Gait Recovery

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April 2005

By Cindy Flom-Meland, PT, PhD, NCS; Alecia Herring, DPT; Amanda S. Olson, DPT; Sarah Perkerewicz, DPT; and Amanda Runyan, DPT

The use of partial body weight support treadmill training has been gaining acceptance.

A common goal of individuals following pathology within the central nervous system, such as a cerebrovascular accident (CVA), is to regain the ability to ambulate. As physical therapists, we spend a lot of time with our patients/clients to improve their ability to ambulate and to achieve postural control. There are many different theories and methods in which these goals are approached clinically in order to work toward success.

Some therapists prefer a neurodevelopmental treatment (NDT), a proprioceptive neuromuscular facilitation (PNF), or a task-oriented approach to recovery of gait. Methods may vary from utilizing some type of assistive device, a raised bedside table, shopping cart, or pole (walking stick) to name a few. In recent years, the use of partial body weight support (PBWS) treadmill training has been gaining recognition as another method of facilitating the recovery of gait in patients/clients with a multitude of pathologies, including those of a neurological or orthopedic nature.

Early support for PBWS treadmill training came from animal studies with adult cats. Following transaction in the low thoracic region, the cats recovered the ability to walk on a treadmill with trunk support.¹

The use of PBWS treadmill training includes several factors that support the recovery of gait. It decreases the delay to gait training since the BWS provides support to the patient, which can allow for earlier initiation of locomotion in the rehabilitation process.² This intervention method also allows for task-specific training with the elements of balance, weight bearing, and stepping incorporated into each training session, all of which are key components of gait.³ Gait training with PBWS allows for high repetitions and for a more rhythmic gait pattern versus the conventional approach to gait training that focuses on isolated components of gait in the early stages of recovery. PBWS can also have an influence on the reduction of compensatory strategies because it is applied symmetrically versus gait training with assistive devices, which typically encourage a more asymmetrical gait pattern.⁴

GAIT RESEARCH
Several studies have evaluated the effectiveness of treadmill training with and without PBWS in the recovery of locomotion in comparison to conventional gait training. Treadmill training or therapeutic interventions that focus on task-specific activities related to gait appear to be more successful than conventional therapy alone.^5-7 Additionally, Visintin et al² reported that PBWS treadmill training was more effective than treadmill training alone.

The purpose of this pilot study was to determine if PBWS treadmill training improves the quality of gait, postural control, and gait velocity in adults with a diagnosis of CVA following a 6-week intervention program. Four subjects—two males and two females—ranging in age from 50 to 78 participated in the study. Three subjects had a right CVA, and one subject had a left CVA. The length of time since the CVA was within 2 years for three subjects and 6 years for one subject.

Pre- and post-assessment was conducted with use of the Berg Balance Measure, a 10-meter timed walk, the gait portion of the Tinetti Assessment Tool, and a template recording of each subject’s footprints during ambulation with use of a gait measuring system. Following the initial assessment, each subject participated in BWS treadmill training three times per week for 6 weeks with use of a BWS system and a treadmill.

Each session consisted of three bouts of ambulation with the duration determined by the subject’s tolerance or to a maximum of 10 minutes. Five minutes of rest was allowed between each bout. There were three levels of BWS (40%, 20%, and 0%, respectively) and speed (0.5 mph, 0.7 mph, and 1.0 mph) that were utilized for this study. At the onset of the study, each subject began with 40% BWS and a treadmill speed of 0.5 mph. Treadmill speed was increased, and BWS was decreased jointly when the subject was able to demonstrate good limb kinematics bilaterally, accept weight on the hemiparetic limb without the knee buckling, and tolerate a minimum of 5 minutes at the current speed. Depending on the impairments of the subjects, one or two therapists assisted with the training. If two were needed, one therapist would provide pelvic support and/or facilitation by standing behind the patient while straddling the treadmill belt. The second therapist was positioned on the involved side of the subject and assisted the subject with their hemiparetic lower extremity with advancement and control. The subjects were encouraged not to use upper extremity support throughout the training.

Tables 1&2. Test Scores Prior to and Following 6-Week Intervention,

Simple descriptive statistics were used to analyze and interpret the data for this study. All of the subjects demonstrated positive outcomes in one or all of the assessment tools utilized. The low level of impairment in one of the subjects made quantitative improvements negligible; qualitatively, however, the subject made gains in the quality of gait. The greatest improvements were noted in the 10-meter timed walk, followed by the gait portion of the Tinetti Assessment Tool, and lastly the Berg Balance Measure (see Tables 1 and 2).

Three of the four subjects demonstrated improvements in their foot template measurements. The foot template of subject A did not demonstrate any changes, whereas the other subjects demonstrated positive changes in step quality dependent upon their initial impairments.

The methodology utilized and the ensuing results of this study are similar to the study by Miller et al.⁸ The main difference between the two studies was the addition of a fourth bout of ambulation overground with BWS in the Miller study. The findings of this study are also supported by previous studies that have laid the foundation for PBWS treadmill training in demonstrating promising outcomes for patients with neurological pathologies.^2,5,7,9,10 Improvements noted in this study in regard to gait quality and increased gait velocity are similar to the findings of Hesse et al.⁷

A QUESTION OF SPEED

During PBWS treadmill training, if a patient needed assistance, a therapist stood behind the patient, straddling the treadmill belt.

In this study the speed of the treadmill was set very conservatively and was predetermined prior to the initiation of the study. Sullivan et al11 investigated different treadmill speeds and the motor learning principles of random practice. They had three groups of subjects that all walked at differing treadmill speeds: slow -- 0.5 mph, fast – 2.0 mph, and variable -- 0.5, 1.0, 1.5, and 2.0 mph. The subjects in the fast group had the greatest increase in overground walking velocity at the conclusion of the study.

The amount of body weight support in this study, was also predetermined prior to the initiation of the study. Visintin et al² observed each subject ambulate at 10%, 20%, 30%, and 40% body weight support. The initial percent body weight support selected for training was based on which of the four amounts promoted proper trunk and limb alignment and weight transference onto the hemiparetic lower extremity. Threlkeld et al¹² evaluated gait kinematics in healthy subjects at varying amounts of body weight support. They reported a decrease in gait kinematics above 50% body weight support.

Although this was a pilot study, the small number of subjects makes it difficult to report statistical significance due to lack of power. Another limitation of the study was the inability of the measurement tools to detect change in the subjects with less impairment. Continued research in the use of PBWS treadmill training is warranted to continue to further explore the parameters of treadmill speed and determination of amount of body weight support utilized.

Cindy Flom-Meland, PT, PhD, NCS, is an instructor in the Department of Physical Therapy at the University of North Dakota School of Medicine and Health Sciences, Grand Forks; Alecia Herring, DPT, is a physical therapist at Excel Physical Therapy, Buffalo, Minn; Amanda S. Olson, DPT, is a physical therapist at Methodist Hospital, St Louis Park, Minn; Sarah Perkerewicz, DPT, is a physical therapist at MeritCare, Fargo, ND; and Amanda Runyan, DPT, is a physical therapist at St Joseph’s Area Health Services, Park Rapids, Minn.

REFERENCES

Barbeau H, Rossignol S. Recovery of locomotion after chronic spinalization in the adult cat. Brain Res. 1987;412:84-95.
Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke. 1998;29:1122-1128.
Visintin M, Barbeau H. The effects of parallel bars, body weight support and speed on the modulation of the locomotor pattern of spastic paretic gait: a preliminary communication. Paraplegia. 1994;32:540-553.
Bassile CC, Bock C. Gait training. In: Craik RL, Oatis CA, eds. Gait Analysis: Theory and Practice. St Louis: Mosby-Year Book; 1995:420-435.
Richards CL, Malouin F, Wood-Dauphinee S, Williams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil. 1993;74:612-620.
Kwakkel G, Wagenaar RC, Twisk JW, Lankhorst GJ, Koetsier JC. Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomized trial. Lancet. 1999;354:191-196.
Hesse S, Bertlet M, Jahnke M, et al. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke. 1995;26:976-981.
Miller EW, Quinn ME, Seddon PG. Body weight support treadmill and overground ambulation training for two patients with chronic disability secondary to stroke. Phys Ther. 2002;82(1):53-61.
Visintin M, Barbeau H. The effects of body weight support on the locomotor pattern of spastic paretic patients. Can J Neurol Sci. 1989;16:315-325.
Wernig A, Muller S. Laufband locomotion with body weight support in persons with severe spinal cord injuries. Paraplegia. 1992;30:229-238.
Sullivan KJ, Knowlton, BJ, Dobkin BH. Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. Arch Phys Med Rehabil. 2002;83:683-691.
Threlkeld J, Cooper LD, Monger BP, Craven AN, Haupt HG. Temporospatial and kinematic gait alterations during treadmill walking with body weight suspension. Gait and Posture. 2003;17:235-245.

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