Body-Weight- Supported Gait

Training

Mary Bernardo, Katie Blow, Lauren Bussian, Kaylea Kirven, Sarah Nockengost

Alternative Intervention PresentationLifespan 1 2015

Virginia Commonwealth University

Body-Weight-Supported Treadmill Training (BWSTT)

Body-Weight Supported Treadmill Training, Colorado Physical Therapy Specialists

●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

Video

https://www.youtube.com/watch?v=XLdctmNvACo

Background

●Systematic Review of pediatric studies in 2006

Only 7 articles from peer-reviewed sources

●Still preliminary in pediatric population

●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

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

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 steppingAssist intra- and inter-limb coordination if necessary

Support Using arms/hands Fading use of handrails

Episode of Treatment 2-16 weeks

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

Lokomat®LiteGait®

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

Patient Population

• Down Syndrome

• Cerebral Palsy (CP)

• Spinal Cord Injury (SCI)

• Myelomeningocele

• Stroke

• Guillain-Barre Syndrome

• Traumatic Brain Injury (TBI)

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)

A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in

Pediatric RehabilitationDamaino, 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

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.

A Systematic Review of the Effectiveness of Treadmill Training and Body Weight Support in

Pediatric RehabilitationDamaino, 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

Treadmill Training of Infants With Down Syndrome: Evidence-Based Developmental

OutcomesDale 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 PTHEP

Adult assist treadmill stepping practice8 minutes/day, 5 days/weekSpeed .46mphBiweekly home PT and research staff visitsHEP

Treadmill Training of Infants With Down Syndrome: Evidence-Based Developmental

OutcomesDale 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

Efficacy of Partial Body-Weight-Supported Treadmill Training [PBWSTT] Compared With Overground Walking Practice for Children With

Cerebral PalsyWilloughby, 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

Willoughby, et al. (2010)

n = 26

Outcome Measures: Baseline, Week 10, 14 weeks after training

- 10-meter Walk Test - 10-minute Walk Test

- School Function Assessment

Willoughby, et al. (2010)

Results:

Conclusion:

–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

Locomotor Training Within an Inpatient Rehabilitation Program After Pediatric

Incomplete Spinal Cord Injury: A Case StudyProsser, 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 lesionIntervention: 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

ICF

ICF

ICF

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

References:• Body-Weight-Supported Treadmill Training: Using Evidence to Guide Physical

Therapy Intervention. Section on Pediatrics, American Physical Therapy Association. 2010.

• Body-Weight Supported Treadmill Training. University of Washington Rehabilitation Medicine, 2003. Web. <http://sci.washington.edu/info/newsletters/articles/03sp_body_weight_support.asp>.

• Behrman AL, Harkema SJ. Locomotor Training after Human Spinal Cord Injury: A Series of Case Studies. Physical Therapy. 2000;80(7):688-700.

• Litegait Training. https://www.litegait.com/education/litegait-training• Rehabilitation Institute of Chicago. Pediatric Lokomat Walking Therapy.

http://www.ric.org/conditions/pediatric/services/pediatric-lokomat-walking-therapy/

• Duncan, PW, et. al. Body-Weight-Supported Treadmill Training Rehabilitation after Stroke. N Engl J Med. 2011. 364 (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: 27-44.

• 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. 2010. (3) 333-9.

• Prosser L. Locomotor Training Within an Inpatient Rehabilitation Program After Pediatric Incomplete Spinal Cord Injury. Phys. Ther. 2007; 87: 1124-1232.

Questions?