Rehab Methods Equally Good at Restoring Walking Ability

LOS ANGELES, Feb. 28 – When getting patients with incomplete spinal cord injuries back on their feet and walking, either of two rehab approaches seems to be as good as the other.

So it emerged from a 146-patient multicenter study that tested a method involving body-weight support on a treadmill versus an over-ground mobility training method.

The over-ground practice was no more effective than conventional step training at improving walking or gait, reported Bruce H. Dobkin, M.D., and colleagues at the University of California Los Angeles, in the Feb. 28 issue of Neurology.

But the investigators were surprised to find that regardless of treatment type, a high percentage of patients with incomplete spinal injuries — defined as American Spinal Injury Association Impairment (ASIA) scale C or D — were able to achieve Functional walking speeds averaging 1.1 meters per second.

“We initially expected that body-weight-supported treadmill training would be more effective to regain walking ability than the conventional over-ground mobility therapy, particularly in groups B and C,” said Dr. Dobkin. “But what we found was no significant difference in strategies among individuals in groups C and D, who achieved walking abilities beyond expectations.”

Although the hypothesis that body-weight support on a treadmill would produce more rapid improvement than step training didn’t pan out, the study still served a useful purpose, wrote Jonathan R. Wolpaw, M.D., of the Laboratory of Nervous System Disorders at the New York State Department of Health in Albany, in an accompanying editorial.

The results, he wrote, “suggest that different interventions, when assessed for a population as a whole, can attain more or less comparable results. Body-weight-support treadmill training and conventional locomotor training had similar average outcomes. At the same time, animal studies indicate that certain minimal conditions must be met and also suggest that individual patients can be best served by tailoring interventions to target their specific functional deficits.”

Dr. Dobkin and colleagues conducted a randomized, single-blind study comparing the efficacy of the two approaches for patients with incomplete spinal cord injury admitted for inpatient Rehabilitation.

Of the 146 patients enrolled, they were graded by ASIA scale criteria into one of the following injury categories:

* B, incomplete: Sensory but not Motor function is preserved below the Neurological Level and includes the Sacral segments S4-S5.
* C, incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
* D, incomplete: Motor function is preserved below the neurological level, and at least half of key muscles.

The injuries ranged from involvement of levels C5 to L3, and all patients had a Functional Independence Measure for Locomotion (FIM-L) score of less than 4.

Patients with lesions at the Cervical to T10-11 level were further classified into an upper motor Neuron group, whereas those with lesions occurring between T11 and L3 were classified into a lower motor neuron group, providing that they did not have upper motor neuron symptoms (there were too few patients with lower motor neuron injuries to be included in the analysis).

Patients received 12 weeks of equal sessions of their assigned therapies. For patients in categories B and C, the primary outcome was improvement in Functional Independence Measure for Locomotion. For those in categories C and D, an additional outcome was walking speed six months after injury.

The investigators found that there were no significant differences between the therapy groups either at baseline, or after six months of therapy in either independent locomotion (108 patients) or walking speed and distance (72 patients).

mong patients with upper motor neuron lesions 35% with class B injuries walked independently at six months, as did 92% of those with class C injuries, and all of the patients with class D injuries.

Also in these patients, there were no significant differences between therapy types in velocities for people with ASIA C and D injuries: 1.1 + 0.6 m/sec, in 30 patients in the body-weight-support group, versus 1.1 + 0.7 m/sec in 25 patients treated with over-ground mobility training.

“The Physical Therapy strategies of body-weight-support on a treadmill and defined over-ground mobility therapy did not produce different outcomes,” the authors wrote. “This finding was partly due to the unexpectedly high percentage of ASIA C subjects who achieved functional walking speeds, irrespective of treatment.”
Primary source: Neurology
Source reference:
Dobkin B et al. Weight-supported treadmill vs overground training for walking after acute incomplete SCI. Neurology 2006;66:484-493.

Additional source: Neurology
Source reference:
Wolpaw JR. Treadmill training after spinal cord injury: Good but not better. Neurology 2006;66: 466-467.
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By Neil Osterweil , MedPage Today Staff Writer

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