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Weight-Supported Treadmill Versus Over-Ground Training After Spinal Cord Injury: From a Physical Therapist's Point of View

In this letter, I would like to address the significance for physical therapy of a recent study by Dobkin et al.¹ This randomized clinical trial investigated the effectiveness of a combination of body-weight–supported treadmill training (BWSTT) and over-ground mobility training versus solely over-ground mobility therapy in subjects with an incomplete spinal cord injury (iSCI). A large number of the subjects with iSCI regained walking ability independent of the group to which they were assigned. Compared with historic data, an unexpectedly high percentage (92%) of patients with an American Spinal Injury Association Impairment Scale (ASIA) classification C regained an independent walking ability. In addition, the walking speed of the subjects classified as ASIA C and D did not differ between the groups. The authors concluded that BWSTT was not superior in restoring walking ability compared with over-ground mobility therapy in people with iSCI early after trauma.

From a physical therapist's point of view, the results of the study by Dobkin et al¹ could be considered very encouraging. As even a sensitive outcome measure such as walking speed² did not show any difference, Dobkin and colleagues had evidence that their intervention, which consisted of task-oriented over-ground training, was equally effective when compared with BWSTT. Body-weight–supported treadmill training can be considered an intervention with a thorough theoretical framework based on animal experiments and an impressive amount of animal and (mainly uncontrolled) human evidence indicating effectiveness (for a review, see Dietz³). Because physical therapy interventions often are criticized for their lack of scientific arguments based on theoretical background or treatment effectiveness, the results of Dobkin and colleagues' study are positive findings.

Several ideas might explain the lack of differences found.^1,4,5 In my opinion, the 3 prerequisites for improving loco-motor abilities, as identified by Grillner and Wallen,⁶ are sometimes forgotten, but they might partly explain the findings by Dobkin et al¹:

1. "The basic or stereotyped movement synergy to achieve propulsion"⁶ can be regarded as the rudimentary stepping that is generated by the central pattern generator (CPG), and the CPG can be well trained by applying BWSTT.³
   
2. The "maintenance of equilibrium during propulsive movement"⁶ is not trained to a large extent by BWSTT due to the body-weight unloading.
   
3. "Adaptation of the locomotor pattern to the behavioural goals of the person and the constraints of the environment"⁶ is, in general, not trained by BWSTT, perhaps with the small exceptions of implementing changes in walking speed or tread-mill inclination.
   

Body-weight–supported treadmill training can be considered a safe and practical intervention that can be applied at an early stage during rehabilitation where body-weight support and physical (or robotic) assistance enable patients with iSCI with partial paresis to perform leg movements. It can also be considered task-specific because it retrains reciprocal leg movements with appropriate sensory inputs.³ Training the CPG improves leg muscle activation, but this cannot be sufficiently transferred into function, because patients who remained classified as ASIA B (motor complete) showed no gain in locomotor function.¹ Therefore, supraspinal input appears to be inevitable to restore locomotion, and BWSTT can complement but not replace task-oriented over-ground adaptive locomotor training.

In conclusion, physical therapy, in general, might profit from the results of the study by Dobkin et al¹ as these results increase the body of evidence of the effectiveness of task-oriented training and might get physical therapy out of its "not-better-than-placebo" status. The present multidisciplinary approach to treating patients after an iSCI appears to be successful, as a high percentage of patients with iSCI regained walking ability. More specifically for physical therapists, task-oriented over-ground training with or without BWSTT can result in a promising functional outcome for the patient, which is, from the therapist's and patient's point of view, all that matters.

Hubertus JA van Hedel

Spinal Cord Injury Center
Balgrist University Hospital
Forchstrasse 340
CH-8008 Zurich, Switzerland
hvanhedel{at}paralab.balgrist.ch

References

1. Dobkin B, Apple D, Barbeau H, et al; Spinal Cord Injury Locomotor Trial Group. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI. Neurology. 2006;66:484–493.[Abstract/Free Full Text]
2. van Hedel HJ, Wirz M, Curt A. Improving walking assessment in subjects with an incomplete spinal cord injury: responsiveness. Spinal Cord. 2006;44:352–356.
3. Dietz V. Spinal cord pattern generators for locomotion. Clin Neurophysiol. 2003;114:1379–1389.[CrossRef][Web of Science][Medline]
4. Wolpaw JR. Treadmill training after spinal cord injury: good but not better. Neurology. 2006;66:466–467.[Free Full Text]
5. Dietz V. Good clinical practice in neurorehabilitation. Lancet Neurol. 2006;5:377–378.[CrossRef][Web of Science][Medline]
6. Grillner S, Wallen P. Central pattern generators for locomotion, with special reference to vertebrates. Annu Rev Neurosci. 1985;8:233–261.[CrossRef][Web of Science][Medline]

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				K. E. Musselman, K. Fouad, J. E. Misiaszek, and J. F. Yang Training of Walking Skills Overground and on the Treadmill: Case Series on Individuals With Incomplete Spinal Cord Injury Physical Therapy, June 1, 2009; 89(6): 601 - 611. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when Rapid Responses are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Hedel, H. J. Search for Related Content PubMed PubMed Citation Articles by van Hedel, H. J. Related Collections Adaptive/Assistive Devices Gait and Locomotion Training Spinal Cord Injuries Related Article Social Bookmarking                      What's this?