Body-WeightSupported Gait
Training
Mary Bernardo, Katie Blow, Lauren Bussian, Kaylea Kirven,
Sarah Nockengost
Alternative Intervention Presentation
Lifespan 1 2015
Virginia Commonwealth University
Body-Weight-Supported
Treadmill Training (BWSTT)
● 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
Body-Weight Supported Treadmill Training,
Colorado Physical Therapy Specialists
Video
https://www.youtube.com/watch?v=XLdc
tmNvACo
Background
● 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
● Systematic Review of pediatric
studies in 2006
Only 7 articles from
peer-reviewed sources
● Still preliminary in pediatric
population
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-WeightSupported 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 stepping
Assist 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-weightsupported gait training
• Therapist Support
LiteGait®
Lokomat®
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
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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
Rehabilitation
Damaino, 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
Rehabilitation
Damaino, 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 Outcomes
Dale 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 PT
HEP
Adult assist treadmill stepping practice
8 minutes/day, 5 days/week
Speed .46mph
Biweekly home PT and research staff visits
HEP
Treadmill Training of Infants With Down Syndrome:
Evidence-Based Developmental Outcomes
Dale 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:
Control Group
Experimental
Group
Mean Difference
Raise to Stand
194
134
60
Walking with Help
240
166
73
Walking Independently
401
300
101
Conclusion:
Body-Weight-Supported Treadmill Training is an effective approach in
early intervention to facilitate earlier onset of independent walking.
Efficacy of Partial Body-Weight-Supported Treadmill
Training [PBWSTT] Compared With Overground Walking
Practice for Children With Cerebral Palsy
Willoughby, et al. (2010) Disabil. Rehabil.
Purpose:
•
Determine safety and feasibility of PBWSTT in a school environment
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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:
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Exclusion Criteria:
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Ages 5 – 18 years old
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Physical assistance to walk
•
Diagnosis of CP
•
Concurrent medical condition
•
GMFCS Level III or IV
•
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Able to understand simple
instructions
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
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School Function Assessment
- 10-minute Walk Test
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 Study
Prosser, 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 lesion
Intervention: 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:
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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?