|Year : 2020 | Volume
| Issue : 2 | Page : 73-84
Effects of body-weight-supported treadmill training in persons with spinal cord injury – A scoping review
Wilhelmus Johannes Andreas Grooten1, Prachi Mahesh Borawake2, Joseph Conran3
1 Department of Neurobiology, Division of Physical Therapy, Care Sciences and Society, Karolinska Institutet, Huddinge; Medical Unit Occupational Therapy and Physiotherapy, Allied Health Professionals, Karolinska University Hospital, 171 77 Stockholm, Karolinska University Hospital, Stockholm, Sweden
2 Department of Neurobiology, Division of Physical Therapy, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Neurophysiotherapy, Pravara Institute of Medical Sciences, Loni, Maharashtra, India
3 Department of Neurobiology, Division of Physical Therapy, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden; Department of Health Sciences and Rehabilitation, Division of Physiotherapy, Stellenbosch University, Cape Town, South Africa
|Date of Submission||02-Jul-2020|
|Date of Decision||04-Aug-2020|
|Date of Acceptance||28-Aug-2020|
|Date of Web Publication||04-Jan-2021|
Wilhelmus Johannes Andreas Grooten
Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Division of Physical Therapy, 23100, SE-141 83 Huddinge
Source of Support: None, Conflict of Interest: None
Body-weight supported treadmill training (BWSTT) is used in rehabilitation of persons with complete and incomplete spinal cord injury (SCI), but the effectiveness of this intensive training method is still disputed. The present scoping review aimed to determine the effects of body-weight supported treadmill training in persons with spinal cord injury. The databases PUBMED and CINAHL were searched for clinical trials, and from the initial 350 papers retrieved, 14 papers fulfilled the inclusion criteria. Quality of the studies was assessed using the PEDRO score, and the outcomes of interest were cardiovascular function, psychological and emotional factors, gait, balance, muscle strength and additionally, pulmonary function, health-related quality of life (HR-QoL), as well as adverse events. In total, 374 patients with complete and incomplete SCI included in the 14 studies (PEDRO 4-8) had used the intervention. The training dose was varying largely across the different studies, but on average most studies applied around 50% of the participants' body-weight with 3-5 sessions a week, lasted for 40± 20 minutes and continued for 4.3±3.6 months. There were positive effects of BWSTT on cardiovascular function, gait, balance, psychological and emotional factors, and muscle strength. This study conclude that BWSTT appears to be a safe and useful treatment in persons with spinal cord injury; however more randomized controlled trials are needed to assure these effects and to establish the evidence of BWSTT on complementary outcomes, as well as finding evidence for the most suitable dose.
Keywords: Body-weight support, Cardiovascular function, Gait, Spinal cord injury, Treadmill walking
|How to cite this article:|
Grooten WJ, Borawake PM, Conran J. Effects of body-weight-supported treadmill training in persons with spinal cord injury – A scoping review. Indian J Phys Ther Res 2020;2:73-84
|How to cite this URL:|
Grooten WJ, Borawake PM, Conran J. Effects of body-weight-supported treadmill training in persons with spinal cord injury – A scoping review. Indian J Phys Ther Res [serial online] 2020 [cited 2021 Jun 15];2:73-84. Available from: https://www.ijptr.org/text.asp?2020/2/2/73/189940
| Introduction|| |
Spinal cord injury (SCI) is highly disabling, leading to sensation loss and paralysis, which, in turn, set in motion a myriad of complications. Although a cure for SCI is not yet available, the role of rehabilitation is unequivocal. Locomotor training for a patient with incomplete SCI using partial body-weight supported treadmill training (BWSTT) is a promising intervention to retrain walking. This intervention is also thought to address additional patient-related outcomes; however, no conclusive evidence is available. The present scoping review aims to determine the breadth and depth of BWSTT effects in persons with SCI.
| Materials and Methods|| |
The design of this study was a scoping review. Scoping reviews have been described as a process of mapping the existing literature in a first step to reach evidence-based rehabilitation.
Locating and selection of the studies
The databases PubMed and CINHAL were searched using the following search terms in different combinations and truncations: SCI, body-weight support (BWS), gait, training, depression, psychology, heart rate, and cardiovascular. Searches were not limited by date but were restricted to the English language and human participants. In addition, the references of relevant studies, i.e., gray literature, were hand searched.
Inclusion criteria of the study were peer-reviewed clinical trials on adults with acute or chronic complete and incomplete SCI according to the American Spinal Injury Association (ASIA) impairment scale; BWS treadmill training was provided where participants were fitted with a harness; intervention with or without normal assistance; and full-text papers available. Exclusion criteria were animal studies, robotic-assisted BWS training; functional electrical stimulation and neuromuscular electrical stimulation; intervention with backward walking; studies with non-ambulatory subjects, and single case studies.
The Pedro scale is a valid measure of the methodological quality of clinical trials with acceptable reliability. It is valid to sum Pedro scale item scores to obtain a total score (ranging from 0 to 10) that can be treated as an interval level measurement and subjected to parametric statistical analysis. The Pedro scale assesses a reasonable breadth of methodological quality and a score of 6 or higher is considered “high” quality, while a score of 5 or 4 is considered “fair” quality and a lower score as “poor.”
Complete data sets were not available for any of the studies, and the calculations refer only to the information displayed in the tables, along with the conclusion of the authors. A narrative synthesis was performed.
| Results|| |
From the databases and additional searches, we screened 353 articles on their titles and abstracts. Of these 24 articles were read in full text and 10 were excluded due to several reasons [Figure 1]. In total, 14 studies were included in this scoping review.,,,,,,,,,,,,, From those, three were randomized controlled trial (RCT),,, eight were prospective cohort studies,,,,,,,, in which one included a comparison group of healthy controls, one study had a group-level randomized crossover design, and two studies were case studies,, in which one had a randomized crossover design, and one had a controlled single-case design. The quality of the majority of the included studies (9/14) was considered as “fair” on the PEDro scale (4–5 points), but five studies were classified as “high”: two studies scored 6,, two scored 7 points,, and one scores 8 points. [Table 1] presents the total PEDRO scores and all separate domains.
The demographic characteristics of all participants are depicted in [Table 2]. A total of 374 participants took part in the intervention. Of those, 280 were male (75%) and 94 were female (25%). The mean age ranged from 27 to 48 years in the different studies, and the mean postinjury time varied between 0.8 years and 9.6 years. All participants were selected based on their neurological assessments according to the American SCI Association Impairment Scale (ASIA). There was a large variation between and within the studies on the level of injury and ASIA classification. The most common level was “C” (range A to D).
|Table 2: Characteristics of participants in body-weight supported treadmill training|
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Only in nine studies,,,,,,,, ambulation status was mentioned. The ambulation status varied largely between and within the studies. For example, in Hicks et al., 2005, 11 out of 14 patients had no walking capability, even with the help of two therapists, while in Covarrubias-Escudero et al., 2019, all participants were able to stand for 30s, and had the ability to walk with or without assistance (mean score on WSCI II 18). In Morrison et al. 2018, there were 22 individuals without walking capability (47%), but there were 16 using walkers (34), and 5 were crutches or canes (11%), and 4 were independent walkers (9%) [Table 2].
Details of locomotor training regimens, training frequency, and the number of sessions for all participants can be found in [Table 3].
Four studies,,, used 50% or more of body weight (BW), three studies used 20%–40% of BW,,, while seven studies,,,,,, did not provide the percentage BWS used. The training dose was varying largely across the different studies, but on average was the training performed with 3–5 sessions a week, lasting for 40 ± 20 min, and continued for 4.3 ± 3.6 months. Only three studies described the progression during the training period.,,
Details on the outcome used in the included studies are presented in [Table 4]a, [Table 4]b, [Table 4]c, [Table 4]d, [Table 4]e, [Table 4]f, [Table 4]g. In total, five primary outcomes were investigated: (1) cardiovascular function (such as heart rate, blood pressure), (2) psychological and emotional factors (such as depression and anxiety), (3) gait parameters (speed, distance, walking capability, cadence, and step length) and gait performance, (4) balance, and (5) muscle strength. Interestingly, there were two additional (secondary) outcomes reported: (6) pulmonary function and (7) health-related quality of life (HR-QoL). Finally, we checked all papers if there were any (8) adverse events reported.
| Cardiovascular Function|| |
Four studies,,, used cardiovascular function as an outcome measure, and inconclusive results were found. Two studies showed positive effects on HR when comparing before and after training with BWSTT,, while two studies did not., Furthermore, inconclusive results were found on other heart function-related variables., For blood pressure variables, only one study showed significant results. Neither the duration of the training period, the number of included patients, nor training intensity (%BWS) and timing (minutes/session and times/week) could explain the differences between the studies with and without effects. Interestingly, all studies concluded that the training could have positive effects on cardiovascular function [Table 4]a.
| Psychological and Emotional Factors|| |
Three studies (n = 36) investigated psychological and emotional factors, and all found positive effects after BWSTT on different outcomes [Table 4]b.,, It seems that the length of the training period has no influence on the results since the training period varied in all studies. One study had a training period of 6 weeks (30 min/session), one study lasted for 12 weeks (15 min/session), and the participants in one study trained for a total of 12 months (15 min/session).
| Gait Parameters and Gait Performance|| |
Gait parameters were used as the main outcome in eight studies,,,,,,,, and many used different gait parameters such as speed, distance, walking ability, cadence, and step length, which makes it difficult to summarize the results [Table 4]c. In terms of gait speed, 6 medium-high quality studies (PEDRO 4–7) used speed as the temporal parameter for the outcome and 4 studies,,, found positive effects of BWSTT, while one study did not find any significant effects of the training over time. All these studies used the 10-m walking test (MWT) to measure gait speed. For gait distance, six studies used this spatial parameter as an outcome measure. Here, all studies used the 6MWT as an outcome measure. Of these, four studies,,, found positive effects of BWSTT on distance and two studies did not find any significant effects., The training period in studies with no demonstrated effect was only 4–8 weeks, compared to studies with positive effects which had much longer training periods (12 weeks to 1 year). Concerning subjective assessments of walking ability, two studies used walking ability as an outcome measure and one study reported a positive effect on the “Walking index for spinal cord injury” (n = 16) and the other study did not find a significant effect on walking ability using “the modified emory functional ambulation profile.”
With respect to cadence, step length and maximal angles during different phases of the gait cycle, these parameters were only studied in one paper and the authors showed significant increases after BWSTT in several of the parameters, but there were no differences between the BWSTT group and the control group.
In summary, several studies have shown positive effects of BWSTT on different gait parameters, but none of the three studies that included a control group which were exposed to other (and cheaper) interventions, for example, physiotherapy, BW-supported overground training with overhead suspension, or skill training could demonstrate that BWSTT was superior.
| Balance|| |
Six studies used balance measured on the berg balance scale as an outcome measure,,,,, and in all except one there were positive effects on the balance after BWSTT [Table 4]d. In the studies where positive effects were found,,,,, a variety of training intensities were used (%BWS) and also the duration of the training sessions and training periods were varying largely, which makes it difficult to conclude on the optimal dosage for balanced effects. None of the studies could show that BWSTT was superior compared to other interventions.
| Muscle Strength|| |
Muscle strength was used as an outcome measure in three studies [Table 4]e.,, One study showed that muscle strength increased after BWSTT, but there were no statistically significant between-group differences in lower extremity muscle scores. Another study found also 6%–9% improved muscle strength due to BWS gait training (P < 0.05). In addition, in a well-conducted single-case study with three participants, there were changes in muscle strength in some muscle groups after the intervention period and at the time of follow-up.
| Additional Outcomes|| |
Two studies used pulmonary functions as an outcome [Table 4]f., Of these studies, one study found limited effect after BWSTT and the other failed to find any positive effects. The training period in the study with no effects was 13 weeks (60 min/session) compared to the other study that showed effects after 6 weeks.
Health-related quality of life
Three studies used HR-QoL as an outcome measure [Table 4]g.,, One study found positive effects after the intervention period, while one study found favorable effects at the time of follow-up. Based on a single question, Hicks et al. could not show any improvement of HR-QoL after BWSTT.
Of the 14 papers included, seven papers mentioned that they followed their participants for adverse events ,,,, and in four papers, adverse events occurred.,, Alexeeva et al. (2011) reported two drop-outs due to an episode of acute cardiorespiratory distress, while two more subjects deteriorated in their physical function after training. One patient in Ditor et al., developed a pressure sore over vertebrae due to irritation from the harness but could continue the training without further problems (2005a). Furthermore, additional adverse events that were reported in the studies were pain and overuse injuries, which were most common at the beginning of the training period but were reversible and of short duration. All in all, it seems that BWSTT seems to be a safe exercise intervention since relatively few adverse events were reported of the 374 participants that conducted BWSTT over a period of time.
| Discussion|| |
This scoping review aimed to provide an overview of the current evidence on locomotor training (BWSTT) approaches for a range of functioning domains in patients with SCI. In the present study, there is conclusive evidence on the effect of BWSTT on psychological and emotional factors, and compelling evidence on gait parameters (speed, distance, cadence, and step length), balance, and muscle strength. On the other hand, BWSTT is not superior to other interventions such as physical therapy and other gait-based interventions. There is inconclusive evidence on the effect of BWSTT on cardiovascular function, walking ability, pulmonary outcomes, and health-related quality of life, and few studies reported adverse events.
| Main Findings|| |
Concerning cardiovascular function, there is, to our knowledge, only one previous study available. They found improvement not only in sensorimotor function but also in systo/diastolic left ventricular function, coronary flow reserve, and endothelial dysfunction associated with a reduction of the inflammatory status in patients with incomplete SCI, using robotic treadmill training. Although we found inconclusive results on the effects of BWSTT on heart function and also on pulmonary outcomes, there is an indication that both robotic treadmill training, as well as BWSTT, could have positive effects on the heart and lungs, but future research should be performed in this field before widespread recommendations could be made.
Concerning psychological and emotional factors, such as depression and anxiety, no previous study is available, providing evidence on the effects of BWTSS, to our knowledge. In this scoping review, we found conclusive positive results. However, we should be cautious on making any definitive conclusions since the available studies lacked control groups.,, Hence, there is a need to perform well-powered RCTs in this field. Still, we postulate that BWSTT instils positive body image and self-esteem, along with improving self-efficacy, which could augment one's mental status.
Concerning gait parameters, such as walking distance and gait speed, cadence, and step length, our findings seem to differ from findings of a previous review on the effects of BWSTT. While we found compelling evidence on the effect of BWSTT on gait distance, gait speed and gait parameters, the review by Morawietz and Moffat did not show the superiority of the locomotor treatment approach over other treatments. They included eight studies and based their results on between-group analyses, where the lack of effect could thus depend on the effect that was observed in the control groups, since all included therapies showed potential for improvement. In our study, most studies lacked a control group and only within-group analyses were performed. Further studies which include a control group without any treatment could provide important insights into the efficacy of BWSTT on gait parameters.
Concerning balance, we found compelling evidence on the effect of BWSTT on balance performance, and to our knowledge, there is no other systematic review performed in this area. The underlying mechanism of BWSTT on balance control should be further researched.
Concerning the effect of BWSTT on muscle strength, our results are in concordance with a previous systematic review suggests that exercise training has a positive effect on muscle strength. Still, between-group effects are lacking. Hence, there is a need to perform more controlled studies to ascertain the effect of BWSTT on muscle strength, particularly that of major muscle groups.
Concerning HR-QoL, our findings are congruent with the findings in a previous review on the effects of BWSTT. In this study, we included three papers in which one showed positive effects and the other two not. We can thus, likewise Wessels et al., conclude that there is insufficient evidence that BWS gait training affects the multifaceted HR-QoL outcome.
The sparse reporting of adverse events after BWSTT could indicate that BWSTT is a safe intervention for these patients. However, the quality of most of the included studies was fair, and we should be careful to interpret the lack of information as the absence of adverse events.
| Implications for Research and Clinics|| |
This study has some implications for researchers and clinicians. The scoping review showed a large variety of studies with different outcomes, different populations, and different study designs. Moreover, research should be focused on exploring the intervention dose for different ASIA impairment categories as well; i.e., to increase knowledge on the amount of BWS that should be provided to the participant, the frequency of intervention sessions per week, and the total duration of intervention. We encourage future researchers to include reporting of adverse events in their papers to be able to study the safety of the intervention, which is essential in determining whether the benefits outweigh the potential risks.
| Strength and Limitations|| |
Since research in this area is still sparse, we decided to approach this literature study as a scoping review. A scoping review is used to identify the areas in which further research is needed. This means that we have used a selection of all databases available and that this study should not be seen as a systematic review of all studies available. However, we used the largest databases and believe that although this approach could have led to a limited number of studies, we have provided a good overview of all outcomes available on all levels of the International Classification of Functioning classification system, highlighting the potential role of BWSTT in improving functioning. All studies included reached the level of moderate to good quality, but none of the studies were able to perform the intervention blinded to the patient and therapist, which could have led to an over the interpretation of the results. Moreover, the large variation of the functional level of the included participants between and within the studies, for example, ASIA level and ambulation status, makes it difficult to draw extensive conclusions. For these reasons, we kept relatively modest in our interpretation of the available levels of evidence, and we encourage researchers to conduct RCTs in this important field of rehabilitation.
| Conclusions|| |
This review of the literature showed inconclusive results for training with body-weight supported treadmill in persons with SCI. We found favorable outcomes related to both psychological/emotional and physical functioning parameters. We identified several areas where further research is warranted, preferably using randomized controlled trials, to assure these effects and to establish the evidence of BWSTT on a large range of outcomes, as well as trying to identify any evidence for the most suitable dose (intensity, frequency, and duration).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]