Transcript 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.

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
Describe the pros/cons of robotic-BWSTT (Locomat or DGO)
Describe and differentiate aspects of conventional BWSTT
and Robotic BWSTT
Describe the outcomes of Conventional BWSTT in pts with
SCI and CVA
Describe the pros/cons of Conventional BWSTT
Summarize differences between conventional BWSTT and
Robotic BWSTT and how it will affect your decision making
as a physical therapist.
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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
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(Fulk, G. 2004)
Why Choose BWSTT?
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Greater number of steps can be performed within
a single training session
 Higher repetition: up to 1000s steps/20 min on
treadmill vs. 50-100 steps/20 min conventional
PT

Most appropriate training intensity:
 Adjust the speed
 Adjust amount of body weight support
 Adjust 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 deviations
 Labor intensive
 Min. 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 in
 Time “Up & Go”
 Functional Reach Test
 6’ Walk Test
 Sum 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?
Title: Prospective, Blinded, Randomized Crossover Study of
Gait Rehabilitation in Stroke Patients Using the Lokomat Gait
Orthosis.
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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
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.
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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 PT
 More repetition
 More consistent force

Cons
 Cannot alter force as needed
○ Once programmed for session, can’t change
 Decreased specificity
 Expensive
 Too 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.
VS
Physical Therapy Journal Vol. 85, No. 1, January 2005, pp. 52-66
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
Clinical Rehabilitation, Vol 15, No. 5, 515-527 (2001)

73 first acute stroke hemiparetic patients; RCT

BWSTT vs. On-Ground Training
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No significant difference:
○
○
○
○
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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)
Title: A New Approach to Retrain Gait in Stroke Patients
through BWSTT stimulation.
Stroke. 1998; 29: 1122-1128.

100 chronic stroke patients
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With BWS vs. Without BWS
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Significant difference in BWSTT
○ Berg Balance Score
○ St.Re.A.M. score (also post 3 months)
○ Ground walking
 Speed (also post 3 months)
 Endurance.
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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)
Title: Effects of Task-Specific Locomotor and Strength Training in
Adults Who Were Ambulatory After Stroke: Results of the STEPS
Randomized Clinical Trial
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80 chronic stroke patients
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4 Groups
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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
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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
Neurorehabilitation and Neural Repair, Vol. 22, No. 1, 22-30 (2008)

14 chronic stroke patients

Ground Training alone vs. Ground Training + BWSTT
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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)
Cochrane Corner
Stroke. 2003;34:3006
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.”

Title: Spinal Cord Injury Locomotor Trial Group. Weight-supported
treadmill vs over-ground training for walking after acute incomplete
SCI.
Neurology.

2006; 66: 352 - 356
146 subjects within 8 weeks of incomplete SCI.
 ASIA Scale B, C, D only

BWSTT vs. Over-ground mobility therapy
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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)
Title: Efficacy of partial body weight-supported treadmill
training compared with overground walking practice for
children with cerebral palsy: a Randomized Controlled
Trial
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26 children with CP classified level III or IV
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PBWSTT vs. Over-Ground Walking
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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 repetition
 Safety
○ % 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 leg
 Can decrease likelihood of developing
compensatory mechanisms in abnormal gait

Cons
 Cost
 Manual labor of 2 PTs
Summary of Conventional
BWSTT and Robotic BWSTT
Conventional BWSTT
Pros:
•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
•Safety
Cons:
Not task specific:
•Does not mimic
real life situations
•Does not require
normal balance in
gait
Robotic BWSTT
Pros:
•Does not require manual
labor of 2 pts
•More consistent force
Cons:
•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
Describe the pros/cons of robotic-BWSTT (Locomat or DGO)
Describe and differentiate aspects of conventional BWSTT
and Robotic BWSTT
Describe the outcomes of Conventional BWSTT in pts with
SCI and CVA
Describe the pros/cons of Conventional BWSTT
Summarize differences between conventional BWSTT and
Robotic BWSTT and how it will affect your decision making
as a physical therapist.
o
o
o
o
o
References
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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
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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.
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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.
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