Repetitive Transcranial Magnetic Stimulation with Body Weight-supported Treadmill Training Enhances Independent Walking of Individuals with Chronic Incomplete Spinal Cord Injury: A Pilot Randomized Clinical Trial.

The purpose of this study is to evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) combined with body weight-support treadmill training (BWSTT) for improving walking function of individuals with chronic incomplete spinal cord injury (iSCI). A 4-week, double-blinded, randomized, sham-controlled pilot study involved 12 sessions of real (10 Hz, 1800 pulses) or sham rTMS combined with BWSTT (15-20 min, moderate intensity). Walking independence was assessed using the Walking Index for Spinal Cord Injury II (WISCI-II). Lower extremity motor function (lower extremity motor score [LEMS]) and spasticity, sensory function, functional independence (Spinal Cord Injury Measure III [SCIM-III]), and quality of life were also assessed. Walking independence (WISCI-II) after the 6th session was higher in the BWSTT/rTMS real (n = 7) (median change (IQR): 3 (1.5 to 3.5)) than in the sham group (n = 8) (median change (IQR): 0 (0 to 0.25), but there was no difference between groups after 12th session (BWSTT/rTMS real median change (IQR): 4 (2 to 5); BWSSTT/rTMS sham median change (IQR): 0 (0 to 3.25). Compared to baseline, LEMS and SCIM-III mobility scores were increased after 12 sessions in the BWSTT/rTMS real but not in the sham group. Within- and between-group sensory function, functional independence, and quality of life remained similar. This preliminary result suggests that combining BWSTT with rTMS could lead to earlier gait improvement in patients with chronic iSCI.

Independent community walking after a short protocol of repetitive transcranial magnetic stimulation associated with body weight-support treadmill training in a patient with chronic spinal cord injury: a case report.

PURPOSE: Our report describes the effect of repetitive transcranial magnetic stimulation (rTMS) combined with body weight-supported treadmill training (BWSTT) on independent gait recovery in a patient with incomplete spinal cord injury (iSCI). CASE DESCRIPTION: The patient was a 31-year-old male, household ambulator (aid walker) and community wheelchair user who was 8.5 year post traumatic iSCI (T8 vertebra injury, AIS D). INTERVENTION: The patient participated in 12 sessions (three times/week for four weeks) of rTMS (1800 pulses, 10 Hz, intensity of 90% resting motor threshold) followed by BWSTT (15-20 min, moderate intensity). OUTCOMES: After treatment, the patient's score increased 3 points on the Walking Index for Spinal Cord Injury II (walking independence) and he became a community ambulator with crutches. His American Spinal Injury Association (ASIA) lower extremities motor score (motor function) increased from 33 to 45 points and the Spinal Cord Independence Measure III (functional independence) score increased from 23 to 29 for the mobility indoors/outdoors subscale. The patient's lower limb spasticity was reduced (Modified Ashworth Scale), and quality of life improved based on the Short-Form Health Survey - 36, and the Patient Global Impression of Change Scale showed considerable perception of improvement. CONCLUSION: Our report suggests that a short protocol of rTMS combined with BWSTT improved walking independence, motor function, spasticity, functional mobility and quality of life in this patient with iSCI.

Effects of body weight-support treadmill training on postural sway and gait independence in patients with chronic spinal cord injury.

OBJECTIVE: To examine the effects of a six-week body weight-support treadmill training (BWSTT) program on center-of-mass control and gait independence in chronic, incomplete spinal cord injury (iSCI) patients. DESIGN: Descriptive. SETTING: Clinica Los Coihues. Neurorehabilitation center in Santiago, Chile. PARTICIPANTS: 17 chronic iSCI patients and 17 healthy subjects. OUTCOME MEASURES: An instrumented sway (ISway) test was performed before and after the implementation of a six-week BWSTT program. The standing balance of participants was measured by Normalized jerk (NJ) and root mean square (RMS). These values were used to assess the standing balance of participants, and were correlated with the scores obtained on the Walking Index Spinal Cord Injury (WISCI) II test. RESULTS: Significant differences were found in standing balance (i.e., through NJ) after the BWSTT program (P = 0.016), but no significant differences were found in RMS values for postural sway (P = 0.693). None of the patients obtained improved WISCI II scores pre- vs. post-intervention. CONCLUSION: While a BWSTT program can improve center-of-mass control in iSCI patients, no effects were recorded for gait independence. TRIAL REGISTRATION: National Clinical Trials, registry number NCT02703883.

Gait initiation and partial body weight unloading for functional improvement in post-stroke individuals.

BACKGROUND: To better understand gait initiation in individuals with stroke and suggest possible training strategies, we compared the gait initiation of individuals with stroke and age-matched controls, and we examined the influence of different amounts of body weight support (BWS) during the execution of gait initiation in individuals with stroke. MATERIALS AND METHODS: Twelve individuals with stroke and 12 age-matched controls initiated gait after a verbal command at a self-selected and comfortable speed, and individuals with stroke also initiated gait wearing a harness with 0%, 15%, and 30% of BWS. Length and velocity of the first step, distance between heels, and weight bearing in both lower limbs in the initial position were calculated. We also assessed the displacement and average velocity of the center of pressure (CoP) in the medial-lateral (ML) and anterior-posterior (AP) directions in 3 distinct sections during gait initiation, which correspond to the CoP position toward the swing limb, stance limb and progression line, respectively. RESULTS: Individuals with stroke presented shorter and slower step, shorter and slower CoP-ML and CoP-AP toward swing limb and Cop-ML towards stance limb, and longer and faster CoP-AP toward stance limb compared to their peers. The BWS lead individuals with stroke to decrease step length and to increase CoP-ML displacement and average velocity toward stance limb. CONCLUSION: Individuals with stroke present impairments in executing gait initiation mainly during the preparation period and the employment of an overground BWS system promotes a better performance. These results suggest that BWS is a functional strategy that enables individuals with stroke to modulate gait initiation and it could be adopted for gait intervention.

Efeitos da prática do suporte de peso corporal em crianças com paralisia cerebral: uma série de casos / Effects of the practice of the body weight support in children with cerebral paralysis: a series of cases

Introdução: A paralisia cerebral (PC) é a causa mais comum de incapacidade motora na infância. Essa lesão cerebral pode resultar em comprometimentos neuromotores variados que, geralmente, estão associados à gravidade da sequela e a idade da criança. Objetivo: Avaliar a influência do Suporte de Peso Corporal (SPC) sobre a função motora e flexibilidade de crianças com paralisia cerebral. Método: Participaram do estudo sete crianças que não apresentavam o padrão de marcha, GMFCS nível IV e V, onde foi realizada a identificação do desempenho da função motora grossa por meio da Gross Motor Function Measure (GMFM), da flexibilidade por meio do teste Flexiteste,e do número de passos e distância percorrida antes e após um ano de tratamento com SPC em esteira ergométrica. Tendo assistência de dois terapeutas que auxiliavam em pontos chaves de joelho e tornozelo simulando o padrão de marcha da criança. As sessões foram realizadas uma vez por semana, durante 30 minutos. Resultado: O GMFM apresentou aumento das pontuações obtidas antes e após o tratamento, onde os itens deitar e rolar teve aumento de 14,09%, sentar teve aumento de 10,43%, engatinhar e ajoelhar teve, aumento de 7,27%, e por fim, o item em pé teve aumento de 8,10%. A variável flexibilidade apresentou diferença antes e após o tratamento, obtendo como flexibilidade inicial pequena e final médio negativa, com aumento de 7,85 pontos. Já o número de passos teve aumento de 175 passos e a distância percorrida de 132 metros Conclusão: The proposed SPC therapy in children with cerebral palsy proved to be efficient and could enhance motor performance, flexibility, number of steps and distance traveled. [AU]

Introduction: Cerebral palsy (CP) is the most common cause of motor disability in childhood. This brain injury can result in varied neuromotor compromises that are usually associated with the severity of the sequela and the child's age. Objective: To evaluate the influence of the Body Weight Support (SPC) on the motor function and flexibility of children with cerebral palsy. Methods: Seven children who did not present gait pattern, GMFCS level IV and V, participated in the study, where the identification of the gross motor function performance was performed through the Gross Motor Function Measure (GMFM), flexibility using the Flexitest test , and the number of steps and distance traveled before and after one year of SPC treadmill treatment. With assistance from two therapists assisting in key knee and ankle points simulating the child's gait pattern. The sessions were held once a week for 30 minutes. Results: The GMFM showed an increase of the scores obtained before and after the treatment, where the items of throwing and rolling had an increase of 14.09%, sitting had an increase of 10.43%, crawling and kneeling had an increase of 7.27% and finally, the standing item increased by 8.10%. The flexibility variable showed difference before and after treatment, obtaining as initial small flexibility and medium negative end, with increase of 7.85 points. However, the number of steps increased by 175 steps and the distance covered by 132 meters. Conclusion: The proposed physiotherapeutic treatment (SPC) presented to these patients with cerebral palsy was efficient and could increase motor performance, flexibility, number of steps and distance traveled. [AU]

Efeito da prática do suporte de peso corporal na função motora de crianças / Effect of the practice of body weight support in the motor function of children

Objetivo. Avaliar a influência do Suporte de Peso Corporal (SPC) sobre a função motora de crianças não deambulantes. Método. Participaram do estudo oito crianças que não apresentavam o padrão de marcha. Foi realizada a identificação do desempenho da função motora grossa por meio da Gross Motor Function Classification Measure (GMFM) e da flexibilidade por meio do Teste Flexiteste, antes e após 10 sessões e um período de retenção durante 3 meses de tratamento com SPC em esteira ergométrica. Tendo assistência de dois terapeutas que auxiliavam em pontos chaves de joelho e tornozelo simulando o padrão de marcha da criança. As sessões foram realizadas uma vez por semana, durante 30 minutos, por um período de 3 meses e o mesmo de retenção. Resultado. O GMFM apresentou aumento das pontuações obtidas pré/pós-tratamento e retenção nos itens deitar/rolar e sentar, já o item engatinhar/ajoelhar mostrou diferença significativa apenas no período pré/pós-tratamento. A variável flexibilidade apresentou diferença significativa entre o pré e pós-tratamento e no pós-tratamento com o período de retenção. Conclusão. O tratamento com SPC em esteira ergométrica pode potencializar o desempenho funcional de crianças não-deambulantes, possibilitando a evolução de sua função motora grossa e flexibilidade. (AU)

Objective: To evaluate the influence of the Body Weight Support (SPC) on the gross motor in non-ambulant children. Method: Eight children participated in the study, they did not present gait pattern (GMFCS IV and V). To access the gross motor function, the Gross Motor Function Classification Measure (GMFM) test was applied, the flexibility values were collected through flexitest. Both tests were conducted before and after 10 clinical sessions and three months after the end of the treatment. The intervention were performed on a treadmill, with the subject attached to the SPC, being accompanied by two physiotherapists that helped to maintain the gait pattern by maintaining key positions of the knees and ankles. Each session had duration of 30 minutes, once per week during three months. Results: The GMGM scores for lay down/roll and sit increased after the treatment and on the retention when compared with pre tests. The crawl/kneel score only presented difference after the end of treatment. Flexibility presented higher values for post and retention in comparison with pre tests. Conclusion: The SPC treatment during treadmill gait may potentiate the functional performance of non-ambulant children, improving the gross motor skills and flexibility. (AU)

MIT-Skywalker: considerations on the Design of a Body Weight Support System.

BACKGROUND: To provide body weight support during walking and balance training, one can employ two distinct embodiments: support through a harness hanging from an overhead system or support through a saddle/seat type. This paper presents a comparison of these two approaches. Ultimately, this comparison determined our selection of the body weight support system employed in the MIT-Skywalker, a robotic device developed for the rehabilitation/habilitation of gait and balance after a neurological injury. METHOD: Here we will summarize our results with eight healthy subjects walking on the treadmill without any support, with 30% unloading supported by a harness hanging from an overhead system, and with a saddle/seat-like support system. We compared the center of mass as well as vertical and mediolateral trunk displacements across different walking speeds and support. RESULTS: The bicycle/saddle system had the highest values for the mediolateral inclination, while the overhead harness body weight support showed the lowest values at all speeds. The differences were statistically significant. CONCLUSION: We selected the bicycle/saddle system for the MIT-Skywalker. It allows faster don-and-doff, better centers the patient to the split treadmill, and allows all forms of training. The overhead harness body weight support might be adequate for rhythmic walking training but limits any potential for balance training.

Ground reaction forces during level ground walking with body weight unloading

Background: Partial body weight support (BWS) systems have been broadly used with treadmills as a strategy for gait training of individuals with gait impairments. Considering that we usually walk on level ground and that BWS is achieved by altering the load on the plantar surface of the foot, it would be important to investigate some ground reaction force (GRF) parameters in healthy individuals walking on level ground with BWS to better implement rehabilitation protocols for individuals with gait impairments. Objective: To describe the effects of body weight unloading on GRF parameters as healthy young adults walked with BWS on level ground. Method: Eighteen healthy young adults (27±4 years old) walked on a walkway, with two force plates embedded in the middle of it, wearing a harness connected to a BWS system, with 0%, 15%, and 30% BWS. Vertical and horizontal peaks and vertical valley of GRF, weight acceptance and push-off rates, and impulse were calculated and compared across the three experimental conditions. Results: Overall, participants walked more slowly with the BWS system on level ground compared to their normal walking speed. As body weight unloading increased, the magnitude of the GRF forces decreased. Conversely, weight acceptance rate was similar among conditions. Conclusions: Different amounts of body weight unloading promote different outputs of GRF parameters, even with the same mean walk speed. The only parameter that was similar among the three experimental conditions was the weight acceptance rate. .

Influence of body weight unloading and support surface during walking of children with cerebral palsy / Influência do alívio de peso corporal e da superfície de suporte durante o andar de crianças com paralisia cerebral espástica

Introduction Partial body weight support (BWS) systems have been employed for gait training of children with cerebral palsy (CP). Therefore, it would be important to analyze if the type of walking surface and the amount of body weight unloading over lower limbs change the way these children walk. Objectives Investigate the influence of walking surface and amount of body weight unloading on the spatial temporal characteristics during walking of children with CP. Materials and methods Seven children with spastic CP between four and eight years old and GMFCS (Gross Motor Function Classification System) between I and IV, were videotaped walking with 0%, 15% and 30% of BWS on both dynamic (treadmill) and static (ground level) surfaces. Walking spatial temporal variables were calculated. Results Children walked with similar velocity in all experimental conditions. While stance duration decreased as the percentage of BWS increased, no differences were found for stance and swing periods and cadence. Children walked with longer steps and strides and with faster strides on static surface compared to dynamic surface. Conclusion Children with CP presenting different levels of motor impairment presented some alterations in the spatial temporal walking parameters as they walked with body unloading. However, such alterations might be due mainly to the type of walking surface than the percentage of body weight unloading on lower limbs.

Introdução Sistemas de suporte parcial de peso corporal (SPPC) têm sido utilizados para treinamento do andar de crianças com paralisia cerebral (PC). Sendo assim, seria importante analisar se o tipo de superfície e a quantidade de alívio de peso corporal sobre os membros inferiores interferem na forma como essas crianças andam. Objetivo Investigar a influência do tipo de superfície e da porcentagem de alívio de peso corporal sobre as características espaço-temporais durante o andar de crianças com PC. Materiais e métodos Sete crianças com PC espástica, entre quatro e oito anos de idade, e GMFCS (Gross Motor Function Classification System) entre I e IV, foram filmadas andando com 0%, 15% e 30% de SPPC em superfícies móvel (esteira motorizada) e fixa (chão). Variáveis espaço-temporais do andar foram calculadas. Resultados As crianças andaram com velocidade semelhante em todas as condições experimentais. Enquanto que a duração do período de apoio diminuiu conforme a porcentagem de SPPC aumentou, nenhuma diferença para as fases de apoio e balanço e cadência foi encontrada. As crianças andaram com passos e passadas mais longos e passadas mais rápidas na superfície fixa do que na superfície móvel. Conclusão Crianças com PC com diferentes níveis de acometimento motor apresentaram algumas alterações nos parâmetros espaço-temporais durante o andar com alívio de peso corporal em superfícies móvel e fixa. Entretanto, tais alterações podem ser atribuídas principalmente ao tipo de superfície em que as crianças andam do que às porcentagens de alívio de peso corporal proporcionadas aos membros inferiores.

Gait characteristics of children with cerebral palsy as they walk with body weight unloading on a treadmill and over the ground.

Body weight support (BWS) has become a typical strategy for gait training, in special with children with cerebral palsy (CP). Although several findings have been reported in the literature, it remains uncertain how different types of surfaces and gradual amount of BWS can facilitate the mobility of children with CP. The aim of this study was to investigate gait kinematic parameters of children with CP by manipulating BWS and two different types of ground surfaces. Ten children (7.7 ± 2.1 years old) diagnosed with spastic CP and GMFCS classification between levels II and IV were asked to walk on a treadmill and over the ground. In both conditions, BWS was manipulated to minimize gravitational effects and spatial-temporal gait parameters and lower limb joints were analyzed. The results revealed that the type of ground surface causes greater impact on the gait pattern of children with CP as compared to body weight unloading. This finding may provide new insights into the behavioral heterogeneity of children with CP, and offers critical information to be considered on interventional programs specifically designed to improve mobility on this population.

Desenvolvimento de instrumentação para aplicação e avaliação do treinamento locomotor com suporte parcial de peso / Development of instrumentation for application and assessment of locomotor training with partial body weight support

O treino locomotor com suporte parcial de peso (TLSP) é um método para reabilitação da marcha que consiste em suspender o indivíduo sobre uma esteira enquanto seus membros inferiores são movimentados passivamente. Para aplicar o TLSP de forma apropriada, é preciso que a descarga de peso sobre membros inferiores seja controlada e monitorada. O objetivo deste trabalho foi desenvolver um sistema de suporte de peso (SSP) capaz de medir descarga de peso sobre membros inferiores e superiores. Além disso, instrumentação para medição do ângulo do joelho, contato do pé e eletromiografia foi desenvolvida para avaliação do treino. O SSP foi construído com um sistema de polias, cabo de aço, guincho manual, uma célula de carga fixa ao cabo e duas outras em apoios para as mãos adaptados a uma esteira elétrica. Eletrogoniômetros e footswitches foram construídos para o sistema de medição, e uma plataforma de aquisição de sinais foi desenvolvida em ambiente LabVIEW®. As células de carga e os eletrogoniômetros foram calibrados e testados. Um ensaio piloto foi realizado com um indivíduo saudável a uma velocidade de 1,5 km/h com descarga de 60% do peso corporal sobre membros inferiores. O SSP desenvolvido apresentou erro menor que 1,5% e forneceu medidas das descargas de peso sobre membros superiores e inferiores. Ele permitiu analisar assimetria sobre membros superiores, o que pode ser importante na reabilitação neurológica. O spadrões cinemáticos e eletromiográficos fornecidos pelo sistema de medida foram semelhantes aos mostrados na literatura. A patente do sistema foi requerida junto ao INPI sob o protocolo n° 0000280904043771.

The locomotor training with partial weight support (LTPWS) is a method for gait rehabilitation which consists in suspending the individual over a treadmill while its lower limbs are passively moved mimicking the gait cycle. In order to properly apply LTPWS, the weight load over lower limbs must be controlled and monitored. The main aim of this work was to develop a partial weight support system (WSS) able to measure lower and upper limb loading. Also, instrumentation for measuring knee angle, foot contact and EMG data was developed for training assessment. The WSS was constructed with a pulley system, a steel cable, a manual winch, aload cell fixed at the cable and two other load cells fixed to handrails built on an electrical treadmill. For the measuring system, electrogoniometers and footswitches were constructed and a signal acquisition platform was developed on LabVIEW® environment. The load cells and electrogoniometers were calibrated and tested. A pilot test with a healthy individual was carried out at a speed of 1.5 km/h with a load of 60% of the body weight, over lower limbs. The developed WSS exhibited an error below 1.5% and was able to measure upper and lower limb weight load. It allows analyzing upper limbs loading and lateral unbalance, what might be important for neural rehabilitation. The measuring system was able to provide kinematic and electromyographic patterns similar to those shown in the literature under similar conditions. A patent request was submitted to the INPI under protocol nº 0000280904043771.