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Neurorehabilitation and Neural Repair

DOI: 10.1177/0888439003255508 2003; 17; 153 Neurorehabil Neural Repair

Dudley, Robert Elashoff, Lisa Fugate, Susan Harkema, Michael Saulino and Michael Scott Bruce H. Dobkin, David Apple, Hugues Barbeau, Michele Basso, Andrea Behrman, Dan Deforge, John Ditunno, Gary

for Walking During Inpatient Rehabilitation after Incomplete Traumatic Spinal Cord InjuryMethods for a Randomized Trial of Weight-Supported Treadmill Training Versus Conventional Training

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Copyright 2003 The American Society of Neurorehabilitation 153

The authors describe the rationale and methodology forthe first prospective, multicenter, randomized clinicaltrial (RCT) of a task-oriented walking intervention forsubjects during early rehabilitation for an acute trau-matic spinal cord injury (SCI). The experimental strategy,body weightsupported treadmill training (BWSTT),allows physical therapists to systematically train patientsto walk on a treadmill at increasing speeds typical ofcommunity ambulation with increasing weight bearing.The therapists provide verbal and tactile cues to facilitatethe kinematic, kinetic, and temporal features of walking.Subjects were randomly assigned to a conventional ther-apy program for mobility versus the same intensity andduration of a combination of BWSTT and over-groundlocomotor retraining. Subjects had an incomplete SCI(American Spinal Injury Association grades B, C, and D)from C-4 to T-10 (upper motoneuron group) or from T-11to L-3 (lower motoneuron group). Within 8 weeks of aSCI, 146 subjects were entered for 12 weeks of interven-tion. The 2 single-blinded primary outcome measures arethe level of independence for ambulation and, for thosewho are able to walk, the maximal speed for walking 50feet, tested 6 and 12 months after randomization. Thetrials methodology offers a model for the feasibility of

translating neuroscientific experiments into a RCT todevelop evidence-based rehabilitation practices.

Key Words: Motor learning-Locomotor training-Neurologic rehabilitation-Spinal cord

Ambulation is compromised in most of themore than 10,000 yearly survivors of a trau-matic spinal cord injury (SCI) and for250,000 people in the United States with chronicSCI.1 Patients with complete sensorimotor loss(graded by the American Spinal Injury Associationscale [ASIA] as A; see Table 12) and those gradedASIA B within 1 week to 1 month of the SCI recov-er walking in no more than 10% to 15% of cases.Most subjects who have had enough return ofmotor control to regain the ability to walk will doso at greater than normal energy cost. Outcomestudies of ambulation vary with the method used toclassify impairment, the time of assessment afterSCI, and the measures employed. Previous obser-vational studies of the recovery of walking afterSCI, such as those from the American ModelSystems program,3 have not prospectively assessedrelationships between functional recovery, rate ofrecovery, walking speed and endurance, and qual-ity of life in patients who were admitted for inpa-tient rehabilitation.

During inpatient rehabilitation soon after SCI,physical therapy ordinarily proceeds beyond sup-ported standing only if the patients legs are bracedto lock them in extension or if the patient has thestrength and balance necessary to maintain the legs

Methods for a Randomized Trial ofWeight-Supported Treadmill Training

versus Conventional Training for Walkingduring Inpatient Rehabilitation after

Incomplete Traumatic Spinal Cord Injury

Bruce H. Dobkin, David Apple, Hugues Barbeau, Michele Basso,Andrea Behrman, Dan Deforge, John Ditunno, Gary Dudley, Robert Elashoff,

Lisa Fugate, Susan Harkema, Michael Saulino, and Michael Scott,for the Spinal Cord Injury Locomotor Trial (SCILT) Group

From the Department of Neurology, Reed Neurologic ResearchCenter, University of California, Los Angeles.

Address correspondence to Bruce H. Dobkin, M.D., Departmentof Neurology, Neurologic Rehabilitation and Research Program,University of California Los Angeles, Reed Neurologic ResearchCenter, 710 Westwood Plaza, Los Angeles, CA 90095. E-mail:bdobkin@mednet.ucla.edu.

Dobkin BH, Apple D, Barbeau H, Basso M, Behrman A, DeforgeD, Ditunno J, Dudley G, Elashoff R, Fugate L, Harkema S,Saulino M, Scott M, for the Spinal Cord Injury Locomotor Trial(SCILT) Group. Methods for a randomized trial of weight-sup-ported treadmill training versus conventional training for walk-ing during inpatient rehabilitation after incomplete traumaticspinal cord injury. Neurorehabil Neural Repair 2003;17:153-167.

DOI: 10.1177/0888439003255508

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in extension during weight bearing and to flex atthe hips and knees when taking steps. If the armsare capable of partially supporting the personsweight during stepping in parallel bars or in awalker without inducing great energy cost, gaittraining proceeds.

The Spinal Cord Injury Locomotor Trial (SCILT) isdesigned to compare conventional inpatient andoutpatient physical therapy to an intervention oftencalled body weightsupported treadmill training(BWSTT).4 This technique for locomotor retrain-ing partially supports the weight of a patient bya parachute-type harness attached at the shouldersto an overhead lift. Initial weight support preventsthe paraparetic legs from buckling at the knees.The lift allows vertical displacement during step-ping and supports up to 50% of the subjectsweight. Therapists then systematically train patientsto walk on the treadmill at increasingly fasterspeeds and reduce the amount of weight supportwhen feasible. The therapists aim to optimize thekinematic, kinetic, and temporal components ofgait that are tied to the stance and swing phases ofwalking. This training aims to facilitate walking-related sensory inputs for a rhythmical, reciprocalgait pattern, without the requirements of good pos-tural stability and full weight bearing. The trainingalso carries over facilitative cues and an emphasison sensory inputs relevant to stance and swing forwalking over ground and in the community.

Several quasi-experimental studies in SCI sug-gested that BWSTT may increase the likelihood thatsubjects graded ASIA B, C, and D with uppermotoneuron (UMN) injuries will learn to walk overground.5-9 Experimental neuroscientific studies sug-gested that improved motor output and locomotionafter SCI may be inducible by mechanisms of neu-roplasticity that are influenced by task-orientedsensorimotor training and paradigms for motorlearning. These include 1) sprouting from primarysensory neurons and from residual descendinginputs to the lumbosacral motor pools; 2) modifi-cation of spinal gray matter synaptic transmis-sion10,11; 3) conduction through demyelinated butintact axons12,13; 4) locomotor movement patternsfacilitated by lumbar spinal cord central patterngenerators and related circuits for stepping10,14-20; 5)enhancement of activity in residual, subclinicaldescending pathways that must be trained to playa greater role in posture and gait21,22; and 6)changes in residual cortical and subcortical neu-ronal assemblies that represent the kinematics andforces associated with walking.23-25

BWSTT does not rely only on theories about cen-tral pattern generators, especially not in incompletesubjects who have some lower extremity motorcontrol. SCILT included subjects who had lowermotoneuron (LMN) injury because 20% of peoplewith traumatic SCI have such lesions. The LMNgroup may not have access to the lumbosacral gen-erators if damaged by an injury near the T-12 ver-tebral body. These subjects may still make use ofsegmental sensory inputs and reorganization with-in the cord above the lesion, as well as withinbrainstem and cortical sensorimotor networks.

SCILT, then, draws its face validity from a gener-al hypothesis about motor skills relearning inpatients with a moderate to profound loss ofascending and descending spinal pathways. Byassisting patients to step so that proprioceptive andcutaneous sensory inputs to the spinal cord andbrain are more typical of ordinary walking thanwhat patients with paraparesis achieve during con-ventional training, and by intensive practice of suchstepping on a treadmill, mechanisms of activity-dependent plasticity may increase rehabilitativegains.1

Progress in acute protection of spinal cord neu-rons and tracts and in the regeneration of axonsand neuronal connections with, for example, neu-rotrophic factors, immune blocking substances, cellimplants, and neural bridges across the level ofinjury offers hope for biological interventions forSCI in patients.26 Well-defined training strategieswill also be necessary to optimize the functionalutility of