Sean Knight

Lisa Forster

Shelby Kantar

Learning Objectives Students will be able to:

oDescribe the history and facts of BWSTT

oDescribe the populations best suited for BWSTT

oDescribe the outcomes of Robotic BWSTT in pts with SCI, CVA, MS

oDescribe the pros/cons of robotic-BWSTT (Locomat or DGO)

oDescribe and differentiate aspects of conventional BWSTT and Robotic BWSTT

oDescribe the outcomes of Conventional BWSTT in pts with SCI and CVA

oDescribe the pros/cons of Conventional BWSTT

oSummarize differences between conventional BWSTT and Robotic BWSTT and how it will affect your decision making as a physical therapist.

Introduction

3 months post stroke

• 25% of stroke survivors are wheelchair dependent

• 60% have reduced gait velocity and endurance(Hesse, S. 2008)

Restoration of gait is major functional goal for both patients and therapists in rehab

At this point an optimal Rx for gait has yet

to be identified

BWSTT is a task-oriented

intervention that targets gait(Fulk, G. 2004)

Why Choose BWSTT?

Greater number of steps can be performed within a single training sessionHigher repetition: up to 1000s steps/20 min on

treadmill vs. 50-100 steps/20 min conventional PT

Most appropriate training intensity:Adjust the speedAdjust amount of body weight supportAdjust amount of PT assistance

(Roy, M. 2009)

History Animal research in 1960s

Cats with transected spinal cords could produce stepping patterns after several weeks of BWSTT○ Partially supported in a sling and hind legs were

manually assisted on a treadmill (Cardenas, D. 2003)

First used in clinical settings in1980s

Costs Treadmills: range from $100s - $1000s

Body weight support harness system $15,500

2 PTs manually assist pt’s gait deviationsLabor intensiveMin. time: 20 min/treatment session

(Roy, 2009)

Research

Populations Best Suited for BWSTT Stroke Traumatic Brain Injury Spinal Cord Injury Cerebral Palsy Down Syndrome Parkinson’s Disease Amputees Multiple Sclerosis

Robotic-BWSTT Literatures used term also:

DGO (Driven Gait Orthosis)

Lokomat (manufacturer’s company)

RAGT (Robot Assisted Gait Training)

A motorized exoskeleton computer-controlled device that generates passively guided, symmetrical lower-extremity trajectories that are consistent with a normal physiological gait pattern.

Robotics may help in BWSTT in incomplete SCI Subjects:

2 males and 1 female with incomplete motor SCI Purpose:

Effectiveness of Robotic BWSTT Results:

Improvements inTime “Up & Go”Functional Reach Test6’ Walk TestSum of Modified MMT Over-ground ambulation

Authors’ Conclusion: Lack of control condition

○ Too many confounding factors○ Only used 3 subjects

Hornby, G., et al, Physical Therapy Journal 2005

Robotics vs. PT Intervention

Subjects: Twelve ambulatory subjects with motor incomplete spinal cord injury

Purpose: To investigate differences in metabolic costs and lower-limb muscle activity patterns

during robotic- and therapist-assisted treadmill walking.

Results: EMGs were lower in subjects using robotics Metabolic costs were higher in subjects using robotics

Authors’ Conclusion: When compared to PT assisted treadmill training:

○ Robotics use passive assistance which teaches dependence○ Robotics reduces subsequent motor performance and retention○ Robotics reduces voluntary muscle activity and neuroplastic changes in the CNS

Jeffrey F Israel, et al, Physical Therapy 2006

Title: Robot-assisted gait training in multiple sclerosis: a pilot randomized trial

Subjects: 35 stable MS patients

Purpose: To compare Robotic Assisted Gait Training (RAGT) with Conventional Gait Training with PT.

Results: ○ Walking velocity, distance, and knee-extensor strength increased more with

RAGT than conventional PT○ Conventional PT gait training only improved velocity

Author’s Conclusion○ RAGT may be helpful in decreasing impairment in MS patients○ RAGT can be especially helpful with patients who are severely impaired or

patients where weight may be an issue

Beer, S., et al, Multiple Sclerosis 2008

Who does Robotic BWSTT REALLY help?

Subjects: 16 stroke patients

Purpose: To compare Robotic BWSTT with Conventional BWSTT with PT.

Results: Significant improvement in Robotic-BWSTT in:

○ Rivermead Motor Assessment Scale○ 6 minute test - distance○ Ashworth scale

Authors’ Conclusion: Lokomat training eliminates prolonged repetitive movements of non-ergonomic

position on physical therapists.

May, A., et al, Neurorehabilitation and Neural Repair 2007

Title: Prospective, Blinded, Randomized Crossover Study of Gait Rehabilitation in Stroke Patients Using the Lokomat Gait Orthosis.

People, not robots, prove to be better walking assistants Subjects:

48 stroke patients, 6+ months post stroke

Purpose: To compare Robotic BWSTT using Lokomat with Conventional BWSTT with PT.

Results: Robotic passive swing assistance may have reduced volitional drive

necessary for motor memory consolidation. Lokomat was unable to increase intensity enough to match

conventional BWSTT intensity levels.

Authors’ Conclusion: “If robotic devices are altered to provide compliant assistance or

assistance as needed for all biomechanical tasks associated with walking in the same way therapists can, then they may become equal or even superior.”

Kristen J. Light., BioMechanics Magazine 2008

Pros/Cons of Robotic BWSTT Pros

Reduces manual labor of PTMore repetitionMore consistent force

ConsCannot alter force as needed

○ Once programmed for session, can’t change

Decreased specificityExpensiveToo much afferent input

Conventional BWSTT

When looking at the points of contact, what would be a disadvantage to robotic training?

Robotic training places much more contact on the patient generating an excess of sensory input, which is not typical of ambulation. This is not the case with PT assisted BWSTT.

Physical Therapy Journal Vol. 85, No. 1, January 2005, pp. 52-66

VS

Title: Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground

73 first acute stroke hemiparetic patients; RCT

BWSTT vs. On-Ground Training

No significant difference: ○ Fugl-Meyer Stroke Assessment ○ FIM score○ Berg Balance Assessment○ Walking Velocity

Conclusion: BWSTT was no better than ground training BWSTT rehabilitation in early stages of stroke is a “comparable choice”

to ground walking.

(Nilsson, L. 2001)

Clinical Rehabilitation, Vol 15, No. 5, 515-527 (2001)

Title: A New Approach to Retrain Gait in Stroke Patients through BWSTT stimulation.

100 chronic stroke patients

With BWS vs. Without BWS

Significant difference in BWSTT○ Berg Balance Score○ St.Re.A.M. score (also post 3 months)○ Ground walking

Speed (also post 3 months) Endurance.

Conclusion: Retraining of gait in stroke population with BWSTT resulted in “better

walking abilities” than without-BWSTT. BWS allows for more symmetrical gait by not allowing for compensatory

mechanisms to develop(Visintin, B.

1998)

Stroke. 1998; 29: 1122-1128.

Title: Effects of Task-Specific Locomotor and Strength Training in Adults Who Were Ambulatory After Stroke: Results of the STEPS Randomized Clinical Trial

80 chronic stroke patients

4 Groups BWSTT/LE-Ex BWSTT/UE-Ex BWSTT/Cycling Cycling/UE-Ex

Significant increases in:○ walking speed for BWSTT/UE-Ex compared to Cycling/UE-Ex○ No difference for walking distance for any groups

Conclusion: BWSTT is more effective in improving walking speed and maintaining these gains

at 6 months.

(Sullivan, K. J. et al. 2007)

Title: Gait Training – Induced Changes in Corticomotor Excitability in Patients With Chronic Stroke

14 chronic stroke patients

Ground Training alone vs. Ground Training + BWSTT

Significant changes in GT + BWSTT:○ Berg Balance Scale○ Walking speed and Step Length○ Decreased threshold for TA in unaffected side○ AH in affected hemisphere only

General increases in Map Size for :○ TA in both hemispheres.

Correlation was found between corticomotor excitability and “functional improvement.”

Conclusion: GT + BWSTT may

○ Induce changes in corticomotor excitability.○ Improve balance and gait performance.

(Yen, C. 2008)

Neurorehabilitation and Neural Repair, Vol. 22, No. 1, 22-30 (2008)

Cochrane Corner

11 trials 458 participants “There was NO statistically significant

differences between BWSTT and other interventions for walking dependence for participants who were dependent walkers at the start of the treatment.”

Stroke. 2003;34:3006

Title: Spinal Cord Injury Locomotor Trial Group. Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI.

146 subjects within 8 weeks of incomplete SCI. ASIA Scale B, C, D only

BWSTT vs. Over-ground mobility therapy

No significant difference in○ FIM-L scores (functional tests)○ Walking speeds (functional tests)

Conclusion: Physical therapy strategies of BWSTT and over ground training did not

produce different outcomes This finding was partly due to the unexpectedly high percentage of

American Spinal Injury Association C subjects who achieved functional walking speeds, irrespective of treatment

(Dobkin, B. 2006)

Neurology. 2006; 66: 352 - 356

Title: Efficacy of partial body weight-supported treadmill training compared with overground walking practice for children with cerebral palsy: a Randomized Controlled Trial

26 children with CP classified level III or IV

PBWSTT vs. Over-Ground Walking

No Significant Difference 10-meter walk test (self-selected walking speed) 10-minute walk (walking endurance)

Conclusion: safe and feasible to implement, however, it may be no

more effective than over-ground walking for improving walking speed and endurance for children with CP

(Willoughby, K. Arch Phys Med Rehabil. 2010)

Pros/Cons of Conventional BWSTT Pros

More repetitionSafety

○ % of pts BW is supported○ Risk of falling during training decreased/eliminated

PT can control speed, inclination, percent un-weighted

PT can control movement aspects of legCan decrease likelihood of developing compensatory

mechanisms in abnormal gait Cons

CostManual labor of 2 PTs

Summary of Conventional BWSTT and Robotic BWSTT

Conventional BWSTTPros:•Less Expensive•Control Speed•Control angle of inclination•Control % weighted•Control sensory input the patient will feel and closer replicates normal gait

BOTH:Pros:•Repetition•SafetyCons: Not task specific:•Does not mimic real life situations•Does not require normal balance in gait

Robotic BWSTTPros:•Does not require manual labor of 2 pts•More consistent forceCons:•Robots are expensive•Force cannot be readily altered•Too much afferent input, which is unlike normal gait

Considerations of BWSTT Supraspinal input is necessary in order to restore

gait.Thus, BWSTT can complement, but NOT replace task

oriented over ground gait training. – Hubertus Hedel, Ph.D., P.T.

Maintenance of equilibrium is NOT trained due to body weight unloading.

Lack of specificity to patient’s functional goal○ Can alter only inclination

Review of Learning Objectives Students should be able to:oDescribe the history and facts of BWSTT

oDescribe the populations best suited for BWSTT

oDescribe the outcomes of Robotic BWSTT in pts with SCI, CVA, MS

oDescribe the pros/cons of robotic-BWSTT (Locomat or DGO)

oDescribe and differentiate aspects of conventional BWSTT and Robotic BWSTT

oDescribe the outcomes of Conventional BWSTT in pts with SCI and CVA

oDescribe the pros/cons of Conventional BWSTT

oSummarize differences between conventional BWSTT and Robotic BWSTT and how it will affect your decision making as a physical therapist.

References Beer, S., Aschbacher, B., Manoglou, D., Gamper, E., Kool, J., Kesselring, J. Robot-assisted gait training in multiple sclerosis: a pilot randomized trial.

Multiple Scleorsis Journal 2008; Vol. 14, No. 2, 231-236 Biodex System. http://www.biodex.com/rehab/unweighing/unweighing_470feat.htm Cardenas, Diana. Body-weight-supported treadmill training for SCI. University of Washington School of Medicine: Department of Rehabilitation

Medicine. 2003; 12(1) Fulk, George. Locomotor training with body weight support after stroke: the effect of different training parameters. Journal of Neurolgic Physical

Therapy. March 2004 Hesse, Stefan. Treadmill training with partial body weight support after stroke: a review. NeuroRehabilitation 2008; 23: 55–65. Hornby, G., Zemon, D., Campbell, D. Robotic-sssisted, body-weight–supported treadmill training in individuals following motor incomplete spinal cord

injury. Physical Therapy Journal 2005, pp 52-66 Jeffrey F Israel, Donielte D Campbetl, Jennifer H Kahn^ T George Hornby. Metabolic Costs and Muscle Activity Patterns During Robotic- and Therapist-Assisted

Treadmill Walking in Individuals With Incomplete Spinal Cord Injury. Physical Therapy November 2006. Volume 86, Number 11. Kristen J. Light. People, not robots, prove to be better walking assistants. BioMechanics Magazine Sep2008, Vol. 15 Issue 9, p17-18 2p. May, A., Kofler, M., Quirback, E., Matzak, H., Frohlinch, K., Saltuari, L. Prospective, blinded, randomized crossover study of gait rehabilitation in

stroke patients using the lokomat gait orthosis. Neural Repair 2007; 21; 307 Mosely, A. M., Stark, A., Cameron, I. D., Pollock, A. Treadmill training and body weight support for walking after stroke. Journal of the American

Heart Association. 2003; 34: 3006 Neville Hogan, PhD, et al. Motions or muscles? Some behavioral factors underlying robotic assistance of motor recovery. Journal of Rehabilitation Research &

Development August/September 2006. Volume 43, Number 5, Pages 605–618. Nilsson, L., Carlsson, J., Danielsson, A., Fugl-Meyer, A., Hellstrom, K., Kristensen, L., Sjolund, B., Sunnerhagen, K. S., Grimby, G. Walking training

of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground. Clinical Rehabilitation. 2001; 15: 515-527

Nuberwalker. http://www.nciia.org/WebObjects/NciiaResources.woa/wa/View/GrantProfile?n=1000460 Roy, Marc-Andre. Body Weight Supported Treadmill Training for Stroke: Family/Patient. Information. http://strokengine.ca/ Sullivan, K. J., Brown, D. A., Klassen, T., Mulroy, S., Ge, T., Azen, S. P., Winstein, C. J. Effects of task-specific locomotor and strength training in

adults who were ambulatory after stroke: Results of the STEPS randomized clinical trial. Physical therapy. 2007; 87: 1580-1602. Visintin, M., Barbeau, H., Korner-Bitensky, N., Mayo, N. E. A new approach to retain gait in stroke patients through body weight support and treadmill

stimulation. Journal of the American Heart Association. 1998; 29: 1122-1128. Dobkin, B., Apple, D., Barbeau, H., Basso, M., Behrman, A., Deforge, D., Ditunno, J., Dudley, G., Elashoff, R., Fugate, L., Harkema, S., Saulino, M.,

Scott, M. Weight-supported treadmill training vs. over-ground training for walking after acute incomplete SCI. Neurology. 2006; 66(4): 484-93 Yen, C., Wang, R., Liao, K., Huang, C., Yang, Y. Gait training induced change in corticomotor excitability in patients with chronic stroke.

Neurorehabilitation and Neural Repair. 2008.; 22: 22-30. Willoughby, K , Dodd, K, Shields, N., Foley, S.. Arch Phys Med Rehabil. 2010 Jan;91(1):115-22. www.costhelper.com