Gait quality is improved by locomotor training in individuals with SCI regardless of training approach

Carla F J Nooijen, Nienke Ter Hoeve, Edelle C Field-Fote, Carla F J Nooijen, Nienke Ter Hoeve, Edelle C Field-Fote

Abstract

Background: While various body weight supported locomotor training (BWSLT) approaches are reported in the literature for individuals with spinal cord injury (SCI), none have evaluated outcomes in terms of gait quality. The purpose of this study was to compare changes in measures of gait quality associated with four different BWSLT approaches in individuals with chronic motor-incomplete SCI, and to identify how gait parameters differed from those of non-disabled (ND) individuals.

Methods: Data were analyzed from 51 subjects with SCI who had been randomized into one of four BWSLT groups: treadmill with manual assistance (TM), treadmill with electrical stimulation (TS), overground with electrical stimulation (OG), treadmill with locomotor robot (LR). Subjects with SCI performed a 10-meter kinematic walk test before and after 12 weeks of training. Ten ND subjects performed the test under three conditions: walking at preferred speed, at speed comparable to subjects with SCI, and with a walker at comparable speed. Six kinematic gait quality parameters were calculated including: cadence, step length, stride length, symmetry index, intralimb coordination, and timing of knee extension.

Results: In subjects with SCI, all training approaches were associated with improvements in gait quality. After training, subjects with SCI walked at higher cadence and had longer step and stride lengths. No significant differences were found among training groups, however there was an interaction effect indicating that step and stride length improved least in the LR group. Compared to when walking at preferred speed, gait quality of ND subjects was significantly different when walking at speeds comparable to those of the subjects with SCI (both with and without a walker). Post training, gait quality measures of subjects with SCI were more similar to those of ND subjects.

Conclusion: BWSLT leads to improvements in gait quality (values closer to ND subjects) regardless of training approach. We hypothesize that the smaller changes in the LR group were due to the passive settings used for the robotic device. Compared to walking at preferred speed, gait quality values of ND individuals walking at a slower speed and while using a walker were more similar to those of individuals with SCI.

Figures

Figure 1
Figure 1
Gait parameters of subjects with SCI before and after the four different forms of body weight supported locomotor training (TM = manual assistance, TS = peroneal nerve stimulation, OG = overground with peroneal nerve stimulation, LR = robotic assistance), and gait parameters of non disabled subjects during the condition in which they walked at a slow speed while using a walker. Error bars represent standard deviation and n represents the number of individuals with SCI included in analysis of each parameter. CAD = cadence, SI = symmetry index, ACC = angular component of coefficient of correspondence, TOK = timing of knee extension onset.

References

    1. Lapointe R, Lajoie Y, Serresse O, Barbeau H. Functional community ambulation requirements in incomplete spinal cord injured subjects. Spinal Cord. 2001;39:327–335. doi: 10.1038/sj.sc.3101167.
    1. Protas EJ, Holmes SA, Qureshy H, Johnson A, Lee D, Sherwood AM. Supported treadmill ambulation training after spinal cord injury: a pilot study. Arch Phys Med Rehabil. 2001;82:825–831. doi: 10.1053/apmr.2001.23198.
    1. 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.
    1. Wernig A, Muller S, Nanassy A, Cagol E. Laufband therapy based on 'rules of spinal locomotion' is effective in spinal cord injured persons. Eur J Neurosci. 1995;7:823–829. doi: 10.1111/j.1460-9568.1995.tb00686.x.
    1. Wernig A, Nanassy A, Muller S. Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies. Spinal Cord. 1998;36:744–749. doi: 10.1038/sj.sc.3100670.
    1. Dobkin B, Barbeau H, Deforge D, Ditunno J, Elashoff R, Apple D, et al. The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial. Neurorehabil Neural Repair. 2007;21:25–35. doi: 10.1177/1545968306295556.
    1. Field-Fote EC, Lindley SD, Sherman AL. Locomotor training approaches for individuals with spinal cord injury: a preliminary report of walking-related outcomes. J Neurol Phys Ther. 2005;29:127–137.
    1. Barbeau H, Ladouceur M, Mirbagheri MM, Kearney RE. The effect of locomotor training combined with functional electrical stimulation in chronic spinal cord injured subjects: walking and reflex studies. Brain Res Brain Res Rev. 2002;40:274–291. doi: 10.1016/S0165-0173(02)00210-2.
    1. Johnston TE, Finson RL, Smith BT, Bonaroti DM, Betz RR, Mulcahey MJ. Functional electrical stimulation for augmented walking in adolescents with incomplete spinal cord injury. J Spinal Cord Med. 2003;26:390–400.
    1. Ladouceur M, Barbeau H. Functional electrical stimulation-assisted walking for persons with incomplete spinal injuries: longitudinal changes in maximal overground walking speed. Scand J Rehabil Med. 2000;32:28–36. doi: 10.1080/003655000750045712.
    1. Wieler M, Stein RB, Ladouceur M, Whittaker M, Smith AW, Naaman S, et al. Multicenter evaluation of electrical stimulation systems for walking. Arch Phys Med Rehabil. 1999;80:495–500. doi: 10.1016/S0003-9993(99)90188-0.
    1. Field-Fote EC. Combined use of body weight support, functional electric stimulation, and treadmill training to improve walking ability in individuals with chronic incomplete spinal cord injury. Arch Phys Med Rehabil. 2001;82:818–824. doi: 10.1053/apmr.2001.23752.
    1. Postans NJ, Hasler JP, Granat MH, Maxwell DJ. Functional electric stimulation to augment partial weight-bearing supported treadmill training for patients with acute incomplete spinal cord injury: A pilot study. Arch Phys Med Rehabil. 2004;85:604–610. doi: 10.1016/j.apmr.2003.08.083.
    1. Field-Fote EC, Tepavac D. Improved intralimb coordination in people with incomplete spinal cord injury following training with body weight support and electrical stimulation. Phys Ther. 2002;82:707–715.
    1. Hornby TG, Zemon DH, Campbell D. Robotic-assisted, body-weight-supported treadmill training in individuals following motor incomplete spinal cord injury. Phys Ther. 2005;85:52–66.
    1. Wirz M, Zemon DH, Rupp R, Scheel A, Colombo G, Dietz V, et al. Effectiveness of automated locomotor training in patients with chronic incomplete spinal cord injury: a multicenter trial. Arch Phys Med Rehabil. 2005;86:672–680. doi: 10.1016/j.apmr.2004.08.004.
    1. Mehrholz J, Kugler J, Pohl M. Locomotor training for walking after spinal cord injury. Spine. 2008;33:E768–E777.
    1. Ely DD, Smidt GL. Effect of cane on variables of gait for patients with hip disorders. Phys Ther. 1977;57:507–512.
    1. Foley MP, Prax B, Crowell R, Boone T. Effects of assistive devices on cardiorespiratory demands in older adults. Phys Ther. 1996;76:1313–1319.
    1. Li S, Armstrong CW, Cipriani D. Three-point gait crutch walking: variability in ground reaction force during weight bearing. Arch Phys Med Rehabil. 2001;82:86–92. doi: 10.1053/apmr.2001.16347.
    1. Opila KA, Nicol AC, Paul JP. Forces and impulses during aided gait. Arch Phys Med Rehabil. 1987;68:715–722.
    1. Smidt GL, Wadsworth JB. Floor reaction forces during gait: comparison of patients with hip disease and normal subjects. Phys Ther. 1973;53:1056–1062.
    1. Youdas JW, Kotajarvi BJ, Padgett DJ, Kaufman KR. Partial weight-bearing gait using conventional assistive devices. Arch Phys Med Rehabil. 2005;86:394–398. doi: 10.1016/j.apmr.2004.03.026.
    1. Alkjaer T, Larsen PK, Pedersen G, Nielsen LH, Simonsen EB. Biomechanical analysis of rollator walking. Biomed Eng Online. 2006;5:2. doi: 10.1186/1475-925X-5-2.
    1. Mulcahey MJ, Gaughan J, Betz RR, Vogel LC. Rater agreement on the ISCSCI motor and sensory scores obtained before and after formal training in testing technique. J Spinal Cord Med. 2007;30:S146–S149.
    1. Finch L, Barbeau H, Arsenault B. Influence of body weight support on normal human gait: development of a gait retraining strategy. Phys Ther. 1991;71:842–855.
    1. Behrman AL, Harkema SJ. Locomotor training after human spinal cord injury: a series of case studies. Phys Ther. 2000;80:688–700.
    1. Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, et al. A targeted home- and center-based exercise program for people after total hip replacement: a randomized clinical trial. Arch Phys Med Rehabil. 2008;89:1442–1447. doi: 10.1016/j.apmr.2007.11.058.
    1. Tepavac D, Field-Fote EC. Vector coding: A technique for quantification of intersegmental coupling in multicyclic behaviors. Journal of Applied Biomechanics. 2001;17:259–270.
    1. Girden E. ANOVA: Repeated Measures. Sage; 1992.
    1. Cohen J. Eta-Squared and Partial Eta-Squared in Fixed Factor Anova Designs. Educational and Psychological Measurement. 1973;33:107–112. doi: 10.1177/001316447303300111.
    1. Hesse S, Malezic M, Schaffrin A, Mauritz KH. Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Scand J Rehabil Med. 1995;27:199–204.
    1. Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, et al. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke. 1995;26:976–981.
    1. Hesse S, Konrad M, Uhlenbrock D. Treadmill walking with partial body weight support versus floor walking in hemiparetic subjects. Arch Phys Med Rehabil. 1999;80:421–427. doi: 10.1016/S0003-9993(99)90279-4.
    1. Lindquist AR, Prado CL, Barros RM, Mattioli R, da Costa PH, Salvini TF. Gait training combining partial body-weight support, a treadmill, and functional electrical stimulation: effects on poststroke gait. Phys Ther. 2007;87:1144–1154.
    1. McCain KJ, Smith PS. Locomotor treadmill training with body-weight support prior to over-ground gait: promoting symmetrical gait in a subject with acute stroke. Top Stroke Rehabil. 2007;14:18–27. doi: 10.1310/tsr1405-18.
    1. McCain KJ, Pollo FE, Baum BS, Coleman SC, Baker S, Smith PS. Locomotor treadmill training with partial body-weight support before overground gait in adults with acute stroke: a pilot study. Arch Phys Med Rehabil. 2008;89:684–691. doi: 10.1016/j.apmr.2007.09.050.
    1. Patterson SL, Rodgers MM, Macko RF, Forrester LW. Effect of treadmill exercise training on spatial and temporal gait parameters in subjects with chronic stroke: a preliminary report. J Rehabil Res Dev. 2008;45:221–228. doi: 10.1682/JRRD.2007.02.0024.
    1. Chen G, Patten C. Treadmill training with harness support: selection of parameters for individuals with poststroke hemiparesis. J Rehabil Res Dev. 2006;43:485–498. doi: 10.1682/JRRD.2005.04.0063.
    1. Hidler J. Robotic-assessment of walking in individuals with gait disorders. Conf Proc IEEE Eng Med Biol Soc. 2004;7:4829–4831.
    1. Alton F, Baldey L, Caplan S, Morrissey MC. A kinematic comparison of overground and treadmill walking. Clin Biomech (Bristol, Avon) 1998;13:434–440. doi: 10.1016/S0268-0033(98)00012-6.
    1. Lee SJ, Hidler J. Biomechanics of overground vs. treadmill walking in healthy individuals. J Appl Physiol. 2008;104:747–755. doi: 10.1152/japplphysiol.01380.2006.
    1. Parvataneni K, Ploeg L, Olney SJ, Brouwer B. Kinematic, kinetic and metabolic parameters of treadmill versus overground walking in healthy older adults. Clin Biomech (Bristol, Avon) 2009;24:95–100. doi: 10.1016/j.clinbiomech.2008.07.002.
    1. Riley PO, Paolini G, Della CU, Paylo KW, Kerrigan DC. A kinematic and kinetic comparison of overground and treadmill walking in healthy subjects. Gait Posture. 2007;26:17–24. doi: 10.1016/j.gaitpost.2006.07.003.
    1. Whittle M. Gait Analysis: An Introduction. 4. Butterworth-Heinemann; 2007.
    1. Daly JJ, Sng K, Roenigk K, Fredrickson E, Dohring M. Intra-limb coordination deficit in stroke survivors and response to treatment. Gait Posture. 2007;25:412–418. doi: 10.1016/j.gaitpost.2006.05.007.
    1. Farmer SE, Pearce G, Stewart C. Developing a technique to measure intra-limb coordination in gait: applicable to children with cerebral palsy. Gait Posture. 2008;28:217–221. doi: 10.1016/j.gaitpost.2007.12.005.
    1. Behrman AL, Lawless-Dixon AR, Davis SB, Bowden MG, Nair P, Phadke C, et al. Locomotor training progression and outcomes after incomplete spinal cord injury. Phys Ther. 2005;85:1356–1371.

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