Investigation of the Effects of C-Mill (Hocoma AG, Switzerland) Treadmill Training on Trunk Balance in Patients with Spinal Cord Injury

March 10, 2025 updated by: Sinem Yıldırım, Ankara City Hospital Bilkent

This study examines how C-Mill treadmill training affects balance and stability in people with spinal cord injury (SCI). Many individuals with SCI experience difficulty with sitting and walking balance, which affects their daily activities and independence. This research aims to explore whether C-Mill, a treadmill that combines virtual reality and sensor-based walking support, can improve trunk stability and mobility.

Who Can Join the Study?

People who:

Are between 18-65 years old Have a spinal cord injury at T4 or lower Are classified as ASIA C or D (moderate to mild impairment) Have stable spinal alignment and can safely participate in walking exercises People who have osteoporosis, heart or lung conditions, additional neurological diseases, or severe joint problems cannot participate.

Our study is a prospective observational study. Regardless of whether exercises are performed conventionally or on an alternative gait platform such as the C-Mill, all interventions are part of routine clinical practice. Patients whose treatment programs already align with the aforementioned procedures will be included. In robotic rehabilitation and assisted gait device laboratories equipped with the C-Mill platform, spinal cord injury patients follow a standardized rehabilitation protocol. These laboratories operate on an appointment-based system. After random group allocation, patients in the study group will undergo assessments at the beginning and end of C-Mill therapy, while control group patients will be enrolled before initiating C-Mill treatment. Following data collection for the control group, these patients will also receive C-Mill therapy.

What Will Happen in the Study?

Participants will be randomly assigned to one of two groups:

C-Mill Group: Receives standard rehabilitation plus C-Mill treadmill training for balance and walking exercises (10 sessions over 4 weeks).

Conventional Therapy Group: Receives standard rehabilitation plus traditional balance and walking exercises (10 sessions over 4 weeks).

How Will the Results Be Measured?

Researchers will assess:

Balance and Stability using functional reach and trunk control tests Independence in Daily Life using a spinal cord-specific scale (SCIM-III) Quality of Life using a health questionnaire (SF-36) Fear of Falling using a visual scale Why Is This Study Important? The study aims to determine if C-Mill training is more effective than traditional rehabilitation in improving balance, stability, and confidence in movement for people with SCI.

Study Overview

Status

Active, not recruiting

Conditions

Spinal Cord Injuries (SCI)

Detailed Description

Enhancing trunk balance and stability is a key objective in SCI rehabilitation. Various exercise modalities, including proprioceptive training, core strengthening, yoga, and Pilates, are employed to improve motor skills, coordination, and quality of life. Recently, virtual reality (VR)-based approaches, such as the C-Mill treadmill (Hocoma AG, Switzerland), have gained prominence. The C-Mill integrates visual and motor training through a suspension-supported system that ensures safe ambulation while adapting to the patient's pace. Unlike conventional treadmills and robotic-assisted devices, it uniquely incorporates VR to simulate real-world gait challenges, bridging the gap between traditional therapies and independent walking.

This study aims to investigate the effects of gait exercises performed with the C-Mill treadmill on trunk balance and stability by leveraging its advantages, such as gradual weight-bearing, improved gait stability, and reduced fatigue.

Data Quality and Management Procedures Patients admitted for inpatient treatment at the Spinal Cord Injury Rehabilitation Clinic of Ankara Bilkent City Hospital, who meet the inclusion criteria and voluntarily agree to participate in the study by reading and signing the informed consent form, will be included in the study. The medical status of all participants will be evaluated and recorded by the clinical research responsible physician.

A predefined data management plan will be implemented for missing, inconsistent, or erroneous data. Missing data will be identified and analyzed using statistical methods such as multiple imputation when necessary.

To ensure the integrity of data entry, regular audits and consistency checks will be performed by a physiotherapist involved in the study. To increase the reliability of the data, patient records and assessment reports will be cross-checked with the collected data. This will include comparisons made with electronic health records, paper-based case reports, and direct observation notes. All study procedures, including patient recruitment, data collection, data entry, data analysis, and reporting of adverse events, will be carried out according to predefined criteria.

Any adverse events or unexpected complications occurring during the study will be systematically documented and reported.

The determination of the appropriate sample size was based on the study by Khurana et al. A priori power analysis was conducted using the G* Power software (version 3.0.10, Universität Düsseldorf, Düsseldorf, Germany). The sample size for our study was calculated to include a minimum of 11 patients per group, ensuring 80% power with an alpha error rate of 0.05.

For statistical analysis, descriptive statistics will be presented as the mean and standard deviation for numerical variables if the parametric assumptions are met, and as the median and minimum-maximum values if the parametric assumptions are not met. For categorical variables, frequency and percentage values will be reported. The statistical significance of differences between groups will be examined using the Independent Samples T-Test if parametric assumptions are met, and the Mann-Whitney U Test if parametric assumptions are not met. Analyses will be conducted with a significance level of p < 0.05.

Study Type

Observational

Enrollment (Estimated)

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

Turkey
- - Ankara, Turkey
    - Ankara Bilkent City Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

Adult
Older Adult

Accepts Healthy Volunteers

Sampling Method

Probability Sample

Study Population

Patients will be treated at Ankara City Hospital, Department of Physical Medicine and Rehabilitation, within the Neurophysiological Exercise and Robotic Rehabilitation Laboratories.

Description

Inclusion Criteria:

Age between 18-65 years
SCI at T4 or below
ASIA classification C or D
Spinal stabilization achieved
Willingness to participate voluntarily

Exclusion Criteria:

Osteoporosis
Cardiopulmonary disease
Neurological conditions other than SCI
Joint or musculoskeletal disorders
Presence of orthostatic hypotension

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

Number of groups / cohorts

Cohorts and Interventions

Group / Cohort
conventional balance exercises In addition to conventional therapy, conventional balance exercises group will undergo conventional balance exercises and gait training, either within or outside the parallel bars, for a minimum of two days per week in 30-minute sessions. Over four weeks, they will complete a total of 10 sessions of gait and balance training.
Treadmill training group In addition to conventional therapy, the Treadmill training group will undergo static and dynamic balance exercises and gait training on the C-Mill platform for a minimum of two days per week, with sessions lasting 30 minutes each. Over four weeks, they will complete a total of 10 sessions of gait and balance training on the C-Mill platform.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Functional Reach Test Time Frame: Four weeks	The patient is instructed to stand next to, but not touching, a wall and position the arm that is closer to the wall at 90 degrees of shoulder flexion with a closed fist. The assessor records the starting position at the 3rd metacarpal head on the yardstick. Patient is instructed to reach as farther as possible without moving from the ground The location of the 3rd metacarpal is recorded again. Scores are determined by assessing the difference between the start and end position is the reach distance, usually measured in inches. Three trials are done and the average of the last two is noted	Four weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Berg Balance Scale Time Frame: Four weeks	The Berg Balance Scale (BBS) is used to objectively determine a patient's ability (or inability) to safely balance during a series of predetermined tasks. It is a 14 item list with each item consisting of a five-point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of function and takes approximately 20 minutes to complete. It does not include the assessment of gait.	Four weeks
36-Item Short Form Survey (SF-36) Time Frame: Four weeks	SF-36 Short Form will be used to assess quality of life. This questionnaire consists of 36 questions and 8 sub-parameters in total. Sub-parameters are determined as physical function, physical role difficulty, pain, general health, vitality, social function, emotional role function and mental health. It is in the form of a scale with points from zero (worst health) to 100 (best health status).	Four weeks
Spinal Cord Independence Measure (SCIM) Time Frame: Four weeks	The SCIM has been developed to address three specific areas of function in patients with spinal cord injuries (SCI). It looks at self-care (feeding, grooming, bathing, and dressing), respiration and sphincter management, and a patient's mobility abilities (bed and transfers and indoors/outdoors). A clinician or member of the clinical staff scores the patient on the items that this outcome measure addresses. Its scoring system is self-explanatory; therefore there isn't a manual to instruct the clinician in the scoring process. Scores range from 0-100, where a score of 0 defines total dependence and a score of 100 is indicative of complete independence. Each subscale score is evaluated within the 100-point scale (self-care: 0-20; respiration and sphincter management: 0-40; mobility: 0-40).	Four weeks
Trunk Stability Measurement Time Frame: Four weeks	Trunk Stability assessment will be performed using the HUR Smart Balance® (HUR International, FINLAND) device. The HUR Smart Balance System® consists of a BTG4-FE platform, All-in-One Computer, Balance Support Station and HUR Smart Balance Software. The platform will be checked before each test. The analysis will be performed with the patient standing on the platform, barefoot, 2 cm between heels, arms on both sides of the body. At least 5 seconds (preliminary phase) will be immobile before starting the assessment. After the preliminary phase, patients will stand in an upright position with their arms at their sides. The analysis duration will be 60 seconds. Postural sway and balance parameters will be measured in the static balance test.	Four weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Ankara City Hospital Bilkent

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 10, 2025

Primary Completion (Estimated)

September 21, 2025

Study Completion (Estimated)

September 21, 2025

Study Registration Dates

First Submitted

March 5, 2025

First Submitted That Met QC Criteria

March 10, 2025

First Posted (Actual)

March 25, 2025

Study Record Updates

Last Update Posted (Actual)