Body Weight Supported Treadmill Body Weight Supported Treadmill Training and Underwater Treadmill Training and Underwater Treadmill

TrainingTraining

Gabriele Moriellomorieg@sage.edu

ObjectivesObjectives

By the end of this presentation, you should be able By the end of this presentation, you should be able to:to:

summarize findings from research to retrain running in summarize findings from research to retrain running in those with TBIthose with TBI

outline the differences between land and water outline the differences between land and water treadmill trainingtreadmill training

describe two intervention approaches used to retrain describe two intervention approaches used to retrain running in those with brain injuryrunning in those with brain injury

understand potential outcomes following completion understand potential outcomes following completion of such programsof such programs

Running vs. walkingRunning vs. walking

Stance phase <50%, Swing phase >50%Stance phase <50%, Swing phase >50%↑ ↑ velocityvelocity↓ ↓ time in stancetime in stanceNo period of double supportNo period of double support↑ ↑ joint excursions and joint speedjoint excursions and joint speed↑ ↑ eccentric muscle strengtheccentric muscle strengthForward propulsion more dependent upon Forward propulsion more dependent upon

swing legswing leg

Biomechanical deviationsBiomechanical deviations

↑ ↑ cadence with ↓ cadence with ↓ stride lengthstride length

↓ ↓ self-selected speedself-selected speed

↓ ↓ stance timestance time

↓ ↓ float phasesfloat phases

↑ ↑ BOS and lateral BOS and lateral COM displacementCOM displacement

↑ ↑ knee flexion at initial knee flexion at initial contactcontact

↑ ↑ knee extension at knee extension at midstancemidstance

↑ ↑ knee flexion at push knee flexion at push offoff

↓ ↓ ankle power ankle power generation at push offgeneration at push off

↑ ↑ hip extensor power hip extensor power in early stancein early stance

Gavin WilliamsGavin Williamshttp://www.epworth.org.au/Our-Services/rehabilitation/Pages/High-Level-Mobility-Running-Group.aspx

““The Running Group” (Epworth Hospital)The Running Group” (Epworth Hospital) Higher level mobility program to facilitate Higher level mobility program to facilitate

participation in social, leisure, sporting and participation in social, leisure, sporting and employment rolesemployment roles

High level mobility training (2x/week)High level mobility training (2x/week)

General strength and cardiovascular fitness (3-General strength and cardiovascular fitness (3-4x/week)4x/week)

Williams & Morris (2009)Williams & Morris (2009)

Program evaluation of “The Running Program evaluation of “The Running Group” (n=28)Group” (n=28)

HiMAT scores increased from an average of HiMAT scores increased from an average of 20.3 to 29.220.3 to 29.2

No adverse eventsNo adverse events

Walking Walk backwardWalk on toes Walk over obstacleRun SkippingHop forward (affected leg) Bound (more affected leg)Bound (landing on less-affected leg) Up 14 stairs Down 14 stairs

Other optionsOther options

Biomechanical deviations are potentially associated with detrimental forces Biomechanical deviations are potentially associated with detrimental forces and balance impairments place people with TBI at higher risk for falls……..and balance impairments place people with TBI at higher risk for falls……..

Body Weight Supported Treadmill Training (BWSTT)

Underwater Treadmill Training (UWTT)

BWSTT vs UWTTBWSTT vs UWTTBWSTT UWTT

Body weight support Provides partial body weight support

Provides partial body weight support

Reduction in ground reaction forces

Yes Yes

Joint angles while running

Similar to land Different than BWSTT and land, especially at ankle and knee

Angular velocities while running

11-22% less than land 35%-89% less than land

Postural control YES Yes

Cardiovascular response Increases function

Thermal stress Same as land Decreased

Resistance No Yes

Sensory stimulation No Yes

An in-depth look into our An in-depth look into our running therapy protocol running therapy protocol

(BWSTT and UWTT)(BWSTT and UWTT)

InterventionIntervention

Phase I (6 weeks)Phase I (6 weeks)preparation for runningpreparation for running

Phase II (6 weeks)Phase II (6 weeks) treadmill training using BWSTT or UWTTtreadmill training using BWSTT or UWTT

Phase III (3 weeks)Phase III (3 weeks)carry over trainingcarry over training

Phase I: Preparation for runningPhase I: Preparation for running

Warm up (10 minutes)Warm up (10 minutes)

Balance training (15-20 minutes)Balance training (15-20 minutes)

Agility training (15-20 minutes)Agility training (15-20 minutes)

Core and extremity strengthening (15-20 Core and extremity strengthening (15-20 minutes)minutes)

Passive stretchingPassive stretching

Warm up (10 minutes)Warm up (10 minutes)

Hip pendulumsHip pendulums Dynamic lungesDynamic lunges

A. Walking or stationary bikeB. Dynamic stretching

Balance training (15-20 Balance training (15-20 minutes)minutes)

Agility exercises (15-20 minutes)Agility exercises (15-20 minutes)

Agility exercisesAgility exercises

Strengthening (20 minutes)Strengthening (20 minutes)

Passive stretchingPassive stretching

www.googleimages

Phase II: Treadmill trainingPhase II: Treadmill trainingWarm Up

- 5 minute slow walk

Two speed trials- 1 min-2 min-1 min

One distance trial- at a self-selected speed

Cool down- 5 minute slow walk

Over ground running

First day of the week Second day of the week

BWSTT or UWTTBWSTT or UWTT

Phase III: Carry over trainingPhase III: Carry over training

Running over Running over groundground

Return to sport Return to sport activities/agility activities/agility exercisesexercises

OutcomesOutcomesBWSTT and UWTTBWSTT and UWTT

Case descriptions (n=9)Case descriptions (n=9)

Average age: late 20sAverage age: late 20s

5 female5 female

6 presented with left hemiplegia6 presented with left hemiplegia

On average 5-6 years post-injuryOn average 5-6 years post-injury

Ranchos Scale: ranged from 5-8Ranchos Scale: ranged from 5-8

All had impaired standing balanceAll had impaired standing balance

Outcomes: Speed (m/sec)Outcomes: Speed (m/sec)

BWSTT UWTT

Outcomes: Distance (meters)Outcomes: Distance (meters)

UWTT

Outcomes: HiMATOutcomes: HiMAT

^MDC value >4

^

^

^

^

BWSTT UWTT

OutcomesOutcomesImprovements in strengthImprovements in strength

BWSTTBWSTT Knee flexorsKnee flexors

Ankle dorsiflexors and Ankle dorsiflexors and plantarflexorsplantarflexors

UWTTUWTT Hip extensors and Hip extensors and

abductorsabductors

Knee flexors and Knee flexors and extensorsextensors

Ankle plantarflexorsAnkle plantarflexors

(↓ ankle dorsiflexors)(↓ ankle dorsiflexors)

Lessons learnedLessons learned

People with brain injury CAN run/jog!!!!!People with brain injury CAN run/jog!!!!!

Need intensity and repetition!!!!!!Need intensity and repetition!!!!!!Plasticity (even years later)Plasticity (even years later)

Importance of continued activity beyond traditional Importance of continued activity beyond traditional rehabilitationrehabilitation

Important to monitor vital signs due to Important to monitor vital signs due to possible autonomic disruption (and they possible autonomic disruption (and they are most likely deconditioned)are most likely deconditioned)

Transferring this protocol to the Transferring this protocol to the clinical settingclinical setting

Remember this was a research protocol!Remember this was a research protocol!

It is very intense It is very intense PhysicallyPhysicallyTimeTime

Use the protocol as a basic guidelineUse the protocol as a basic guideline

Individualize the program to your patientIndividualize the program to your patient

Matthew FrearMatthew Frear Kristin SeaburgKristin Seaburg Michelle HallerMichelle Haller Alexandra AdamsAlexandra Adams Andrea BelangerAndrea Belanger Jeffrey CollinsJeffrey Collins Dereck SilvermanDereck Silverman

Alyssa IngegniAlyssa Ingegni Lydia CableLydia Cable Katie StoneKatie Stone Matthew Van SlykeMatthew Van Slyke Shi Feng LinShi Feng Lin Kaitlyn KohlenbergerKaitlyn Kohlenberger Erin HendersonErin Henderson

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Farley CT, Ferris DP. Farley CT, Ferris DP. Biomechanics of walking and running: Center of mass movements to muscle Biomechanics of walking and running: Center of mass movements to muscle actionaction. 1998. Available at: http://www-personal.umich.edu/~ferrisdp/Farley&Ferris,1998.pdf . . 1998. Available at: http://www-personal.umich.edu/~ferrisdp/Farley&Ferris,1998.pdf . Accessed 9/29/07.Accessed 9/29/07.

Moriello G, Frear M, Seaburg K. The recovery of running ability in an adolescent male after traumatic Moriello G, Frear M, Seaburg K. The recovery of running ability in an adolescent male after traumatic brain injury: a case study. brain injury: a case study. J Neurol Phys TherJ Neurol Phys Ther. 2009;33(2):111-120.. 2009;33(2):111-120.

Moriello G, Haller M, Adams A, Cable L, Stone K, Ingegni A. Running outcomes following an intensive exercise program in those with brain injury. Clinical Kinesiology (in press).

Moriello G, Haller M, Henderson E, Kohlenberger K, Lin SF, VanSlyke M. Running outcomes following an intensive balance, agility, strengthening and underwater treadmill training program for individuals with traumatic brain injury: A case series.

Neurology and Cardiovascular & Pulmonary Sections of the American Physical Therapy Association. Neurology and Cardiovascular & Pulmonary Sections of the American Physical Therapy Association. Exercise & physical activity guidelines based on best available evidence for individuals post stroke. Exercise & physical activity guidelines based on best available evidence for individuals post stroke. Alexandria, VA: American Physical Therapy Association.Alexandria, VA: American Physical Therapy Association.

Park SE, Lee MJ, Yoon BC et al. Comparison of underwater and overground preadmill walking exercise Park SE, Lee MJ, Yoon BC et al. Comparison of underwater and overground preadmill walking exercise to improve gait and physical function in people after stroke. to improve gait and physical function in people after stroke. J Int Acad Phys Ther Res. J Int Acad Phys Ther Res. 2012;1:120-2012;1:120-125.125.

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