Locomotor Training Using Body-SCI

8/4/2019 Locomotor Training Using Body-SCI

1/10

Locomotor Training Using Body-

Weight Support on a Treadmill inConjunction With Ongoing PhysicalTherapy in a Child With SevereCerebellar AtaxiaKristin Cernak, Vicki Stevens, Robert Price, Anne Shumway-Cook

Background and PurposeThis case report describes the effects of locomotor training using body-weight

support (BWS) on a treadmill and during overground walking on mobility in a child with severe cerebellar ataxia who was nonambulatory. To date, no studies haveexamined the efficacy of this intervention in people with cerebellar ataxia.

Case DescriptionThe patient was a 13-year-old girl who had a cerebellar/brainstem infarct 16 monthsbefore the intervention. Her long-term goal was to walk independently in her home

with a walker.

InterventionLocomotor training using a BWS system both on the treadmill and during overground

walking was implemented 5 days a week for 4 weeks in a clinic. Locomotor training

using BWS on a treadmill was continued 5 days a week for 4 months at home.

OutcomesPrior to training, she was able to take steps on her own with the help of anotherperson, but did not take full weight on her feet or walk on a regular basis. At 6months, she walked for household distances. Prior to training, her Pediatric Func-tional Independence Measure scores were 3 (moderate assistance) for all transfers, 2(maximal assistance) for walking, and 1 (total assistance) for stairs. At 6 months, herscores were 6 (modified independence) for transfers, 5 (supervision) for walking, and4 (minimal assistance) for stairs. Prior to training, she was unable to take independentsteps during treadmill walking; at 6 months, all of her steps were unassisted.

Discussion and ConclusionLocomotor training using BWS on a treadmill in conjunction with overground gaittraining may be an effective way to improve ambulatory function in individuals withsevere cerebellar ataxia, but the intensity and duration of training required forfunctionally significant improvements may be prolonged.

K Cernak, PT, DPT, MPH, is Phys-

ical Therapist, Division of PhysicalTherapy, Department of Rehabili-tation Medicine, University ofWashington Medical Center, 1959NE Pacific St, Seattle, WA 98195(USA). Address all correspon-dence to Dr Cernak at: [email protected].

V Stevens, PT, is Physical Thera-pist, Division of Physical Ther-apy, Department of RehabilitationMedicine, University of Washing-ton Medical Center.

R Price, MSME, is Research Scien-tist, Department of RehabilitationMedicine, University of Washing-ton Medical Center.

A Shumway-Cook, PT, PhD,FAPTA, is Professor, Division ofPhysical Therapy, Department ofRehabilitation Medicine, Univer-sity of Washington Medical Center.

[Cernak K, Stevens V, Price R,Shumway-Cook A. Locomotortraining using body-weight sup-port on a treadmill in conjunctionwith ongoing physical therapy in a

child with severe cerebellar ataxia.Phys Ther. 2008;88:8897.]

2008 American Physical TherapyAssociation

Case Report

Post a Rapid Response orfind The Bottom Line:www.ptjournal.org

88 f Physical Therapy Volume 88 Number 1 January 2008


2/10

One of the most commonlystated goals in the rehabilita-tion of populations with neu-

rologic problems is the recovery ofwalking capacity.14 Although there

is no consensus currently on the bestway to train safe, efficient, and inde-pendent walking, evidence existsthat task-specific gait training canhave more beneficial effects on func-tional gait outcomes than nonspe-cific rehabilitation approaches.5,6 Lo-

comotor training using body-weightsupport on a treadmill (BWST) is anexample of task-specific gait trainingthat uses a harness to provide partialbody-weight support in conjunction

with a motorized treadmill. Re-

searchers examining locomotortraining have suggested that trainingusing BWST has several advantages:

(1) the body-weight support harnessallows a progressive increase in thedemands for postural control, (2) thetreadmill allows systematic controland progression of the speed at

which walking is performed, and (3)the repetitive training of a completegait cycle enables a more appropri-ate pattern of sensory input associ-

ated with the different phases of gaitto stimulate the locomotor pat-tern.79 In addition, locomotor train-ing using BWST allows the therapistto provide manual assistance to helpthe patient simulate a more normal

walking pattern.

Previous research has presented

mixed results regarding the efficacyof locomotor training using BWST inpatients with a variety of diagnoses,including stroke,1,5,10 spinal cord in-

jury,11,12 and cerebral palsy.13 A Co-chrane review by Moseley et al10 in-

vestigated the results of gait trainingusing BWST after stroke in 11 ran-domized controlled trials involving

458 participants and reported no sta-tistically significant differences be-tween gait training using a treadmill

with or without body-weight sup-port and other interventions for

walking speed and dependency.

Matching the type of locomotortraining to specific patient character-istics, such as gait speed, may be

required to optimize outcomes. Forexample, patients who have had a

stroke and walk slower than 0.4 m/sbenefited most from body-weightsupport and treadmill training,

whereas those who walked fasterthan 0.4 m/s required the addition ofoverground training to training usingBWST.1

Guidelines regarding optimal waysto combine overground training andtraining using BWST in specific pa-tient subgroups are still being devel-oped. Helbostad14 suggested that,

despite the mixed evidence for theefficacy of training using BWST forimproving gait in patients who are

ambulatory, it may be the only alter-native for ambulation training in peo-ple who are unable or require signif-icant assistance to walk.

Disordered or ataxic gait is a definingcharacteristic of cerebellar pathol-ogy. Ataxic gait has been character-ized by a widened or alternatively

variable base of support, inappropri-ate timing of foot placement and re-duced step frequency, increasedstep width, and prolonged time indouble-limb support.15 Both im-paired postural stability and decom-position of multijoint leg movementsappear to be factors in cerebellar gaitataxia.16,17 This combination of im-

paired balance and dyscoordinationin lower-limb dynamics suggests astrong rationale for the use of loco-motor training using BWST in people

with ataxic gait. However, BWSTuses unweighting during locomotortraining, and this unweighting is incontrast to previous authors18 whohave recommended the use of

weights on the trunk and limbs todecrease ataxic movements in pa-tients with cerebellar pathology.

In addition to their role in the con-trol of balance and gait, cerebellar

structures also are important inpractice-dependent motor adapta-tion and learning in many different

systems, including those controllinglocomotion.16,17 Damage to the cer-

ebellum affects the extent and rate atwhich individuals adapt locomotionto new contexts.16 This suggests thatthe training of individuals with cere-bellar pathology may require alonger duration or intensity of prac-tice to improve locomotor function

regardless of the type of training.

The purpose of this case report is todescribe the effect of locomotortraining using BWST in conjunction

with overground walking training on

mobility function in a 13-year-old pa-tient with severe cerebellar ataxia.

Case DescriptionPatient DescriptionThe patient was a 13-year-old girl

who had been healthy previouslyand who had a spontaneous poste-rior fossa hemorrhage with resultantcerebellar and brainstem infarcts.She was initially unresponsive andon a ventilator. She regained con-

sciousness after approximately 11 weeks. In addition to rendering hernonambulatory, initial sequelae fromthe hemorrhage included ataxia, de-creased coordination, weakness, andmultiple cranial nerve palsies.

This individual was selected for thecase report involving locomotor

training using BWST for several rea-sons: one of her goals for therapy

was to improve her ability to walkindependently, she was limited inher ability to participate in mobilitytraining because she required maxi-mum assistance of 2 people to walk,she had a brief exposure (less than10% of total treatment time) to loco-

motor training using BWST duringher inpatient rehabilitation stay and

was receptive to it, and her family was very supportive and willing totransport her to the clinic for physi-cal therapy every day. In addition,

Locomotor Training in a Child With Cerebellar Ataxia

January 2008 Volume 88 Number 1 Physical Therapy f 89


3/10

during her inpatient stay, weights were tried on both limbs and the

trunk to reduce ataxic movements,with no appreciable gains in eitherfunctional limb movements or im-

proved postural stability in sitting,standing, or walking. The patient be-gan the intervention outlined in thiscase report 16 months after herinjury.

Examination A physical therapist performed thetests and measures before the begin-

ning of clinic training, immediatelyafter completion of clinic training, 1month after completion of clinictraining, and after the completion of4 months of home training. At thebeginning of the intervention, (16months after the hemorrhage), ourpatient required a tracheotomy andfeeding tube, she was dependent in

all activities of daily living, and sheused a wheelchair for in-home andcommunity mobility.

Table 1 summarizes her physical im-pairments at the initiation of train-ing. She exhibited significant ataxiaduring both upper- and lower-extremity movements, including dys-

metria when reaching for objects,dysdiadochokinesia when perform-ing rapid alternating movements,

weakness (4 out of 5 on the manualmuscle test),19 spasticity greater onthe right side (score of 2 on the Mod-

ified Ashworth Scale),20 clonus, anda tight Achilles tendon on the right

lower extremity. She also demon-strated multiple cranial nerve palsies(left vocal cord paresis, facial nerve

palsies, and swallowing dysfunction)and sensory and perceptual deficitsprimarily on the left side, includingdecreased vision, decreased proprio-ception, and impaired hearing.

At the beginning of the intervention,she required the assistance of 2 peo-ple to ambulate because of an inabil-

ity to maintain upright posture andto produce an appropriate locomo-tor pattern in her legs. During gait,she exhibited poorly coordinated legmovements, which resulted in ab-normal and variable swing foot tra-

jectories and foot placement, in-creased variability in length andtiming of steps, slow walking speed,

profound trunk sway, and an incon-sistent base of support (alternatingtoo narrow or too wide). Because ofthe severity of her gait impairment,locomotor training using BWST wasconsidered the only feasible methodfor this patient to safely and consis-tently practice walking. In addition,body-weight support allowed the

therapists to provide manual assis-tance with stepping rather than hav-ing to assist with weight support andpostural stability.

Her physical therapy diagnosis wasImpaired Motor Function and Sen-

sory Integrity Associated With Non-progressive Disorders of the CentralNervous SystemAcquired in Ado-

lescence or Adulthood (PreferredPhysical Therapist Practice Pattern5D).21

Two measures of mobility were usedas outcome measures: the PediatricFunctional Independence Measure(WeeFIM), specifically the transfersand locomotion subscales,22,23 and

the Gillette Functional WalkingScale.24 The WeeFIM is a modified

version of the Functional Indepen-dence Measure designed to indicateseverity of disability based on theconcept of burden of care, whichrefers to the amount of assistancerequired to perform a given activity.The WeeFIM has 18 items in 6 sub-

scales; however, only the transfersand locomotion subscales were con-sidered as outcome measures for thiscase report. We chose this test for itsability to monitor change over timein children with chronic disabilities.Ottenbacher et al23 found the re-sponsiveness of the WeeFIM to bestatistically significant (P.05) for

detecting change in functional abili-ties in 174 children with chronicdisabilities over a 1-year period.Interrater reliability is high (intra-class correlation coefficient [ICC].90.99), as is test-retest reliability

Table 1.Impairments in Body Structure and Function as Measured at Baseline

Impairment Tests and Measures Finding

Spasticity Resistance to passive stretch measuring

using the modified Ashworth Scale

Right lower extremity: 2

Left lower extremity: 1

Strength Manual muscle test (05) 4/5 in bilateral lower extremities, except

for hip extension and hip abduction

bilaterally (3/5)

Dysmetria Past pointing

Finger to nose

Heel to shin

Moderate impairment on all tests

Right heel cord tightness Goniometry 2 of neutral

Clonus Quick stretch 2 beats of clonus on right




4/10

(ICC.98.99).22 Ottenbacher etal22 also demonstrated that the ICC

was the highest (.99) for the trans-

fers and locomotion subscales thatwe used with our patient.

The Gillette Functional WalkingScale (the walking-scale portion ofthe Gillette Functional Assessment)is a 10-level scale that includes theentire range of walking abilities fromnonambulatory to completely inde-

pendent ambulation in all commu-nity settings and terrains. This scale

was chosen for its ability to help doc-ument current functional status andfor its ability to evaluate change as aresult of interventions, specifically to

track an individuals progress in es-tablishing more independent gait. Itis a reliable tool both between and

within raters for a range of commu-nity ambulation over a time frame of1 to 6 months.24 Good test-retest(ICC.92), intrarater (ICC.92),and interrater (ICC.81) reliabilityhave been demonstrated, and con-tent and concurrent validity (as-sessed using Pearson correlations)also are significant at the .01 level.24

Mobility function also was measuredduring overground walking and dur-ing treadmill walking. Distance andlevel of assistance required wereused to evaluate overground mobil-ity function. In addition, the numberof independent steps the patient wasable to take while walking on the

treadmill was measured weekly dur-ing the clinic training and then againat 1 and 5 months after completionof the clinic training.

InterventionThe patient received locomotortraining using BWST on a LiteGaitsystem (model LGI 500)25,* (Fig. 1) inconjunction with practice in over-ground walking, 5 times a week for 4

weeks in the clinic. This was fol-

lowed by 4 months of training usingBWST in the home. At the conclu-sion of the 4-week intervention inthe clinic, the patient had no loco-motor training using BWST for 1

month because of a delay in locating

a suitable in-home treadmill system.Factors that affected the selection ofa home unit included limited spacethat required a treadmill that couldbe folded up and a treadmill thatcould be used at a speed of0.2 m/s.

The family purchased a Vision Fit-

ness treadmill, and a Pneumex over-head frame and harness (model07PW-1). The Pneumex harnessneeded to be altered because of thepatients discomfort with the leg at-tachments to the support harness. Agroin piece was ordered from Lite-Gait and altered to fit the Pneumexharness to achieve the desired un-

weighting needed for training. Onceher home treadmill system was in-stalled (Fig. 2), she continued her

locomotor training with BWST andoverground training for 30 minutes aday, 5 days per week, with the assis-tance of a home care physical thera-pist or a trained rehabilitation aide.

In the clinic, each 1-hour treatmentsession consisted of 15 minutes oflocomotor training using BWST, fol-lowed by 15 to 20 minutes of over-ground walking training using theBWS harness. She was seen for a totalof 19 sessions, and missed one treat-ment for surgical revision of her

feeding tube. At the beginning ofeach session, the patient donned aharness with assistance and wasbrought into the standing positionand assisted onto the treadmill.

Training Parameters andProgressionThe parameters of training that were

progressed with treatment are de-scribed below and summarized inTable 2.

Training time. Initially, the pa-tient attempted to ambulate on thetreadmill for 20 minutes with 2 rest

* Mobility Research, PO Box 3141, Tempe, AZ85280.

Vision Fitness, 500 South CP Ave, PO Box280, Lake Mills, WI 53551-0280. Pneumex Inc, 2605 N Boyer Ave, Sandpoint,ID 83864.

Figure 1.Body-weightsupported treadmill training system used in the clinic.




5/10

breaks. As she fatigued, her step con-trol deteriorated and she requiredgreater assistance; therefore, 15 min-utes was set as the maximum time

for treadmill walking for the remain-ing sessions. The gait training recom-mendations issued by the manufac-turer of the body-weightsupportedtreadmill training system25 were fol-lowed, including keeping each tread-mill training session to 15 minutes orless, ensuring that the patient tookmost of the steps with correct pat-

terns, and ending each session whenthe therapist or patient fatigued orthe patients gait deteriorated. By theend of training, this patient was ableto walk on the treadmill for 15 min-utes with no rests. She was initially

able to tolerate only 5 minutes ofoverground walking with body-

weight support but progressed to 15to 20 minutes with gradually de-

creasing percentage of support.

Body-weight support. The levelof body-weight support (determinedby using a scale to measure body

weight while standing on the tread-mill in the harness) was adjustedacross sessions to maximize uprightposture and independent stepping.

Initially, the harness provided ap-proximately 30% of body-weightsupport for walking on the treadmilland during overground walkingpractice. This was progressively de-creased to 10% of body-weight sup-

port by the second month of training.

Manual assistance. Amount andtype of manual assistance was de-

creased across training sessions. Ini-tially, 3 physical therapists were re-quired to provide manual assistanceto the patient while walking on thetreadmill in the support harness.One physical therapist assisted witheach lower leg by placing one hand

at the top of each foot to facilitatetoe clearance at swing phase andheel-strike at initial stance and theother hand behind the knees to pre-

vent knee hyperextension. As shownin Figure 1, the therapists providing

manual assistance to control lower-limb placement either squatted orsat on the edge of the treadmill ap-

paratus or on a low stool. A thirdassistant stabilized the patient at thehips and manually assisted with pel-

vic rotation. The patient was initiallyinstructed to hold lightly onto hand-rails to provide additional supportand upright posture on the treadmillas needed. Upper-extremity support

was discontinued 2 months after the

start of training, when the patientwas able to maintain a vertical trunkposition without the assistance ofher arms; however, she still requiredmanual assistance from the therapistat the hips. This assistance at thehips was maintained for almost 4months because of her severe ataxiaof the trunk.

Training speed. Based on re-search with a stroke population thatshowed the efficacy of increasedtraining speed on locomotor out-comes,26 our goal was to train gait atthe fastest speed manageable by thepatient. However, Hidler27 sug-gested that training speeds need to

be set according to each personsability to retain adequate motor con-trol of his or her legs. At the begin-ning of training, our patient required3 people to help her walk at a tread-mill speed of 0.18 m/s with approx-

Figure 2.Body-weightsupported treadmill training system used in the home.




6/10

imately 30% of body-weight support. We tried to increase her trainingspeed, but found that if we at-

tempted to increase treadmill speedfaster than 0.31 m/s, our patient wasnot able to retain adequate motorcontrol and stepping ability. We

were not able to increase speed afterthe second week in the clinic, andthe patient consistently trained at ap-proximately 0.3 m/s.

Visual cues for foot placement.Because of impaired lower-extremityproprioception, the patient used vi-sual cues to guide foot placementduring walking; however, this led toa forward head and trunk posture

that decreased her postural stability. We alternated practicing stepping with visual guidance (eg, looking at

her feet while walking) with lookingstraight ahead (increased use of pro-prioceptive and kinesthetic cues forfoot placement). The amount of timespent in visually guided foot place-ment was gradually decreased, al-lowing the patient to gradually in-crease the number of steps she wasable to take independently without

visual guidance for foot placement.

Progression of training parametersinvolved first reducing the amount ofmanual assistance of the legs pro-

vided by therapists to improve step-

ping ability, then reducing body- weight support while maintainingindependent stepping ability, and fi-

nally increasing speed of trainingwhile maintaining both postural sta-bility and independent stepping abil-ity. Concomitant to the progressionof treadmill training parameters, weincreased the time and duration ofoverground walking training, pro-gressively decreased body-weightsupport in the harness, and in-

creased gait speed during over-ground walking. The decision to pri-oritize independent stepping ability(decreased manual assistance) overpostural stability (decreased body

weight in the harness) was twofold:

Table 2.Parameters for Training on a Treadmill and Overground Training With Body-Weight Support a

Clinic Training (1 mo) NoTraining(1 mo)

Home Training (4 mo)

Week 1(Pretest)

Week 2 Week 3 Week 4(Posttest)

1-MonthRetentionTest

Months 34 Months 56

Treadmill time

(min)

15 15 15 15 15 15 15

Treadmill

speed (m/s)

0.18 0.31 0.31 0.31 0.36 0.54 0.54

Body-weight

support

30% 25% 20% 15% 15% 10% 10%

No. of rest

breaks

required

2 1 0 0 0 0 0

Amount ofassistance 3 people 3 people 3 people 13 people 1 person 1 person CG/SBA

Overground

walking time

with BWS

(min)

5 12 15 15 15 N/A N/A

Distance

walked

overground

with BWS

(m)

50 91 125 157 188 N/A N/A

Distance

walked

overground

without BWS

(m)

8 with 4WW 152 with U-Stepb

a BWSbody-weight support, N/Anot applicable, CG/SBAcontact guard or standby assist, 4WW4-wheeled walker.b In-Step Mobility Products Corp, 8027 N Monticello Ave, Skokie, IL 60076.




7/10

first and foremost, the patient herselfwas strongly committed to moving

her limbs independently, and, sec-ond, manually advancing the limbs

was physically taxing and fatiguingto the therapists. As the patient be-gan to master independent stepping,body-weight support was reduced.Each session she attempted to ambu-late by loading the maximum weightshe was able to support and still

maintain adequate stepping ability.Training time on the treadmill wasconsistently set at 15 minutes, buttime spent on walking overground

was increased as the patient devel-oped stepping ability and tolerancefor physical activity.

Vital signs were monitored daily in

her home by a registered nurse andwere stable, so they were not takenin the clinic. Oxygen saturation lev-els were taken when the patientshowed any signs of respiratory dis-tress, and they did not go below90%.

Our patient also received in-home

physical therapy twice a week for90-minute sessions from the time ofher discharge home from the reha-bilitation center 6 months prior tothe clinic intervention, during the4-week session of training using

BWST in the clinic, and for at least ayear afterward. The goals of her in-

home physical therapy program were to increase strength and coor-dination, to improve her ability tomaintain balance in sitting and stand-ing, and to increase independence intransfers. Specific interventions aresummarized in the Appendix.

Outcomes

Table 3 compares scores on the 3primary outcome measures over thecourse of the intervention. Prior totraining, her score on the GilletteFunctional Walking Scale was 2 (cando some stepping on her own withthe help of another person, but doesnot take full weight on her feet or

walk on a regular basis) and re-

mained at 2 at the 4-week mark (ie, when the clinic training was com-pleted) and at retention test 1 monthafter completion of the clinic train-ing. Six months after initiation of theintervention, her score improved to6 (walks for household distances).

Prior to training, her score on the

WeeFIM was 3 (moderate assistance)for transfers and 2 (maximum assis-tance) for walking. At 4 weeks and atthe retention test 1 month after thecompletion of the clinic training, hertransfer score improved to 4 (mini-

mal assistance), but her walkingscore did not change. Six months

after the initiation of the interven-tion, her score was 6 (modified inde-pendence) for transfers and 5 (super-

vision) for walking.

The number of independent stepstaken during treadmill walking was 0prior to training, and improved

weekly to 128 steps at 4 weeks and

to 200 steps at the1-month follow-upafter completion of the clinic train-ing. Six months after initiation of theintervention, all steps on the tread-mill were unassisted.

As noted in Table 2, there was asteady improvement in all trainingparameters for the training using

BWST, including: an increase in gaitspeed from 0.18 to 0.31 m/s on thetreadmill, increased endurance asshown by fewer rest breaks duringthe 15-minute treadmill sessions, de-creased body-weight support fromapproximately 30% to 15%, and de-creased level of assistance requiredfor walking on the treadmill from 3

people to 1 person.

The body-weight support harnesswas used during overground walkingtraining during the first 4 weeks oftraining. In the home setting, how-

Table 3.Intervention Outcomes

Pretest Week 2 Week 3 Posttest 1-MonthRetention TrialWithoutTraining

6-MonthFollow-up

Gillette Functional

Walking Scalea2 NTb NT 2 2 6

WeeFIMc transfers

subscale

3 NT NT 4 4 6

WeeFIM mobility

subscale

2 NT NT 2 2 5

No. of unassisted

steps

0 10 84 128 200 All

a Range of scores: 110.b NTnot tested.cWeeFIMPediatric Functional Independence Measure (range of scores: 17).




8/10

ever, the harness was anchored tothe ceiling and, therefore, was notavailable for overground walking

training. At 2 weeks, the assistivegait device was changed from a rear

support walker, which she wasnever able to successfully control, toa front 4-wheeled walker. A U-Step

walker was introduced at home 2months into her home training. Asshown in Table 2, there was steadyimprovement in overground walk-

ing, as indicated by a gradual in-crease in the distance walked from50 m at 1 week to 152 m at thecompletion of training, and a reduc-tion in the personal assistance re-quired from maximum assistance

from 3 people to supervision by 1person.

DiscussionThis case report examined the effect

of locomotor training using BWST inconjunction with home physicaltherapy on mobility function in a 13-

year-old girl with severe cerebellarataxia. After 5 months of this train-ing, our patient progressed from be-ing nonambulatory at the start of

training to being able to walk 152 m with supervision using a U-Step

walker. Other functional improve-ments included improved indepen-dence in transfers. She continued touse her wheelchair for long dis-tances in the community and for in-dependent mobility in the home.Her increased independence in step-ping on the treadmill after 4 weeksof training with BWST in the clinic

encouraged the family to purchase a

BWST system for the home so thattraining could be continued 5 days a week for 4 months. She continuedto make slow, but steady, gainsthroughout her 5 months of training,despite the fact that training was be-gun 16 months after her injury.

Previous research28,29 suggests that,following a neurologic injury such asstroke, physical improvements pla-

teau after 6 months. However, re-cent studies examining the effect of

constraint-induced therapy in people with stroke have suggested thatgains can be made with intensivetherapy several years after the inju-ry.30 Consistent with this research,our patient, whose injury occurred16 months previously, made signifi-

cant functional gains with intensivephysical therapy (5 days per weekfor 5 months) that included locomo-tor training using BWST in conjunc-tion with overground walking.

Our results are similar to those of thecase report by Day et al13 on a 9-year-old boy with cerebral palsy who was

nonambulatory but was able to com-plete up to 60 independent steps onthe treadmill with body-weight sup-port after 44 sessions of training anddemonstrated carryover to over-ground walking by walking short dis-tances with a rolling walker withminimal assistance 4 months aftertraining. In our patient, functional

independence in walking wasachieved only after 5 months (ap-proximately 99 training sessions us-ing BWST). This suggests that, in ad-dition to intensity, duration is acritical factor in determining out-comes. Although walking on thetreadmill improved steadily over thefirst month, significant improve-

ments in overground walking werenot seen until after 5 months oftraining.

We believe that a number of factorscontributed to the outcomes, includ-ing the motivation of the patient andthe support and dedication of herfamily. This family was able to afford

a home BWST system and was will-ing to work with her 5 days per

week. In addition, she received in-home physical therapy and occupa-tional therapy several times a weekas well as benefiting from additional

time from a trained rehabilitationaide. The relative contribution of lo-comotor training using BWST to the

outcomes in light of the fact that shereceived additional interventions

cannot be determined. It is notewor-thy, however, that she was nonam-bulatory after 1 year of in-home ther-apy, but achieved independentambulation with the addition of 5months of intensive locomotor train-ing using BWST.

Results from this case report suggestthat locomotor training using BWSTis a promising intervention for im-proving gait in patients with severecerebellar ataxia who are nonambu-

latory. Functional gains in walking,however, may require months ofconsistent practice and training.

Findings from this case report provide possible support for researchdemonstrating the importance ofcerebellar structures in locomotor ad-aptation and in practice-dependentmotor learning.16,17 It also supportsfindings that the rate of locomotor ad-aptation and thus motor recoverymay be slower in the presence of

cerebellar pathology compared withother brain regions.16,17 The inten-sity and duration of locomotor train-ing using BWST required to achievefunctional gains in patients withlesser severity of injury is notknown. In addition, it is not clearhow much additional therapy isneeded to achieve these outcomes.

Studies are needed to determine theoptimal intensity and duration of lo-comotor training to optimize func-tional walking outcomes followingcerebellar pathology.

Dr Shumway-Cook provided concept/idea/research design. Dr Cernak, Ms Stevens, andDr Shumway-Cook provided writing, dataanalysis, and project management. All au-thors provided data collection. Ms Stevensprovided the subject. Mr Price provided fa-cilities/equipment. Mr Price, Ms Stevens, DrShumway-Cook, Valerie Kelly, and StaciaLee, PT, provided consultation (including re-view of manuscript before submission).

In-Step Mobility Products Corp, 8027 N Mon-ticello Ave, Skokie, IL 60076.




9/10

This manuscript was received May 3, 2007,and was accepted August 7, 2007.

DOI: 10.2522/ptj.20070134

References

1 Barbeau H, Visintin M. Optimal outcomesobtained with body-weight support com-bined with treadmill training in stroke sub-

jects. Arch Phys Med Rehabil. 2003;84:14581465.

2 Latham NK, Jette DU, Slavin M, et al. Phys-ical therapy during stroke rehabilitationfor people with different walking abilities.Arch Phys Med Rehabil. 2005;86(12 suppl2):S41S50.

3 Lord SE, McPherson K, McNaughton HK,et al. Community ambulation after stroke:how important and obtainable is it and

what measures appear predictive? ArchPhys Med Rehabil. 2004;85:234239.

4 Schenkman M, Cutson TM, Zhu CW, Whetten-Goldstein K. A longitudinal eval-

uation of patients perceptions of Parkin-sons disease. Gerontologist. 2002;42:790798.

5 Hesse S, Bertelt C, Jahnke MT, et al. Tread-mill training with partial body weight sup-port compared with physiotherapy innonambulatory hemiparetic patients.Stroke. 1995;16:976 981.

6 Laufer Y, Dickstein R, Chefez Y, MarcovitzE. The effect of treadmill training on theambulation of stroke survivors in the earlystages of rehabilitation: a randomizedstudy. J Rehabil Res Dev. 2001;38:69 78.

7 Barbeau H. Locomotor training in neuro-rehabilitation: emerging rehabilitationconcepts. Neurorehabil Neural Repair.2003;17:311.

8 Behrman AL, Lawless-Dixon AR, Davis SB,et al. Locomotor training progression andoutcomes after incomplete spinal cord in-

jury. Phys Ther. 2005;85:13561371.

9 Behrman AL, Bowden MG, Nair PM. Neu-roplasticity after spinal cord injury andtraining: an emerging paradigm shift in re-habilitation and walking recovery. PhysTher. 2006;86:1406 1425.

10 Moseley AM, Stark A, Cameron ID, PollockA. Treadmill training and body weight sup-port for walking after stroke. CochraneDatabase Syst Rev. 2005;(4):CD002840.

11 Wernig A, Muller S, Nanassy A, Cagol E.Laufband therapy based on rules of spinallocomotion is effective in spinal cordinjured persons. Eur J Neurosci. 1995;7:1429.

12 Dietz V, Harkema S. Locomotor activity inspinal cord-injured persons. J Appl Physiol.2004;96:19541960.

13 Day JA, Fox EJ, Lowe J, et al. Locomotortraining with partial body weight supporton a treadmill in a nonambulatory child

with spastic tetraplegic cerebral palsy: acase report. Pediatr Phys Ther. 2004;16:106113.

14 Helbostad JL. Treadmill training and/or

body weight support may not improve walking ability following stroke. Aust JPhysiother. 2003;49:278.

15 Stolze H, Klebe S, Petersen G, et al. Typi-cal features of cerebellar ataxic gait. J Neu-rol Neurosurg Psychiatry. 2002;73:310312.

16 Morton SM, Bastian AJ. Cerebellar controlof balance and locomotion. Neuroscien-tist. 2004;10:247259.

17 Morton SM, Bastian AJ. Mechanisms of cer-ebellar ataxia. Cerebellum. 2007;6:7986.

18 Morgan MH. Ataxia and weights. Physio-therapy. 1975;61:332334.

19 Kendall FP, McCreary EK. Muscles: Testingand Function. 3rd ed. Baltimore, Md: Wil-

liams & Wilkins; 1983.20 Bohannon RW, Smith MB. Interrater reli-

ability of a modified Ashworth scale ofmuscle spasticity. Phys Ther. 1987;67:206207.

21 Guide to Physical Therapist Practice. Rev2nd ed. Alexandria, Va: American PhysicalTherapy Association; 2003.

22 Ottenbacher KJ, Taylor ET, Msall ME, et al.The stability and equivalence reliability ofthe Functional Independence Measure forChildren (WeeFIM). Dev Med Child Neu-rol. 1996;38:907916.

23 Ottenbacher KJ, Msall ME, Lyon N, et al.The WeeFIM instrument: its utility in de-tecting change in children with develop-mental disabilities. Arch Phys Med Reha-bil. 2000;81:823829.

24 Novacheck TF, Stout JL, Tervo R. Reliabil-ity and validity of the Gillette Functional

Assessment Questionnaire as an outcomemeasure in children with walking disabil-ities. J Pediatr Orthop. 2000;20:7581.

25 Partial Weight Bearing Gait Training Pro-tocol using LiteGait. Available at: http://

www.litegait.com/protocols.htm. Ac-cessed September 22, 2005.

26 Sullivan KJ, Knowlton BJ, Dobkin DH.Step training with body weight support:

effect of treadmill speed and practice par-adigms on poststroke locomotor recovery. Arch Phys Med Rehabil. 2002;83:683691.

27 Hidler JM. What is next for locomotor-based studies? [Guest editorial.] J Rehabil Res Dev. 2005;42:xixiv.

28 Duncan PW, Goldstein LB, Matchar D,et al. Measurement of motor recovery af-ter stroke: outcome assessment and sam-ple size requirements. Stroke. 1992;23:10841089.

29 Duncan PW, Lai SM, Keighley J. Definingpost-stroke recovery: implications for de-sign and interpretation of drug trials. Neu-ropharmacology. 2000;39:835841.

30 Wolf SL, Winstein CJ, Miller JP, et al; EX-CITE Investigators. Effect of constraint-induced movement therapy on upper ex-tremity function 3 to 9 months afterstroke: the EXCITE randomized clinical tri-al. JAMA. 2006;296:20952104.




10/10

Appendix.Summary of Home Physical Therapy Interventions

Balance

1. Sitting unsupported with light beam target

2. High kneeling with bench for upper-extremity support3. Knee walking with walker and without walker

4. Standing balance: Feet apart Feet together Split stance Weight shifting Stepping without assistive device

Mobility1. Crawling on forearms

On extended arms2. Transfers

Wheel to chair and back Wheelchair to floor Floor to wheelchair Sit to stand and back to sitting

3. Gait

Treadmill with harness

Gait with 4-wheeled walker

Gait with U-Step walkera

Strength1. Progressive resistive exercises for core and extremities2. NuStep (model TRS4000)b with resistance

a In-Step Mobility Products Corp, 8027 N Monticello Ave, Skokie, IL 60076.b NuStep Inc, 5111 Venture Dr, Ste 1, Ann Arbor, MI 48108.



Documents

Locomotor Training Using Body-SCI