Body Weight Support Treadmill Training vs Traditional Training in patients dependent on walking assistance after stroke Andrea Strickland PTA 2710

Purpose Body weight support treadmill training (BWSTT) for walking ability after brain damage is an approach under current investigation Efficiency of this method beyond traditional training is lacking evidence, especially in patients needing walking assistance after stroke The objective of this study was to investigate change in walking and transfer abilities comparing BWSTT with traditional gait training

What is Body weight supported treadmill training? BWSTT is a gait training strategy that involves the unloading of the lower extremities by supporting a percentage of body weight. The strategy utilizes an overhead suspension system to support a percentage of the patient's body weight as the patient walks on a treadmill. Additionally, BWSTT allows therapists to safely initiate gait training earlier in the rehabilitation process.

The theory underlying BWSTT is based on evidence that neural plasticity of the brain and spinal motor mechanisms are influenced by proprioceptive information elicited from upright gait training The main elements to obtain motor control are practiced through high intensity, task specific, and repetitive training BWSTT is ideal for the therapist because speed, distance, and incline can be controlled.. But it can be physically demanding on the therapist by assisting the lower extremities through the phases of gait

Research Method A randomized single-blinded controlled clinical trial was conducted with 2 intervention groups: treadmill group and traditional gait training group 60 stroke patients in an in-patient stroke division were enrolled in this study Inclusion criteria were patients who used wheelchairs and those who were dependent of assistance for walking with or without walking aids

Treadmill Group The patients received 30 BWSTT sessions plus traditional gait training and functional training for 10 weeks Data was collected by a registration form and the control box which included the amount of body weight support, use of handrails, speed, and distance

The mean belt speed at session 1-3 averaged 0 The mean belt speed at session 1-3 averaged 0.8 mph, then was increased to an average of 1.5 mph by sessions 18-20. Sessions 28-30 were increased to a mean average of 3.1 mph The body weight support was reduced from a mean of 7.3 kilo to 0.8 kilo by the end of the treadmill training period Physical assistance initially was one person but was reduced to partly or no assistance by the end of the treadmill period

Traditional Gait Training Group Patients were tested without orthoses or walking aids unless they were needed for safety The patients were instructed to walk as fast as they could receiving balance assistance as little as possible for 30 meters Transfer training and stairs were also tested with this group The patients were tested at baseline, at 4-6 weeks, and after minimum of 10 weeks

Outcome Measures The following outcome measures were used to collect data on both groups Functional Ambulation Categories (FAC) 10 Meter walk test 6 minute walk test Shorter transfer, FIM task 9 Stairs, FIM task 13 Motor Assessment Scale (MAS) Visual Analog Scale (VAS)

Results The test scores at baseline did not differ significantly between the 2 groups, but the treadmill group tended to score better than the traditional group on Functional Ambulation Categories and time taken to climb stairs (FIM 13) Both groups improved walking speed and walking distance on the 10 meter walk test and the 6 minute walk test Both groups also improved in shorter transfer time (FIM 9) Motor Assessment Scale task 1-5 including transfer, balance, and walking showed significant difference between the groups in favor of the treadmill group

Treadmill group Baseline score Treadmill group After score Test Treadmill group Baseline score Treadmill group After score Traditional gait training group Baseline score Traditional gait training group Functional Ambulation Categories 1.5 3.5 1.0 2.5 FIM task 9, bed to chair transfer 5 7 FIM task 13, stairs 6 3 10 meter walk test 0.22m per second 0.40m per second 0.20m per second 0.36m per second 6 minute walk test 70m 138m 59m 115m Motor Assessment Scale Both groups scored 5 for walking, functional scores (1-5), and sum scores (1-8)  

Limitations The researchers expect that there would have been a substantial difference between the 2 groups after 5 weeks if BWSTT was used without traditional gait training The manual assistance of moving limbs may have been strenuous on the therapist which can limit the repetitions of the step cycles during the sessions The time it takes to put on the harness may have been included in training session, decreasing effective training time The participants were 3 to 6 months post-stroke, therefore they cannot be directly compared to patients with acute stroke Another limitation could be that cardiovascular fitness was not separately measured

Conclusion The majority of the clinical outcomes were found to be in favor of the treadmill group, but there was no statistical significant difference in change of the 2 groups after 5 and 11 weeks of training Both groups were found to improve substantially in walking and transfer during the study period. The reason for this is because both groups received the same amount of physical therapy Research supports that the outcome after stroke is associated with the amount of exercise conducted

The participants in this study also received functional training, balance, and transfer training which contributed to positive outcomes for both groups This study showed no significant difference between the 2 groups with the patients in need of walking assistance after stroke The authors of this study suggest that the patients in future studies should be divided into independent and dependent walkers when examining the effectiveness of treadmill training

References Ellen Hoyer, Reidun Jahnsen, Johan Kvalvik Stanghelle and Liv Inger Strand. Body Weight supported treadmill training versus traditional training in patients dependent on walking assistance after stroke: a randomized controlled trial. Disability and Rehabilitation, 34(3):210-219, 2012. Available from: Infroma Healthcare. Bergen, Norway.  Louise Ada, Catherine M Dean, Janine Vargus and Samantha Ennis. Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non- ambulatory patients early after stroke: a systemic review. Journal of Physiotherapy 2010 Vol. 56:153-161. Available from: Australian Physiotherapy Association. Sydney, Australia. Catherine M Dean, Louise Ada, Julie Bampton, Meg E Morris, Pesi H Katrak and Stephanie Potts. Treadmill walking with body weight support in subacute non-ambulatory stroke improves walking capacity more than overground walking: a randomized trial. Journal of Physiotherapy 2010 Vol. 56:97-103. Available from: Australian Physiotherapy Association. Sydney, Australia. Mona Kristin Aaslund PT, PHD; Jorunn Laegdheim Helbostad PT, PHD and Rolf Moe-Nilssen PT, PHD. Walking during body-weight-supported treadmill training and acute responses to varying walking speed and body-weight support in ambulatory patients post-stroke. Physiotherapy Theory and Practice, 29(4):278-289, 2013. Available from: Informa Healthcare. Bergen, Norway. Marco Franceschini, MD; Stefano Carda, MD; Maurizio Agosti, PT; Roberto Antenucci , MD; Daniele Malgrati, MD; Carlo Cisari, MD; on behalf of Gruppo Italiano Studio Allevio Carico Ictus. Walking After Stroke: What does treadmill training with body weight support add to overground gait training in patients early after stroke? STROKEAHA. 2009; 40:3079-3085.