Gait Training Using Partial Body Weight Support During Over Ground Walking
In Individuals With Developmental Disabilities
Stuberg, WA, DeJong, SL, Kelly, ML, Ginsburg, GM Munroe-Meyer Institute, University of Nebraska Medical Center, Omaha, NE
Results
Background Information
Results are presented in Tables 2 and 3. Average walking speed during the last four sessions was significantly
greater than during the first four sessions. SWAPS score improved marginally, and PRS score showed no
significant change. Section E (‘Walking, Running, and Jumping’) of the GMFM showed a small increase, with
no change in Section D (‘Standing’).
Gait training using a treadmill and partial body weight support (PBWS) has been shown to be an effective
intervention for individuals with stroke, spinal cord injury, or cerebral palsy. To date, studies reporting the use
of PBWS systems for children with developmental disabilities have utilized a treadmill to stimulate stepping,
and have included physical guidance of lower extremity movement.
Table 2 Individual Results
Purpose
This study evaluated the effects of a different protocol, using PBWS during over ground walking in children
and young adults with developmental disabilities and severe / profound cognitive impairment.
Subject
#
Walking
Program
Attendance
(%)
1
Subjects
Table 1 provides descriptive data for each of the nine subjects included in this study. All subjects attended
special education classrooms for students with multiple impairments, and all demonstrated severe or
profound cognitive impairment. Two males and seven females were included. Ages ranged from 9 to 21
years, (mean 16.3, standard deviation 5.1). Height ranged from 48.8 to 66.5 inches (mean 56.0, standard
deviation 5.7). Weight ranged from 42.9 to 113.1 lbs (mean 79.9, standard deviation 27.7). For all subjects,
height was less than the 15th percentile and weight was less than the 25th percentile for age and gender.1
Figure 1
Methods
Table 1 Subject Descriptors
Figure 3
Figure 2
Gait Training Program
Subject #
1
2
3
4
5
6
7
8
9
Age
(Yrs)
Gender
Height
(in)
Weight
(lbs)
9.3
female
48.8
42.9
10.6
9.2
18.6
21.1
20.4
19.2
21.1
16.8
male
female
female
female
female
male
female
female
53.5
49.2
56.1
61.3
57.7
66.5
57.5
53.1
64.5
44.4
111.1
83.8
113.1
108.5
88.4
62.7
Diagnosis
Walking Device
Cerebral palsy with
ataxic quadriplegia
Posterior walker with four wheels,
swivel in front, non-swivel in back
Cerebral palsy with
spastic quadriplegia
Orthoses
Bilateral supramalleolar
orthoses,
thoracolumbosacral
orthosis
Posterior walker with non-swivel
wheels in front, tennis balls in
back
Bilateral shoe insert foot
orthoses
Cerebral palsy with
spastic diplegia
Posterior walker with forearm
supports, four wheels, swivel in
front, non-swivel in back
Bilateral ankle foot
orthoses, solid ankle
Cerebral palsy with
spastic quadriplegia
Posterior walker with forearm
supports, four wheels, all nonswivel
Bilateral ankle foot
orthoses, solid ankle
11-22 Chromosome
damage, with
spastic quadriplegia
No assistive device.
Requires at least one hand held.
•
Implemented in a school setting twice weekly for twelve weeks
•
Sessions administered by a physical therapist assistant, supervised by a physical therapist
•
Attendance ranged from 75% to 100%, as listed in Table 2.
•
Each session included 20 minutes of walking over ground in long hallways
•
Using a Biodex Unweighing System (Figures 1, 2 and 3), PBWS equal to 40% of body weight was
provided initially. The amount of PBWS was decreased by 5% of body weight every two weeks.
•
Verbal encouragement was provided.
•
Assistance was provided to guide and turn the Biodex Unweighing System.
•
One child required minimal facilitation to elicit stepping (subject #3). Others received no physical
prompts.
Figure 4
Outcome Measures
Bilateral ankle foot
orthoses, solid ankle,
with flexible
supramalleolar inserts,
thoracolumbosacral
orthosis
Mosaic tetrasomy
12P, with spastic
quadriplegia
Anterior walker with non-swivel
wheels in front, tennis balls in
back
Bilateral Cascade #3
ankle foot orthoses with
pre-tibial straps
History of traumatic
brain injury, with
spastic quadriplegia
Anterior walker with non-swivel
wheels in front, tennis balls in
back
Bilateral ankle foot
orthoses, solid ankle,
4 cm shoe lift on left
Rett Syndrome with
rigidity and
quadriplegia
Anterior walker with forearm
supports with straps, wheels in
front, tennis balls in back
None
Rett Syndrome with
dystonic
quadriplegia
No assistive device.
Requires at least one hand held.
Bilateral ankle foot
orthoses, solid ankle
•
•
•
Average walking speed – Distance walked
was recorded and converted to speed for
each 20 minute gait training session.
Average speed was determined for the
first four sessions and for the last four
sessions.
Supported Walker Ambulation
Performance Scale (SWAPS) (Figure 4),
and the Physician Rating Scale (PRS)
(Figure 5). Before and after the gait
training program, split screen videotape
was recorded while the subject walked
with his or her usual assistive device.
Each observational gait analysis scale was
scored based on the videotape.
Sections D (‘Standing’) and E (‘Walking,
Running, and Jumping’) of the Gross
Motor Function Measure (GMFM)4
Data Analysis
•
Paired t-tests were used to analyze differences
in mean scores for each outcome measure.
Supported Walker Ambulation
Performance Scale (SWAPS)2
A)
0
1
2
3
Support
Under the arms
At the Elbows
At the Hands
No Support
B) Posture
0 Forward Flexion in trunk,
and legs low weight-bearing
1 Forward Flexion in trunk,
and legs good weight-bearing
2 Forward Flexion in trunk
3 Upright Posture
C)
0
1
2
3
Quality of Steps
Vertical Stepping
Short Horizontal Stepping
Medium Horizontal Stepping
Normal Horizontal Stepping
D)
0
1
2
3
Quantity of Steps
No Steps
Less than 3 Consecutive Steps
3 to 6 Consecutive Steps
More than 6 Consecutive Steps
Scoring:
(A x 40)/3 =________
(B x 20)/3 =________
(C x 20)/3 =________
(D x 20)/3 =________
(also multiply D by 0.75 if gait is not
initiated spontaneously)
Sum =
Walking Speed
(ft/min)
SWAPS Score
PRS Score
Post
Pre
GMFM Section D
(%)
Post
Pre
GMFM Section E
(%)
Pre
Post
Pre
Post
Pre
Post
96%
73.1
162.6
86.7
93.3
15.5
15
44
46
28
32
2
100%
92.3
167.2
73.3
73.3
13
10
51
54
35
36
3
96%
3.7
6.2
46.7
33.3
3
5
3
3
0
0
4
100%
49.5
34.3
50.0
56.7
10
10
15
23
8
11
5
75%
62.9
104.5
73.3
80.0
13
14
31
31
32
33
6
86%
53.9
129.8
63.3
73.3
10
12
5
5
0
0
7
100%
80.5
90.2
73.3
73.3
10.5
13.5
26
26
15
15
8
100%
67.5
156.1
50.0
66.7
14
16
5
5
6
6
9
96%
55.5
106.5
60.0
76.7
10.5
12
5
5
8
8
Table 3 Group Results
Figure 5
Physician Rating Scale (PRS)3
A) Knee Position at Mid-Stance:
0 Severe Crouch > 15o
1 Moderate Crouch 10o -15o
2 Mild Crouch 0-10o
3 Neutral
2 Mild Recurvatum < 5o
1 Moderate Recurvatum 5o -10o
0 Severe Recurvatum >10o
B) Initial Foot Contact
0 Toe
1 Forefoot
2 Foot-flat
3 Heel
C)
-1
0
1
2
3
Foot Contact at Midstance
Equinus
Foot-Flat / Early Heel Rise
Foot-Flat / No Early Heel Rise
Occasional Heel / Foot-Flat
Heel / Toe (Normal)
D)
0
1
2
3
0
Timing of Heel Rise
No Heel Contact
Before 25% Stance
Between 25-50% Stance
At Terminal Stance
No Heel Rise (Crouch)
E)
0
1
2
Hindfoot at Midstance
Varus
Valgus
Neutral
F)
0
1
2
3
Base of Support
Frank Scissoring
Narrow Base (Poor knee clearance)
Wide Base
Normal Base (shoulder width)
G)
0
1
2
3
Assistive Devices
Walker with Assistance
Walker (Independent)
Crutches
Independent 10 meters
Sum = 
Outcome Measure
Pre-Training
(Mean ± Std. Dev.)
Post-Training
(Mean ± Std. Dev.)
Mean
Difference
T statistic
(critical value
of t = 1.86)
p value
Walking speed (ft/min)
59.9 ± 25.1
106.4 ± 56.3
46.5
-3.54
0.004
SWAPS
64.1 ± 13.6
69.6 ± 16.8
5.5
-1.80
0.055
PRS
11.1 ± 3.6
11.9 ± 3.3
0.8
-1.47
0.090
GMFM Section D (%)
20.5 ± 18.3
21.9 ± 19.1
1.4
-1.64
0.069
GMFM Section E (%)
14.7 ± 13.6
15.7 ± 14.3
1.0
-2.13
0.033
Discussion
•
•
•
•
This study demonstrated improvement in walking speed following a 12-week program of PBWS gait
training in a group of subjects with severe / cognitive impairment. Utilizing a PBWS system for gait
training over ground resulted in similar improvement in walking speed compared to studies utilizing a
treadmill and physical guidance of lower extremity movement.
Clinically significant changes in the SWAPS and PRS observational gait analysis scales were not seen.
This finding suggests that the gait training method used in this study did not significantly alter the subjects’
walking pattern.
Although a statistically significant increase GMFM Section E was seen, five of the nine subjects showed
no change. The mean difference (1%) is not considered to be clinically significant.
This gait training methodology should be studied further including follow-up measures to assess carryover
of the training effect on walking speed and a control group or non treatment phase.
Conclusion / Clinical Relevance
This study supports over ground gait training with PBWS for individuals with developmental disabilities and
severe / profound cognitive impairment.
References
1. National Center for Health Statistics and National Center for Chronic Disease Prevention and Health Promotion (2000),
http://www.cdc.gov/growthcharts.
2. Malouin F, Richards CL, Menier C, et al. The supported walker ambulation performance scale (SWAPS); development of a new outcome
measure of locomotor status in children with cerebral palsy. Pediatr Phys Ther. 9:48-53, 1997.
3. Koman,LA, Mooney, JF 3rd, Smith, BP, Goodman, A, Mulvaney, T. Management of spasticity in cerebral palsy with botulinum-A toxin: report
of a preliminary, randomized, double-blind trial. J Pediatr Orthop. 1994 May-Jun;14(3):299-303.
4. Russel D, Rosenbaum PL, Gowland C, et al. The Gross Motor Function Measure Manual 2nd Edition, Gross Motor Measures Group,
McMaster University, Hamilton, Canada, 1993.
5. Biodex Unweighing System, Biodex Medical Systems Inc., Shirley NY.
This research is supported in part by the Watt Foundation, Omaha, NE, in part by grant 5 T73 MC 00023-13 0 from the Maternal and Child Bureau, Health Resources Services Administration, Department
of Health and Human Services and in part by grant 90DD0533 from the Administration on Developmental Disabilities (ADD), Administration for Children and Families.