Traditionally, clinicians support gait rehabilitation therapy with both body weight supported Treadmill and Over-ground Training to help patients reach their optimum walking potential. With no recognized clinical indications, selecting a gait approach is a research-based and experience-based decision with considerations for the patient’s injury and current condition, timing and scope of intervention and projected outcomes.

Outlined below are two topical research rehabilitation clinical study references that provides important new understandings and insights for gait rehabilitation treatments as well as validation of traditional best practices.

Research Study 1: Gait Intervention Dosing and Method

Research Study 1 is focused on a comparative analysis of four body-weight supported locomotor training approaches amongst groups of patients with chronic motor-incomplete spinal cord injury (SCI) while detecting relationships between dosing parameters and functional outcomes. Definitely, how distance-dose (distance walked across all sessions) and time-dose (time spent in walking across all sessions) influence overall walking distance and walking speed within each intervention.

The study was conducted with sixty-four participants with at one-year minimum post SCI trained in one of the four locomotor groups:

1. Over-ground Training with Functional Electrical Stimulation (OG).
2. Treadmill Training – Electrical Stimulation (TS).
3. Treadmill Training – Manual Assistance for Stepping (TM).
4. Treadmill Training – Robotic Gait Orthosis; 100% Guidance Force (LR).

After baseline measurements, the study involved the participants in 60-minute training sessions occurred 5 days/week for 12 weeks.

Distance-dose Outcomes

For the Over-ground Training group, it was reported that greater walking distance correlated with better improvements in distance and speed-related outcomes. However, there was no significant correlation for the treadmill patient research groups.

Time-dose Outcomes

The study identified that Increasing walking time did not significantly influence walking speed or distance across all four groups.

Thought-provoking Comments

The Treadmill Training Robotic Gait Orthosis group attained a distance-dose and time-dose noticeably greater than the other three approaches (distance: 10x more than TM and TS and 5x more than OG) (time: 5-6x more than TM and TS and 2x more than OG) but made the slightest functional improvements. This is highlighted by the reported total guidance of robotics use, which fosters active patient efforts, a key aspect in patient motor learning and functional gains.

The Over-ground Training group achieved the second largest distance-dose and time-dose and improved in distance outcomes. Comparing this to the Treadmill Training – Robotic Gait Orthosis group the study proposes that it is not the length of time spent in gait training, but rather how actively a patient participates in the activity that produces the outcomes. However, it appears that a greater number of step repetitions produces greater functional change in walking ability, but only when transferring the skill to a natural walking environment.

Reference

Sandler EB, Roach KE, Field-Fote EC. Dose-response outcomes associated with different forms of locomotor training in persons with chronic motor-incomplete spinal cord injury. J Neurotrauma. 2017;34 (10):1903-08.

Research Study 2: Body-Weight Support in Gait Rehabilitation

Research Study 1 is focused on a comparative analysis of body-weight support (BWS) effects with walking over a treadmill to walking over-ground for patients with chronic stroke. The twenty-eight research participants were all in a six months post-stroke condition, and walking with hemiparetic gait. Both patient research groups performed eighteen gait training sessions.

The amount of BWS during training sessions ranged from 0-30%, conditional on alignment of trunk and limbs and proper weight shift and weight bearing onto the patient’s hemiplegic limb. The patient’s progressed by reducing BWS, increasing gait speed, and/or reducing handhold support.

The report’s key outcome measures highlighted: gait speed, endurance, motor functional independence, and gait parameters including step length, step symmetry ratio, and single-limb support on the affected limb. Measurements were taken at baseline, at one week after the last gait training session and at six weeks after gait training completion.

Gait Speed Outcomes

Both patient research groups increased their speed after the intervention and at follow-up (using the 10-meter walk test). Since gait speed is a measure of walking ability and functional independence, the study suggested that clinicians should exercise clinical judgment when choosing between treadmill training and over-ground gait training to improve gait speed.

Endurance Outcomes

Both research groups displayed improvements in endurance using the six-minute walk test (6MWT). The 50- meter improvements exceeded the 34.4-meter improvement suggested by previous studies to be the “minimal clinically important difference for individuals with stroke. Thus, if the goal is improvement of patient endurance during gait, BWS both over-ground or over a treadmill would be an appropriate intervention.

Also, additional improvements were reported, by both research groups, for recovery of lower limb motor function impairments, functional independence, nonparetic step length and single limb support duration for the paretic limb.

Step-Length Symmetry Ratio

The research reported step-length symmetry ratio improved only in the Over-ground group. This is a significant finding for the below reasons:

• Stroke patients generally desire to look more “normal,” improving gait symmetry through over-ground practice contributes to that goal.
• Improved symmetry in gait may also decrease the energy cost of walking through less demanding gait patterns and completion of ADLs.
• Reduced step length symmetry ratio has been found to increase fall risk. Therefore, improving step length symmetry through over-ground gait training has the potential to decrease fall risk.

The study reported that walking on a treadmill will also increase step symmetry to a certain extent, but other research studies show this does not carry over well to over-ground walking. The active motor requirements in over-ground walking appear to be an important factor for promoting spatial symmetry in gait.

This study supports the use of BWS both over a treadmill and over-ground in the rehabilitation of patients with chronic stroke, but if a BWS is available for over-ground walking, the research proposes that it may be more useful than a treadmill.

Reference

Gama GL, Celestino ML, Barela JA, Forrester L, Whitall J, Barela AM. Effects of gait training with body weight support on a treadmill versus overground in patients with stroke. Arch Phys Med Rehabilitation 2017;98 (4):738-45.