supported gait training
Therapist Support
Sources:
Litegait -
Lokomat -

8. LiteGait®
Lokomat®

9. Continuing Education/Training
Certification and continuing education are not required to utilize BWSTT in physical therapy intervention
Many companies offer training for use of their products
LiteGait ($850-$140)
Lokomat

10. Patient Population Down Syndrome Cerebral Palsy (CP)
Spinal Cord Injury (SCI)
Myelomeningocele
Stroke
Guillain-Barre Syndrome
Traumatic Brain Injury (TBI)
stroke, GB, and TBI = adults
pediatric diagnoses listed in order of evidence strength

11. Contraindications Cardiovascular issues Osteoporosis Fractured ribs
Groin infection or skin graft in groin area
Weight-bearing restrictions
Ventilator dependency
Intravenous drip
Self-harming behavior
**Any contraindication to exercise
(Ex: orthostatic hypotension, thrombocytopenia)
None specific to pediatrics
In adults - contraindications to exercise (ex: cardiovascular issues, infection, thrombocytopenia, recent embolus, osteoporosis), skin breakdown/lesions
- some contraindications for lokomat listed here

12. Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in Pediatric Rehabilitation
Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
Purpose: To explore the strength, quality, and conclusiveness of the scientific evidence supporting BWSTT in children with motor disabilities.
Design: 29 articles met inclusion criteria.
Results for CP:
Highest level study: significant increase in self-selected gait speed and walking distance
High variability across subjects in the amount of change
Positive effects are small and mostly non-significant
No harmful outcomes
Conclusion: Limited evidence that has non-significant outcomes; has not been compared sufficiently to other interventions
I am going to present a systematic review that encompasses the three major diagnoses that we are going to talk about- CP, Down Syndrome, and SCI. This is an overall look at the outcomes, but Kaylea, Mary, and Sarah are going to delve deeper into each separate diagnosis.
This study is a recent, very strong systematic review that encompasses most all the research (including case studies) that has been published on BWSTT in children.
examined evidence for BWSTT in children with CP, Down Syndrome, and SCI. They compiled evidence from various databases between
29 out of 277 articles met in the inclusion criteria. Delving more into the inclusion and exclusion criteria:
did not eliminate studies where other treatments were administered or permitted at the same time
restricted to studies with the primary goal of improving LE motor functioning
populations less than 21 years old who had or were at risk for developing a motor disability affecting gait function
No studies of typically developing children were included
No studies examining the effects of treadmill training on diminished exercise capacity
For CP, the highest level study in the systematic review showed a significant increase in self-selected gait speed and walking distance. BUT, overall there was a high variability across subjects in the amount of change and the positive effects were small and mostly non-significant. No harmful outcomes were reported.
There is limited evidence that shows non-significant outcomes. And it should be noted that no randomized clinical trial has been reported among this population, which limits the ability to draw conclusions.
CP has the largest number of studies (17 total)

13. Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in Pediatric Rehabilitation
Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
Results for Down Syndrome:
Highest level study: practicing step training on a motor treadmill can accelerate development of ambulation
More intense protocol is preferred over lower intensity levels
Long term effect on physical activity levels
Greater stride length
Earlier age of walking onset
Conclusion: Body-weight-supported treadmill training is effective for promoting the development of independent ambulation and enhancing gait qualities.
The highest level study (which was a randomized control trial) showed that practicing step training on a motor treadmill can accelerate development of ambulation. A follow-up study by the same researchers showed that a more intense protocol is preferred over lower intensity levels due to a greater effect on physical activity levels, greater stride length, and earlier age of walking onset. This population has the best evidence supporting BWSTT→ the systematic review shows that it is effective for promoting the development of independent ambulation and enhancing gait qualities.

14. Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in Pediatric Rehabilitation
Damaino, D. et. al. (2009) Journal of Neurological Physical Therapy
Results for SCI:
Mostly positive outcomes with clinically significant changes.
Many children became functional ambulators.
Lack of change in lower extremity motor strength indicates task-specificity of practice.
Data is limited in children compared to adults.
No negative or harmful effects were found.
Conclusion: Limited evidence warrants more rigorous studies in this patient population
For children with SCI, there seems to be mostly positive outcomes with clinically significant changes. Most evidence in this population are case studies, which limits the ability to draw conclusions. Of interest, research showed that children can become more functional ambulators, but their LE motor strength did not change, therefore researchers hypothesized that walking is talk specific and does not necessarily increase voluntary strength. The evidence is promising in this population, which warrants more research.

15. Treadmill Training of Infants With Down Syndrome: Evidence-Based Developmental Outcomes
Dale A. Ulrich, PhD, Beverly D. Ulrich, PhD, Rosa M. Angulo-Kinzler, PhD, Joonkoo Yun, PhD
Purpose: To determine if practice stepping on a motorized treadmill could help reduce the delay in walking onset normally experienced in infants with Down Syndrome.
Design:
n = 30; began study once able to sit independently for 30 sec.
Control Group
Experimental Group
Biweekly PT
HEP
Adult assist treadmill stepping practice
8 minutes/day, 5 days/week
Speed .46mph
Biweekly home PT and research staff visits
I’m going to dig deeper into the specifics of BWSTT in children with DS.
As Katie mentioned, best evidence of the diagnoses mentioned today/studies in the systematic review
RCT - Although done in 2001, still the best evidence to date
Not much evidence since (most involving Dr. Dale Ulrich - University of Michigan, Effects of Intensity RCT in 2008, Obstacle Clearance after different types of treadmill training 2008, etc.)
The purpose of this trial was to determine if practice stepping = reduced delay in walking onset
Walking = one of goals valued most by parents of infants with DS
As we learned earlier this semester, infants with DS normally experience a delay in onset of walking. (around 2yr. old)
All infants with Trisomy 21 type of DS, mean chronological age of 22 months
Strong factor of this study was homogeneity - infants were not different at entry in terms of age, BSID raw motor score, parents’ education level, and family income
*In average infants in control group had 1 more sibling than the experimental group
Family provided with custom engineered treadmill In home - Adult holding infant upright over treadmill with a speed of .46mph → stepping movements on moving surface.
This was done 8min/day, 5days/week
Parent kept log of time on treadmill and infant response
BOTH GROUPS receive Biweekly visits from PT and PT implemented HEP,
Also, research staff conducted Bailey Scales of Infant Development and took growth measurements
Until child demonstrated ability to walk independently (at least 3 steps)

16. Treadmill Training of Infants With Down Syndrome: Evidence-Based Developmental Outcomes
Dale A. Ulrich, PhD, Beverly D. Ulrich, PhD, Rosa M. Angulo-Kinzler, PhD, Joonkoo Yun, PhD
Results: Length of time (days) from entry of study to onset of:
Conclusion:
Body-Weight-Supported Treadmill Training is an effective approach in early intervention to facilitate earlier onset of independent walking.
Control Group
Experimental Group
Mean Difference
Raise to Stand
194
134 60
Walking with Help
240
166 73
Walking Independently
401
300
101
The Results showed that the infants who received BWSTT, began to walk with help and independently sooner than the control group.
There was a statistically significant difference between the two groups - red.
Control average age independent walking at 23.9 month
Experimental months
Conclusion: Specific skill of stepping leads to functional behavior of walking - practiced patterns allowed opportunities to improve balance, build strength in LE, and stimulate neuronal connections
Further research needed on long term effects - level of physical activity and stamina/CV health, Intensity, and Negotiating obstacle (which Ulrich did 2008)
Limitation: no literature on optimal training protocol during infancy, quality of gait?

17. Willoughby, et al. (2010) Disabil. Rehabil.
Efficacy of Partial Body-Weight-Supported Treadmill Training [PBWSTT] Compared With Overground Walking Practice for Children With Cerebral Palsy
Willoughby, et al. (2010) Disabil. Rehabil.
Purpose:
Determine safety and feasibility of PBWSTT in a school environment
Investigate if PBWSTT can increase walking endurance, walking speed, and walking function at school for children – adolescents with CP (GMFCS III & IV)
Design:
Inclusion Criteria:
Ages 5 – 18 years old
Diagnosis of CP
GMFCS Level III or IV
Able to understand simple instructions
Exclusion Criteria:
Physical assistance to walk
Concurrent medical condition
Lower limb orthopedic surgery or botulinum toxin injection within 6 months of study
RANDOMIZED Controlled Trial
Treadmill training group – constructed based on the concepts of task-specificity and repetitive practice to improve a motor skill – In this case, walking

18. Outcome Measures: Baseline, Week 10, 14 weeks after training
Willoughby, et al. (2010)
n = 26
Outcome Measures: Baseline, Week 10, 14 weeks after training
10-meter Walk Test minute Walk Test
School Function Assessment
~ 30 min. → Session ended early if child indicated a desire to stop or when child stopped actively stepping
Treadmill:
Mirror!!!!
Orthotic
Usual footwear
Overground:
- Usual assistive device
- Usual footwear
- Orthotic device
BOTH groups continued with usual physical therapy = Primarily group-based sessions
- Bike riding
- Aquatics program
- Walking in school corridors

19. Results: Willoughby, et al. (2010) Conclusion: Limitations:
–PBWSTT is safe & feasible to conduct in a school setting for children with CP
–But, BWSTT is no more effective than practicing overground walking
Limitations:
–Q of L, psychological outcomes, physiological outcomes not measured
–Severity of CP

20. Locomotor Training Within an Inpatient Rehabilitation Program After Pediatric Incomplete Spinal Cord Injury: A Case Study
Prosser, L. (2007) Phys. Ther.
Purpose: Describe a comprehensive inpatient rehabilitation program with a locomotor training component in a child with a severe incomplete SCI.
Patient: 5 y/o female with C4 level lesion
Intervention: Inpatient rehabilitation program including a component of BWSTT and overground gait training; 3-4x/week for 6 months
Outcome Measures: ASIA Impairment scale, WeeFIM II, Walking Index for Spinal Cord Injury II, Parent-report
Results:
Walking independently with rolling walker and L AFO (30-100m)
Clinically significant improvements in UE and LE motor scores
Clinically significant improvements in WeeFIM II and WISCI II scores
Participation - walking in school 100% of the time
5 year old girl injured at C4 (MVA)
CT scan revealed fractures at C4 and C5
ASIA A classification and mild TBI
intervention:
handlebars used at first then removed as soon as child could tolerate
AFO used initially, facilitation of gait to achieve heel strike and foot flat; heel off facilitated with greater knee flexion
overground - posterior walker and 2 therapists providing manual assistance
Results:
UE ASIA motor → 8-31/50, LE ASIA motor → 4-29/50
WeeFIM II: 5/35-21/35 in mobility; 8/54-34/54 in self care
WISCI II: 0-12 (2 crutches, braces, no assistance, 10 m)
Participation:
achieved long term goal of walking down the aisle in her family’s church
walked 100% of the school day after discharge

21. ICF
Ulrich et al. looked at outcomes at the activity level only, and found differences
An important Body Structure and Function level note is that inclusion criteria included “sufficient strength and balance” although there is nothing in the article that specifies how this was measured
Factors involved: subjects in control group had on average 1 more sibling (motivation?); height and weight was hypothesized to be related to ambulation, but found not to be factor

22. ICF
Willoughby et. al hypothesized a change in these levels of the ICF model, however found no significant difference between the BWSTT group and the control group
The systematic review stated that for CP, none of the studies were RCTs. The study with the highest level of evidence found significant increases in self-selected gait speed and walking distance, but overall within the systematic review they only saw small increases in gait that were not clinically significant.

23. ICF
In the SCI population, the case study showed significant differences in all areas of the ICF model, as the individual child saw changes in her ASIA motor score, gait distance, WeeFIM score, and accomplishment of her goals in the community.
That being said, the systematic review did not see statistically significant differences in these categories

24. Recommendations
Safe!
Positive results in certain pediatric populations
Financial burden
Time-intensive
When do we stop working on gait and focus on other skills?
Need more RCTs and studies comparing BWSTT to other gait training methods
None of the studies found detrimental effects of BWSTT, so it is a safe alternative to on ground gait training
In terms of recommending to parents of children with special healthcare needs, it goes back to the right child, in the right situation, at the right time. We would not recommend it for populations with little to no research behind it, so most support would be for children with down syndrome, CP, and potentially SCI.
It can be a significant financial burden to families, as some clinics require they pay separately to come in for BWSTT services. Additionally, it is not something many families in the community would be able to use at home, due to the expense of the equipment.
Lastly, we would need to weigh the options of focusing on gait versus focusing on other skills for each individual patient. As we have talked about previously, a child with CP with functional abilities consistent with GMFCS level IV may not be appropriate, as we do not anticipate they will be able to ambulate in the future.

25. References:
Body-Weight-Supported Treadmill Training: Using Evidence to Guide Physical Therapy Intervention. Section on Pediatrics, American Physical Therapy Association
Body-Weight Supported Treadmill Training. University of Washington Rehabilitation Medicine, Web. <
Behrman AL, Harkema SJ. Locomotor Training after Human Spinal Cord Injury: A Series of Case Studies. Physical Therapy. 2000;80(7):
Litegait Training.
Rehabilitation Institute of Chicago. Pediatric Lokomat Walking Therapy.
Duncan, PW, et. al. Body-Weight-Supported Treadmill Training Rehabilitation after Stroke. N Engl J Med (21).
Damiano DL, DeJong, SL. A Systematic Review of the Effectiveness of Treadmill Training and Body Weird Support in Pediatric Rehabilitation. J Neurological Phys. Ther. 2009; 33:
Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics 2001;108
Willoughby, KL, et. al. Efficacy of partial body-weight supported treadmill training compared with overground walking practice for children with cerebral palsy: a randomized controlled trial. Archives Phys. Med. Rehabil (3)
Prosser L. Locomotor Training Within an Inpatient Rehabilitation Program After Pediatric Incomplete Spinal Cord Injury. Phys. Ther. 2007; 87:

26. Questions?