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Laurance Johnston, Ph.D.

Sponsor: Institute of Spinal Cord Injury, Iceland


  1) Dr. Anton Wernig (Germany)

2) Dr. A. L. Hicks (Canada)

3) Dr. Bruce Dobkin (United States)

4) Dr. Patricia Winchester (United States)

5) Drs. Sarah Thomas and Monica Gorassini (Canada)

6) Dr. Edelle Field-Fote (United States)

7) Dr. Markus Wirz (Switzerland, Germany, USA)

8) Dr. Susan Harkema (USA)

Over the past decade, a number of programs and researchers have emphasized treadmill training to increase ambulatory ability after SCI. Often such therapy uses some degree of body-weight support through harness devices and, at least in part, is controlled by the neural circuits within the spinal-cord below the injury site that can sustain lower-limb repetitive movement, such as walking, independent of direct brain control. Procedures vary considerably between programs, and as a result, there is considerable variability in reported benefits. Brief discussions of a few of these treadmill programs are included below:

1) Dr. Anton Wernig and his colleague Sabine Műller (Karlsbad, Germany) carried out key pioneering work documenting the ability of treadmill training to increase ambulation after SCI. In a 1992 article (Paraplegia, 30), they reported the results of training eight persons with incomplete SCI with a “Laufband” variable speed treadmill, on which the patient was partially supported with a harness. Over time, bodyweight support was reduced from 40 to 0%. Starting 5-20 months after injury, patients trained for 1.5-7 months for five days a week, 30-60 minutes daily. All patients improved their ambulatory ability, including the ability “to walk short distances, to bear their body weight fully without knee stabilizing braces and to climb stairs while needing only a hand rail and one cane.”

In 1995, Wernig and colleagues reported the results of a more extensive study evaluating the effectiveness of Laufband treadmill training in 44 patients with chronic SCI (Eur J Neuroscience, 7 1995). The patients had sustained their injuries on average a year (range 0.5-18 years) before initiating 3-20 weeks of training. Virtually all improved their ambulation. In a comparison study, 14 of 18 patients learned to walk without help from others compared to 1 of 14 of those who received conventional therapy. Follow-up studies indicated that most patients who had improved to the point of walking independently continued to use their new found abilities over time as a part of every-day life. In another example of program effectiveness, after training, 36 of the 44 patients were capable of staircase walking compared to only six before. Of acutely injured patients, 92% who were “wheelchair bound” became independent walkers after Laufband treadmill training compared to only 50% after conventional therapy.

In 2000 review article, Wernig et al indicated that the improvements that accrued from his training of individuals with chronic SCI generally persisted over time (Progress in Brain Research, 128, 2000).

2) Dr. A. L. Hicks and colleagues (Hamilton, Ontario) studied the effects of long-term body-weight-supported treadmill training in 14 subjects with chronic, incomplete SCI (Spinal Cord 43, 2005). Eleven and three were men and women, respectively; the average time since injury ranged from 1.2-24 (average 7.4 years); and 12 and two had ASIA-A and -B (see Appendix 1) incomplete injuries, respectively. Subjects trained three times a week for a total of 144 sessions over 12-15 month period.

All subjects who completed the program (13) improved their treadmill walking ability, including a 54% reduction in body-weight support (from 73 to 19.5%), a 180% improvement in walking speed (from 0.5 to 1.4 kilometers per hour), and a 335% in the distance covered per session (from 221 to 961 meters). These improvements were associated with increased satisfaction with life and physical function, and also improved muscle mass and composition, and blood lipid profiles and glucose tolerance consistent with a lowered risk of SCI-related diabetes and cardiovascular disease. In this study, some of the improvements diminished over time as subjects discontinued training.

This investigative team also studied the effects of twice-weekly body-weight supported treadmill training on muscle mass and bone density in five subjects injured 2-6 months before starting the program (Giangregorio, et al, Spinal Cord 43(11), 2005). Although the training appeared to reverse the muscle atrophy accruing soon after SCI, it not seem to prevent bone loss.

3) Dr. Bruce Dobkin (Los Angeles, California) and colleagues compared the effectiveness of body-weight supported treadmill training with a similar intensity control program of over-ground mobility training (Neurology, 66(4), 2006). A total of 146 subjects, who had sustained incomplete (i.e., ASIA B-D) injuries within the previous eight weeks, were recruited from six US and Canadian collaborating centers. Subjects were randomized to either a 12-week treadmill- or control-training program (e.g., parallel bars, etc.) in which they received about one hour of training per session.

To be included in the analysis, a subject must have completed at least 45 sessions over the 12-week period (the maximum possible being 60) or have reached a defined level of restored ambulation. Improvements were measured by either 1) the Functional Independence Measure Locomotor (FIM-L) score, which assesses the degree of assistance (either from the help of others or assistive devices) the subject needs to walk a defined distance, or 2) walking speed.

The investigators concluded that there was no statistical difference in results between treatment groups and that care must be taken in interpreting putative positive results of past treadmill studies that lack sufficient consideration of potential confounding factors, especially in a post-injury period in which considerable functional improvement already accrues. On the other hand, although this study did not demonstrate a statistically significant benefit for treadmill training - or lacked the statistical power to do so - it conversely does not prove that such benefit does not exist.

4) Dr. Patricia Winchester and colleagues (Dallas, Texas) examined the effects of 12 weeks of body weight-supported training on supraspinal activation (i.e., neuronal activity in brain) in four men with incomplete cervical injuries (Neurorehabil Neural Repair, 19(4), 2005). The study specifically used the Lokomat Driven Gait Orthosis, a robotic treadmill device developed by the Swiss company Hocoma (www.hocoma.ch). The device minimizes the need for assisting therapists. The four subjects had sustained their injuries 14 weeks to four years before starting the training program, and all had sufficient range of motion to stand and some ability to move the ankle and toes.

Basically, the study’s goal was to measure through MRI brain imaging the differences in supraspinal activation before and after this 12-week training program. Simply stated, does such training facilitate ambulation-enhancing brain reprogramming (i.e., plasticity). To measure the intensity of walking-associated brain activity, subjects flexed their ankles and curled their toes while keeping their heads still in the MRI device. At the end of the 12-week training period, three of the four subjects demonstrated improved walking, and all exhibited increased activity in areas of the brain associated with locomotion. The accrued benefits seemed less pronounced when more time had elapsed since injury. Although it is difficult to generalize the results of a small pilot study, the results suggested that body weight-supported treadmill training exerts a beneficial neuro-programming effect in the brain, which, in feedback style, may enhance walking in patients with incomplete SCI.

5) Drs. Sarah Thomas and Monica Gorassini (Alberta, Canada) studied the effects of treadmill training on brain-to-muscle nerve transmission through corticospinal tract pathways in individuals with chronic, incomplete injuries (J Neurophysiol 94, 2005). Mostly male, their age ranged from 29-78 years, and the time since injury ranged from 0.6-28 years. The subjects trained on a body-weight supported treadmill for an hour five times a week for nearly 17 weeks on average.

The capacity of these corticospinal tracts to transmit nerve signals was measured by stimulating areas of the brain’s motor cortex associated with target leg muscles. The stimulation was done by a transcranial-magnetic-stimulation (TMS) device placed over the scalp that activates descending neuronal pathways. The amount of signal getting through to the leg muscles was then measured by surface EMG, a technique in which electrodes are placed on the skin overlying a muscle to detect the muscle’s electrical activity. Overall, the results indicated that such treadmill training program improved ambulatory ability which was associated with an increase in the transmission capacity between the brain and the target muscles.

6) Dr. Edelle Field-Fote et al (Miami, Florida) evaluated the effects of  bodyweight-supported, FES-assisted (functional electrical stimulation) treadmill training on ambulation in 19 subjects with ASIA-C incomplete injuries sustained at least one year before entry into the study (Arch Phys Med Rehabil, 82(6), 2001). Training consisted of three-times-a-week, 1.5-hour sessions for three months. All subjects showed improvement in over-ground walking speed and lower extremity strength.

In a study published the following year (Phys Ther 82(7), 2002), the investigators showed that such training also improved intra-limb coordination in 9/14 subjects with chronic, incomplete injuries.

In a 2005 article (J Neurol Phys Ther, 29(3)), they reported the interim results of a study comparing various body-weight supported training approaches: 1) treadmill training with manual assistance, 2) treadmill training with FES stimulation, 3) over-ground training with FES stimulation, and 4) treadmill training using robotic assistance. Twenty-seven individuals with incomplete SCI were randomly assigned to these groups. Preliminary data suggest that the accruing benefits were comparable across training approaches.  

In a 2009 article, the investigators reported the results of treating 51 subjects with SCI with the aforementioned body-weight-supported training approaches on various parameters of gait quality. These parameters included cadence, step length, stride length, symmetry index, intralimb coordination, and timing of knee extension. The investigators concluded that “all training approaches were associated with improvements in gait quality.”

Reported in 2011, Dr. Edelle Field-Fote’s team compared the results of treating 71 patients with SCI randomized to one of the aforementioned training approaches. In this study, the primary outcomes were walking speed and the distance covered in two minutes. All subjects had ASIA C or D incomplete injuries (see appendix) possessing minimal walking ability. Subjects trained five days per week for 12 weeks with their assigned approach. With the exception of the robotic-assistance method, all the training approaches generated some walking improvement, with the most benefits accruing from overground training. The investigators concluded “overground locomotor training resulted in greater improvements in functional walking capacity than did treadmill training.” They speculated that such training produced the best results because it more closely incorporated the dynamics of real-world walking.

7) Dr. Marcus Wirz (Zurich, Switzerland) and colleagues (USA and Germany) treated 20 subjects with chronic, incomplete injuries with body-weight-supported treadmill training using the aforementioned Lokomat robotic device (Arch Phys Med Rehabil 86, April 2005).  All subjects had ASIA C or D (see appendix) incomplete injuries; 11 and 9 had tetraplegic and paraplegic injuries, respectively; and 18 were men and 2 were women. The time elapsing since injury and training onset ranged between 2-17 (average 5.9) years, and mean subject age was 40 (range 16-64 years). Sixteen patients had some ambulatory ability before training.

The program consisted of three to five 45-minute sessions per week for eight weeks. Ambulatory ability was assess by a variety of tests, including 1) “Walking Index for SCI – II (WISCI-II),” which assesses the amount of assistance required during ambulation and the use of assistive devices or lower-extremity bracing, 2) a 10-meter walk test to measure gait speed, 3)  a  6-minute walk test to determine gait endurance, and 4) a “Timed Up & Go” test to measure performance of multiple tasks, such as getting up from a chair, walking, and returning to chair.

After completing the program, only two subjects improved in walking ability as assessed by the WISCI-II scores. However, as evaluated by the other measures, most patients improved their gait speed, endurance, and performance of functional tasks.

8) In 2012, Dr. Susan J. Harkema and colleagues (USA) published the results of a large, multicenter study evaluating the impact of locomotor training-based rehabilitation on 196 individuals with incomplete injuries, all of whom retained some ability to voluntarily move lower limbs. Of these individuals, 148 were men; 138 and 58 had cervical and thoracic injuries, respectively, and the time since injury ranged from 32 days to over 25 years (~50% had been injured a year or less). In terms of walking ability, 36% were nonambulatory, 36% used a walker, 21% used a cane, and 7% used no assistive devices.

On average, patients received 47 (minimum 20; maximum 251) treatment sessions, consisting of one hour of body-weight-supported treadmill training followed by an overground assessment to evaluate progress and focus future training and an integration component designed to incorporate improvements into daily routines. To assess progress, patients were periodically tested with three outcome measures: 1) balancing ability, 2) the distance covered in six minutes of walking, and 3) the time it takes to walk 10 meters.

Eighty-seven percent of the patients demonstrated improvement on at least one outcome measure, and 57% on all three outcome measures. In general, patients whose injuries were more recent tended to accrue greater benefits. The investigators concluded that “rehabilitation, which provides intensive activity-based therapy, can result in functional improvements in individuals with chronic incomplete SCI.”