Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomised clinical trial.
Article Type: Clinical report
Subject: Walking (Comparative analysis)
Walking (Physiological aspects)
Spinal cord injuries (Care and treatment)
Spinal cord injuries (Physiological aspects)
Motion perception (Vision) (Research)
Motion perception (Vision) (Physiological aspects)
Disabled persons (Physiological aspects)
Author: Dunn, Jennifer
Pub Date: 03/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: March, 2011 Source Volume: 39 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263880340
Full Text: Field-Fote EC & Roach KC (2011): Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomised clinical trial. Physical Therapy 91: 48-60.

Aim

The aim of this single blind, randomised clinical trial was to compare changes in walking speed and distance between four locomotor programmes: treadmill training with manual assistance (TM), treadmill training with electrical stimulation (TS), overground training with electrical stimulation (OG) and treadmill training with robotic assistance using the Lokomat robotic gait orthosis (LR).

Method

Seventy four participants with chronic spinal cord injury (SCI) (> 1 year post injury) were trained five days a week for a 12 week period in one of the locomotor training approaches. Overground walking speed and distance were the primary outcome measures. Lower limb strength was a secondary measure.

Results

Sixty four participants completed training giving an 86% completion rate. There were no significant differences in walking speed between the four groups. The biggest distance gains were seen in the OG group. Effect sizes for speed and distance were similar for the TM and TS groups while no effect was seen with the LR group. Retesting a convenience sample of 10 participants (from each of the training groups) six months following intervention showed a slower walking speed than at the completion of training but it remained faster than before training. There were no significant between-groups differences in lower limb strength.

Conclusion

Walking speed improved with both overground training and treadmill training. However, distance improved to a greater extent with overground training.

Commentary

Ongoing neurological recovery and gains in ambulation in the chronic SCI population is a topical subject at present with the 'repair, regeneration and rehabilitation' debate raging in all corners of the world.

Field-Fote and Roach, well known authors in the field of locomotion training, present a randomised clinical trial aimed at the rehabilitation of locomotion in the chronic SCI population. They use a treadmill with body weight support for the TM and the TS groups, a treadmill with the Lokomat robotic gait orthosis for the LR group and body weight support with the OG group. Electrical stimulation utilising the flexor reflex response on the common peroneal nerve of one or both legs was used in the TS and OG groups. For the LR group the guidance forces were set at 100% to provide maximal assistance (i.e. no effort for stepping required from the participant) throughout the step cycle.

The use of a treadmill for locomotor training programmes supplies biomechanical assistance for the stance phase of stepping. The treadmill belt moves the stance limb into extension and neural assistance for the initiation of swing phase by generating of excitation of the stretch receptors of the hip flexors as the limb is moved into extension. During treadmill training stepping can be assisted by either manual assistance by a therapist, mechanical assistance of a robotic gait orthosis or by electrical stimulation. Each of these has their own advantages and disadvantages. In a clinical setting, the cost and size of the equipment is the biggest disadvantage. Within the spheres of locomotor training following SCI there has been little consensus to the best approach of use in the research setting, let alone the clinical environment (Mehrholz et al 2008).

One of the major barriers in all SCI research is the limited number of participants in studies, often limited by the variability of the resultant impairments following SCI. This study is considered a large clinical trial in terms of SCI research yet the results suggest that even this is too small. Because of the small sample size the authors were not able to control for level of injury in their training groups thus comparing ambulation of people with paraplegia (who may have normal upper limb and trunk strength), to those with tetraplegia (who present with limited upper limb and trunk strength). Another barrier to SCI research is the responsiveness of clinical outcome measures in showing meaningful change following an intervention. The authors in this study used two common outcome measures for ambulation speed and distance (albeit slightly modified); yet, they argue that it may be more salient for therapists to focus on walking distance rather than speed, as small improvements in distance can make meaningful differences to function and participation of an individual within their community.

The results of this study are exciting as they indicate that improvements in walking distance and speed are possible in the motor incomplete SCI population when they participate in a high intensity gait training programme, regardless of the time since SCI. The fact that the biggest gains were made in the group that trained overground as opposed to the treadmill based training indicates that high-tech equipment is not needed to gain these benefits. Clinically this provides us with strong evidence for what we as physiotherapists inherently know that intensive task specific training with trial and error during practice promotes greater walking endurance than any simulated training programme. In addition the maintenance of training effect six months following the programme is encouraging for all those investing in these programmes including therapists, people with SCI and funders of community-based rehabilitation programmes.

Jennifer Dunn, DipPhys, MPhil(Rehab), PhD candidate

University of Otago, Wellington

Senior Physiotherapist, Burwood Spinal Unit

Christchurch

REFERENCES

Mehrholz J, Kugler J, Pohl M (2008); Locomotor training for walking after spinal cord injury. Cochrane Database of Systematic Reviews 2: CD006676
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