Stepping to Success

With the use of an overhead suspension system to assist a patient in treadmill walking, physical therapists can safely initiate gait training earlier in the rehabilitation process.

Body-weight supported treadmill training (BWSTT) integrates essential components of gait, including upright posture, weight-bearing, stepping and balance. With relearning to walk as the main initiative, some or all of a patient's weight is supported while therapists move his lower limbs through the proper gait pattern.

As demonstrated by current studies, using BWSTT with appropriate patients may lead to a better recovery of ambulation, with effects on over-ground walking speed, endurance and physical assistance required to walk.

"The treadmill encourages repetitious practice of normal, continuous steps with the ability to control speed and improve endurance," relayed Cynthia Reilly Simmons, PT, DPT. Dr. Simmons has worked in the International Center for Spinal Cord Injury (ICSCI) at Kennedy Krieger Institute in Baltimore, MD, for nearly four years.

A Leader in the Field

Patients who may benefit from BWSTT include those with traumatic and non-traumatic injuries to the spinal cord, and those with multiple sclerosis, spina bifida or cerebral palsy. "As long as walking is an appropriate milestone for the patient, this modality can be used across the lifespan," Dr. Simmons said.

ICSCI was established in 2005 by neurologist Dr. John McDonald on the philosophy that individuals with paralysis can always hope for recovery of sensation, function, mobility and independence, months and even years after injury.

The center combines innovative research with a unique focus on restoration and rehabilitation for children and adults with chronic paralysis.

Treatment at ICSCI is conducted by an interdisciplinary team and includes two levels of services. The inpatient unit offers a comprehensive evaluation and treatment program for children and young adults, ranging in age from birth to 21, with acute or chronic spinal cord dysfunction, including those requiring ventilator assistance.

The outpatient clinic provides its pediatric and adult patients with specialized outpatient evaluations, intensive therapy programs, periodic follow-up and medical management.

Kennedy Krieger has two body-weight supported treadmills-one in inpatient and one in outpatient-each outfitted with a LiteGait system. Because the department spends about 30 hours per week performing BWSTT, the therapists hope to increase the benefits to the patients by obtaining a TheraStride system. The system is linked to a computer that controls treadmill speed and body-weight support accurately, and allows for improved positioning of patients and therapists.

Adjunct Therapy

The physiological effects of BWSTT are similar to that of any weight-bearing activity, shared Beth Myers, MSPT, ATRIC, senior PT at ICSCI.

These effects include improvements to the vascular response to weight-bearing/standing position, gastrointestinal motility, respiratory capacity and self-esteem, and maintenance of bone density.

Additional physical benefits include increased appropriate input to the nervous system to help it "re-organize" and attempt to restore communication between the brain and spinal cord, Myers explained. Also, BWSTT helps to retrain a patient's nervous system to walk while minimizing compensatory strategies.

BWSTT aims to increase a patient's speed and endurance to normal. A patient's progression on the treadmill depends on where he starts in terms of body-weight support and manual assistance required to facilitate normal gait.

Typically, patients in earlier phases of recovery require more intensive interventions-perhaps four to five days a week for one-hour sessions, where time is split between gait and stand training on the treadmill. Those who have lesser needs may decrease to twice weekly sessions.

Supplementing with over-ground interventions is important to maximize the outcomes of BWSTT, Dr. Simmons shared. ICSCI patients improve strength and sensation with the use of functional electrical stimulation (FES) administered through hand-held units or FES ergometers.

"Restoration of normal gait typically requires the simultaneous training of normal mechanics of bed mobility and functional transfers such as rolling, sit to stand and floor to stand," she said. "Of equal importance is using hands-on techniques including proprioceptive neuromuscular facilitation and neurodevelopmental treatment."

According to Myers, the acuity of patients who use the treadmill in the inpatient setting is of particular concern.

"There are often medical issues that may prevent performing BWSTT such as sutures, blood pressure issues, pain and deep vein thromboses," Myers explained. "But if at all possible, it will be performed on the inpatient unit."

Patients who are more medically stable once they transition from the inpatient program to the outpatient program may begin BWSTT at that time, Myers shared.

Peds Population

Children (and adults) with spina bifida and SCI can greatly improve their gross motor function, speed and endurance by gait training using BWSTT. With greater plasticity in the pediatric nervous systems, the potential for recovery or restoration of normal gait, strength and overall function is much more possible.

The treadmill's harness allows for upright positioning, which improves lower extremity and trunk strength, motility and circulation. The harness also encourages the child to become comfortable standing within a safe setting.

Furthermore, the patient does not need to offload his body weight with his hands-as with using an assistive device-which can become tiring and prevent normal gait mechanics like arm swing and trunk rotation.

The treadmill allows for repetitious practice of normal, continuous steps with the ability to control and gradually progress speed and improve endurance. "Children will almost always take more steps and walk for longer periods of time with BWSTT versus gait training using assistive devices," Dr. Simmons observed.

BWSTT provides immediate feedback to patients and often increases motivation and participation. These benefits can help a child stay focused on the task at hand. Plus, it helps that the child is essentially a "captive audience."

"The treadmill provides a structured/closed environment and the harness system allows freedom for the therapists to manually facilitate normal gait," Dr. Simmons explained. "Facilitating normal mechanics is possible as the therapist does not have to chase after the child."

Some children, however, may not tolerate the harness or the closed environment for the desired length of the treatment session and need to be progressed as tolerated.

In these cases, the therapists are flexible with the treatment times and frequency to suit the patient.

Pediatric patients using BWSTT may exhibit decreased attention span to the task. To overcome this barrier, the PTs either use dissociation tactics such as singing a song or watching a favorite DVD or employ association tactics such as having the child step on stickers on the treadmill or swing his legs to kick balls.

Success Story

Dr. Simmons is currently treating a 46-year-old patient with chronic incomplete SCI from a diving accident more than 28 years ago.

When Paul Johnson first arrived at ICSCI, he was ambulating household and short community distances with two canes. He exhibited notable postural deformities, spasticity and muscle weakness that manifested into poor gait mechanics and constant pain in his lower back and sacroiliac joint.

The patient began a regimen of three-hour sessions two times per week, consisting of hour-long BWSTT, functional and bed mobility training, whole body strengthening, FES ergometry, and aquatic therapy using an underwater treadmill.

"If we see recovery of muscle groups below the level of injury, we often will trial BWSTT for four to eight weeks to see if there are further gains in muscle strength and function," Myers shared. 

Because patients and family members are often unfamiliar with the specialized treadmill, the therapists describe why they do certain things by linking the immediate goals-such as rolling or coming to sit from a supine position-to the common goal of restoring or improving walking.

In the three months since his initial evaluation, Johnson has tripled his distance in the six-minute walk test due to improved gait mechanics, decreased spasticity and increased strength. According to Dr. Simmons, he transitioned from four- to two-point gait, decreased the amount he bears weight through his canes, increased his stride length and improved his trunk posture.

Most importantly, Johnson's quality of life has greatly improved as he can now ambulate for longer periods of time without experiencing an increase in pain. As a result, he is relying less on his manual wheelchair in the community.

"It is truly exciting to work with a chronic patient who still has such great potential for improvement, which demonstrates the impressive plasticity in our nervous systems," Dr. Simmons shared.

Given his steady progress, the plan of care for this patient will focus on restoration of normal gait mechanics by decreasing BWS and increasing speed and endurance on the treadmill until an observable plateau occurs.

Training in Progress

All PTs, PTAs and PT technicians at ICSCI are trained to manually facilitate gait. Because assisting a patient on a body-weight supported treadmill typically requires three people-one person per leg and one hip trainer-everyone on staff is integral to the process.

When Dr. Simmons first began working at Kennedy Krieger, BWSTT was an established treatment intervention used by pediatric and adult patients. "My mentor, Karen Good, PT, OCS, was highly experienced in the use of the LiteGait, and encouraged me from my first patient on to use this modality as a way to retrain normal gait," she shared. From there, Dr. Simmons enrolled in an advanced education class with Mobility Research LLC, the makers of LiteGait. "The training solidified my understanding of the benefits of gait training over a treadmill, including eliciting and training stepping response and maximizing potential central pattern generator activity," she said.The training at ICSCI involves a mentorship with select staff members who receive advanced continuing education on BWSTT, followed by written and practical competencies.

Therapists are schooled in identifying indications, precautions and contraindications, and administering a general protocol for progressing a patient with gait independence. Therapists also learn proper harness positioning, how to use the scale to determine body-weight support, and hands-on facilitation techniques at the patient's legs and hips.

Dr. Simmons furthered her training with an advanced course titled "Activity Based Rehabilitation: Locomotor Training Principles and Practice," taught by BWS gait guru, Andrea Berhman, PhD, PT.

"Dr. Berhman's course was instrumental in fine tuning my hands-on facilitation skills and formatting a way to progress our patients within and between each session," she explained.

Dr. Simmons brought her new knowledge back to ICSCI and organized it to suit the clinic's population. She has been instrumental in getting the entire staff excited about gait training as they witness and document the progress patients make both on and off the treadmill.

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com