Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy.

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy.

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

Program-Level Factors Influencing Positive Graduate Outcomes of Physical Therapy Residency Programs.

Background: Physical therapist clinical residency programs vary widely in administrative structure, instructional characteristics, and program design. The impact of program-level factors on resident outcomes such as graduation and board certification is unknown. Objective: The objective of this study was to examine the influence of program-level factors on participant outcomes of physical therapist residency programs. Design: This was a retrospective cohort study using data from accredited programs from 2010 to 2013. Methods: Data were collected on program characteristics such as administrative structure, size, salary, tuition, full- or part-time options, didactic format, and clinical-site structure. The odds ratios were calculated to examine the impact of program characteristics on graduation, board certification, and passing the exam. A logistic regression analysis to determine the combined contribution of these characteristics on the 3 outcomes was performed. Results: Data from 183 residency programs and 1589 residents were analyzed. Participants attending programs that were single site or multifacility, provided live didactic instruction, did not charge tuition, and paid residents ≥ 70% full-time equivalent salary were 9.8 times more likely to graduate, 5.1 times more likely to become board certified, and 3.2 times more likely to pass the specialty board examination. Limitations: This study did not examine the impact of program location, resident attributes, or resident exposure to patient diagnostic volume and variety. Conclusions: This study has identified some program-level factors that appear to influence the odds of graduating, becoming board-certified, and passing the specialty board examination. This information could inform existing and developing residency programs, as well as applicants, on program-level factors that might influence participant outcomes.

Reliability and validity of the test of incremental respiratory endurance measures of inspiratory muscle performance in COPD.

Purpose: The Test of Incremental Respiratory Endurance (TIRE) provides a comprehensive assessment of inspiratory muscle performance by measuring maximal inspiratory pressure (MIP) over time. The integration of MIP over inspiratory duration (ID) provides the sustained maximal inspiratory pressure (SMIP). Evidence on the reliability and validity of these measurements in COPD is not currently available. Therefore, we assessed the reliability, responsiveness and construct validity of the TIRE measures of inspiratory muscle performance in subjects with COPD. Patients and methods: Test-retest reliability, known-groups and convergent validity assessments were implemented simultaneously in 81 male subjects with mild to very severe COPD. TIRE measures were obtained using the portable PrO2 device, following standard guidelines. Results: All TIRE measures were found to be highly reliable, with SMIP demonstrating the strongest test-retest reliability with a nearly perfect intraclass correlation coefficient (ICC) of 0.99, while MIP and ID clustered closely together behind SMIP with ICC values of about 0.97. Our findings also demonstrated known-groups validity of all TIRE measures, with SMIP and ID yielding larger effect sizes when compared to MIP in distinguishing between subjects of different COPD status. Finally, our analyses confirmed convergent validity for both SMIP and ID, but not MIP. Conclusion: The TIRE measures of MIP, SMIP and ID have excellent test-retest reliability and demonstrated known-groups validity in subjects with COPD. SMIP and ID also demonstrated evidence of moderate convergent validity and appear to be more stable measures in this patient population than the traditional MIP.

Temporal Indices of Ankle Clonus and Relationship to Electrophysiologic and Clinical Measures in Persons With Spinal Cord Injury.

BACKGROUND AND PURPOSE: Clonus arising from plantar flexor hyperreflexia is a phenomenon that is commonly observed in persons with spastic hypertonia. We assessed the temporal components of a biomechanical measure to quantify ankle clonus, and validated these in persons with spasticity due to spinal cord injury. METHODS: In 40 individuals with chronic (>1 year) spinal cord injury, we elicited ankle clonus using a standardized mechanical perturbation (drop test). We examined reliability and construct validity of 2 components of the drop test: clonus duration (timed with a stopwatch) and number of oscillations in the first 10-second interval (measured via optical motion capture). We compared these measures to the Spinal Cord Assessment Tool for Spastic reflexes (SCATS) clonus score and H-reflex/M-wave (H/M) ratio, a clinical and electrophysiologic measure, respectively. RESULTS: Intra- and interrater reliability of clonus duration measurement was good [intraclass correlation coefficient, ICC (2, 1) = 1.00]; test-retest reliability was good both at 1 hour [ICC (2, 2) = 0.99] and at 1 week [ICC (2, 2) = 0.99]. Clonus duration was moderately correlated with SCATS clonus score (r = 0.58). Number of oscillations had good within-session test-retest reliability [ICC (2, 1) > 0.90] and strong correlations with SCATS clonus score (r = 0.86) and soleus H/M ratio (r = 0.77). DISCUSSION AND CONCLUSIONS: Clonus duration and number of oscillations as measured with a standardized test are reliable and valid measures of plantar flexor hyperreflexia that are accessible for clinical use. Tools for objective measurement of ankle clonus are valuable for assessing effectiveness of interventions directed at normalizing reflex activity associated with spasticity.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A179).

Dose-Response Outcomes Associated with Different Forms of Locomotor Training in Persons with Chronic Motor-Incomplete Spinal Cord Injury.

Outcomes of training are thought to be related to the amount of training (training dose). Although various approaches to locomotor training have been used to improve walking function in persons with spinal cord injury (SCI), little is known about the relationship between dose of locomotor training and walking outcomes. This secondary analysis aimed to identify the relationship between training dose and improvement in walking distance and speed associated with locomotor training in participants with chronic motor-incomplete spinal cord injury (MISCI). We compared the dose-response relationships associated with each of four different locomotor training approaches. Participants were randomized to either: treadmill-based training with manual assistance (TM = 17), treadmill-based training with stimulation (TS = 18), overground training with stimulation (OG = 15), and treadmill-based training with locomotor robotic device assistance (LR = 14). Subjects trained 5 days/week for 12 weeks, with a target of 60 training sessions. The distance-dose and time-dose were calculated based on the total distance and total time, respectively, participants engaged in walking over all sessions combined. Primary outcome measures included walking distance (traversed in 2 min) and walking speed (over 10 m). Only OG training showed a good correlation between distance-dose and change in walking distance and speed walked over ground (r = 0.61, p = 0.02; r = 0.62, p = 0.01). None of the treadmill-based training approaches were associated with significant correlations between training dose and improvement of functional walking outcome. The findings suggest that greater distance achieved over the course of OG training is associated with better walking outcomes in the studied population. Further investigation to identify the essential elements that determine outcomes would be valuable for guiding rehabilitation.

Spanish version of SPADI (shoulder pain and disability index) in musculoskeletal shoulder pain: a new 10-items version after confirmatory factor analysis.

BACKGROUND: The Shoulder Pain and Disability Index (SPADI) is a tool designed to evaluate the impact of shoulder pathology. The aim of this study was to cross culturally adapt a Spanish version of the SPADI for Spanish population with a musculoskeletal shoulder pain, and to determine the psychometric properties of this instrument using confirmatory factor analysis (CFA). METHODS: Cross-cultural adaptation was performed according to the international guidelines. To assess factor structure, a confirmatory factor analysis was done. Internal consistency was measured using Cronbach's alpha. Item-total and inter-item correlations were assessed. Pearson and Spearman correlations were calculated to assess the convergent validity between SPADI and quick-DASH. RESULTS: A new Spanish version of SPADI was achieved. The original SPADI factor structure was tested by CFA, obtaining a poor fit: relative chi-square (χ2/df) 3.16, CFI 0.89, NFI 0.92, and RMSEA 0.10 (90 % CI 0.08 to 0.12). An additional model was tested, after deleting items which have had a poor adjustment in the model (1, 11, and 12), obtaining the best fit: relative chi-square (χ2/df) of 1.94, CFI 0.98, NFI 0.95, GFI 0,95, and RMSEA 0.06 (90 % CI 0.04 to 0.09). The analysis confirmed the bidimensional structure (pain and disability subscales). A correlation Spearman's Rho coefficient of 0.752 (p < 0.0001) and a Cronbach's alpha of 0.90 were obtained. CONCLUSIONS: This study validated a new 10-items version of SPADI for Spanish population with musculoskeletal shoulder pain providing a patient reported outcome measure that could be used in both clinical practice and research.

Cross-cultural adaptation and psychometric properties of an Arabic version of the Shoulder Pain and Disability Index.

The aim of the present study was to translate, culturally adapt, and validate the Arabic version of the shoulder Pain and Disability Index (SPADI). This was an observational reliability and validity study. We recruited 64 patients with shoulder pain and dysfunction with a wide variety of diagnoses. Patients completed the following questionnaires: Arabic SPADI, Quick Disability of the arm, shoulder and hand (Quick DASH), and the numerical rating scale (NRS) for pain. The active shoulder range of motion (ROM) was also assessed. Internal consistency was tested using Cronbach α. Reproducibility was assessed by asking the patients to complete another SPADI questionnaire 2 days after the first. Validity was assessed by calculating the Pearson correlation coefficient between the SPADI and the Quick DASH, NRS, and active shoulder ROM. The Cronbach α values for the pain score (0.96), disability score (0.98), and total score (0.98) of Arabic SPADI were all high. Similarly, the intraclass correlation coefficient (ICC) values for the pain, disability, and total score (ICC, 0.87, 0.96, and 0.95, respectively) of Arabic SPADI were all high. With respect to validity, there was a moderate to strong correlation between the Arabic SPADI and the Quick DASH, NRS, and active shoulder ROM. The translated version of SPADI in the Arabic language showed excellent internal consistency and test-retest reliability. Validity was shown by substantial correlations between SPADI and Quick DASH, NRS, and active shoulder ROM. The Arabic SPADI is recommended for the evaluation of patients with shoulder dysfunction.

Return to Sport Following Surgery for a Complicated Tibia and Fibula Fracture in a Collegiate Women's Soccer Player with a Low Level of Kinesiophobia.

BACKGROUND & PURPOSE: Much attention has been solely paid to physical outcome measures for return to sport after injury in the past. However, current research shows that the psychological component of these injuries can be more predictive of return to sport than physical outcome measures. The purpose of this case report is to describe the successful return to sport following surgery of a complicated tibia and fibula fracture of a Division I collegiate women's soccer player with a low level of kinesiophobia. CASE DESCRIPTION: A 22-year-old female sustained a closed traumatic mid-shaft fracture of her tibia and fibula. During a high velocity play she sustained a direct blow while colliding with an opposing player's cleats. As a result of the play, her distal tibia was displaced 908 to the rest of her leg. She underwent a closed reduction and tibial internal fixation with an intramedullary rod. Outcome scores were tracked using the IKDC and TSK-11. The IKDC measures symptoms, function, and sport activity related to knee injuries. The TSK-11 measures fear of movement and re-injury, which was important to assess during this case due to the gruesome nature of the injury. OUTCOMES: At 4 months, the subject became symptomatic over the fibula and was diagnosed with a fibular nonunion fracture. This was unexpected due to the low incidence of and usual asymptomatic nature of fibular nonunion fractures, which required an additional surgery. TSK-11 scores ranged from 19-20 throughout, signifying low levels of kinesiophobia. IKDC scores improved from 8.05 to 60.92. The subject ultimately signed a professional soccer contract. DISCUSSION: The rehabilitation of this subject was complex due to her low levels of kinesiophobia, self-guided overtraining, and the potential role they may have had in her fibular nonunion fracture. This case study demonstrates a successful outcome despite a unique injury presentation, multiple surgeries, and low levels of kinesiophobia. While a low level of kinesiophobia can be detrimental to rehabilitation compliance, it may have benefited her in the long-term. LEVEL OF EVIDENCE: 5.

Development and reliability testing of the Comprehensive High-Level Activity Mobility Predictor (CHAMP) in male servicemembers with traumatic lower-limb loss.

The opportunity for wounded servicemembers (SMs) to return to high-level activity and return to duty has improved with advances in surgery, rehabilitation, and prosthetic technology. As a result, there is now a need for a high-level mobility outcome measure to assess progress toward high-level mobility during and after rehabilitation. The purpose of this study was to develop and determine the reliability of a new outcome measure called the Comprehensive High-Level Activity Mobility Predictor (CHAMP). The CHAMP consists of the Single Limb Stance, Edgren Side Step Test, T-Test, and Illinois Agility Test. CHAMP reliability was determined for SMs with lower-limb loss (LLL) (interrater: n = 118; test-retest: n = 111) and without LLL ( n = 97). A linear system was developed to combine the CHAMP items and produce a composite score that ranges from 0 to 40, with higher scores indicating better performance. Interrater and test-retest intraclass correlation coefficient values for the CHAMP were 1.0 and 0.97, respectively. A CHAMP score equal to or greater than 33 points is within the range for SMs without LLL. The CHAMP was found to be a safe and reliable measure of high-level mobility in SMs with traumatic LLL.

Construct validity of Comprehensive High-Level Activity Mobility Predictor (CHAMP) for male servicemembers with traumatic lower-limb loss.

This study examined the convergent construct validity of a new performance-based assessment instrument called the Comprehensive High-Level Activity Mobility Predictor (CHAMP) as a measure of high-level mobility in servicemembers (SMs) with traumatic lower-limb loss (LLL). The study was completed by 118 SMs. Convergent construct validity of the CHAMP was established using the 6-minute walk test (6MWT) as a measure of overall mobility and physical function and the Amputee Mobility Predictor (AMP) as a measure of basic prosthetic mobility. The known group methods construct validity examined disparities in high-level mobility capability among SMs with different levels of LLL. The CHAMP score demonstrated a strong positive relationship between 6MWT distance (r = 0.80, p < 0.001) and AMP score (r = 0.87, p < 0.001), respectively. In addition, the CHAMP can discriminate between different levels of LLL. Study findings support the CHAMP as a valid performance-based assessment instrument of high-level mobility for SMs with traumatic LLL.

Comparison of 6-minute walk test performance between male Active Duty soldiers and servicemembers with and without traumatic lower-limb loss.

The rehabilitation of U.S. military servicemembers (SMs) who have sustained a traumatic loss of one or both lower limbs requires outcome measures that can assess their physical capabilities in comparison with their uninjured colleagues. Describing reference ranges for the 6-minute walk test (6MWT) in both populations will help clinicians develop appropriate goals for rehabilitation and document progress toward those goals. A convenience sample of 118 male U.S. SMs with and 97 without traumatic lower-limb loss participated in this study. All participants completed a 6MWT, and comparisons were made between SMs with and without limb loss and among the levels of limb loss. The SMs without lower-limb loss performed significantly better than all SMs with lower-limb loss. The SMs with transtibial limb loss performed significantly better than those with all other levels of limb loss. Statistically significant and clinically relevant differences were also noted between the other levels of limb loss. No differences were found between different prosthetic components. Reference ranges were established for U.S. SMs with and without various levels of limb loss, and the 6MWT was able to identify functional differences between groups.

Factors related to high-level mobility in male servicemembers with traumatic lower-limb loss.

The purpose of this study was to examine the possible relationship between factors modifiable by rehabilitation interventions (rehabilitation factors), other factors related to lower-limb loss (other factors), and high-level mobility as measured by the Comprehensive High-Level Activity Mobility Predictor (CHAMP) in servicemembers (SMs) with traumatic lower-limb loss. One-hundred eighteen male SMs with either unilateral transtibial amputation (TTA), unilateral transfemoral amputation (TFA), or bilateral lower-limb amputation (BLLA) participated. Stepwise regression analysis was used to develop separate regression models of factors predicting CHAMP score. Regression models containing both rehabilitation factors and other factors explained 81% (TTA), 36% (TFA), and 91% (BLLA) of the variance in CHAMP score. Rehabilitation factors such as lower-limb strength and dynamic balance were found to be significantly related to CHAMP score and can be enhanced with the appropriate intervention. Further, the findings support the importance of salvaging the knee joint and its effect on high-level mobility capabilities. Lastly, the J-shaped energy storage and return feet were found to improve high-level mobility for SMs with TTA. These results could help guide rehabilitation and aid in developing appropriate interventions to assist in maximizing high-level mobility capabilities for SMs with traumatic lower-limb loss.

The association of foot arch posture and prior history of shoulder or elbow surgery in elite-level baseball pitchers.

STUDY DESIGN: Case-control. OBJECTIVES: The specific aim of this study was to examine the association between abnormal foot arch postures and a history of shoulder or elbow surgery in baseball pitchers. BACKGROUND: Pitching a baseball generates forces throughout the musculoskeletal structures of the upper and lower limbs. Structures such as the longitudinal arch of the foot are adaptable to stresses over time. Repeated pitching-related stresses may contribute to acquiring abnormal foot arch postures. Inversely, congenitally abnormal foot arch posture may lead to altered stresses of the upper limb during pitching. METHODS: A convenience sample of 77 pitchers was recruited from a Division I university team and a professional baseball franchise. Subjects who had a history of shoulder or elbow surgery to the pitching arm were classified as cases. Subjects who met the criteria for classification of pes planus or pes cavus based on longitudinal arch angle were classified as having abnormal foot arch posture. Odds ratios were calculated to examine the association between abnormal foot arch posture and pitching-arm injury requiring surgery. RESULTS: Twenty-three subjects were classified as cases. The odds of being a case were 3.4 (95% confidence interval: 1.2, 9.6; P = .02) times greater for subjects with abnormal foot arch posture and 2.9 (95% confidence interval: 1.0, 8.1; P = .04) times greater for subjects with abnormal foot posture on the lunge leg. CONCLUSION: Abnormal foot arch posture and a surgical history in the pitching shoulder or elbow may be associated. Because the foot and its arches are adaptable and change over time, the pathomechanics of this association should be further explored.

Motor proficiency, strength, endurance, and physical activity among middle school children who are healthy, overweight, and obese.

PURPOSE: To compare motor proficiency, strength, endurance, and physical activity among children from minority backgrounds who were healthy weight (HW), overweight (OW), or obese (OB). METHODS: Eighty-six children, aged 10 to 15 years, of mostly Hispanic ethnicity, participated. Children were categorized according to body mass index-for-age percentile. Bruininks-Oseretsky Test of Motor Proficiency (BOT2) Short Form, Sit-to-Stand (STS), Timed Up and Down Stairs, and 6-Minute Walk Test (6MWT) were administered. Physical activity was measured by using activity monitors. RESULTS: Forty-five percent of children were classified as OW/OB. Children who were OB had lower mean BOT2, STS, and 6MWT performance than children of HW. Among children who were OW/OB, daily mean steps were lower and sedentary minutes higher than children of HW. In children who were OW/OB, body mass index was negatively correlated with BOT2, STS, and abdominal curls. CONCLUSION: Children who are OB demonstrate greater impairments in motor proficiency, strength, and endurance and participate in less physical activity than peers of HW.

Operant conditioning to increase ankle control or decrease reflex excitability improves reflex modulation and walking function in chronic spinal cord injury.

Ankle clonus is common after spinal cord injury (SCI) and is attributed to loss of supraspinally mediated inhibition of soleus stretch reflexes and maladaptive reorganization of spinal reflex pathways. The maladaptive reorganization underlying ankle clonus is associated with other abnormalities, such as coactivation and reciprocal facilitation of tibialis anterior (TA) and soleus (SOL), which contribute to impaired walking ability in individuals with motor-incomplete SCI. Operant conditioning can increase muscle activation and decrease stretch reflexes in individuals with SCI. We compared two operant conditioning-based interventions in individuals with ankle clonus and impaired walking ability due to SCI. Training included either voluntary TA activation (TA↑) to enhance supraspinal drive or SOL H-reflex suppression (SOL↓) to modulate reflex pathways at the spinal cord level. We measured clonus duration, plantar flexor reflex threshold angle, timed toe tapping, dorsiflexion (DF) active range of motion, lower extremity motor scores (LEMS), walking foot clearance, speed and distance, SOL H-reflex amplitude modulation as an index of reciprocal inhibition, presynaptic inhibition, low-frequency depression, and SOL-to-TA clonus coactivation ratio. TA↑ decreased plantar flexor reflex threshold angle (-4.33°) and DF active range-of-motion angle (-4.32°) and increased LEMS of DF (+0.8 points), total LEMS of the training leg (+2.2 points), and nontraining leg (+0.8 points), and increased walking foot clearance (+ 4.8 mm) and distance (+12.09 m). SOL↓ decreased SOL-to-TA coactivation ratio (-0.21), increased nontraining leg LEMS (+1.8 points), walking speed (+0.02 m/s), and distance (+6.25 m). In sum, we found increased voluntary control associated with TA↑ outcomes and decreased reflex excitability associated with SOL↓ outcomes.

Validation of the Revised Physical Therapist Clinical Performance Instrument (PT CPI): Version 2006.

BACKGROUND: Based on changes in core physical therapy documents and problems with the earlier version, the Physical Therapist Clinical Performance Instrument (PT CPI): Version 1997 was revised to create the PT CPI: Version 2006. OBJECTIVE: The purpose of this study was to validate the PT CPI: Version 2006 for use with physical therapist students as a measure of clinical performance. DESIGN: This was a combined cross-sectional and prospective study. METHODS: A convenience sample of physical therapist students from the United States and Canada participated in this study. The PT CPI: Version 2006 was used to collect CPI item-level data from the clinical instructor about student performance at midterm and final evaluation periods in the clinical internship. Midterm evaluation data were collected from 196 students, and final evaluation data were collected from 171 students. The students who participated in the study had a mean age of 24.8 years (SD=2.3, range=21-41). Sixty-seven percent of the participants were from programs in the United States, and 33% were from Canada. RESULTS: The PT CPI: Version 2006 demonstrated good internal consistency, and factor analysis with varimax rotation produced a 3-factor solution explaining 94% of the variance. Construct validity was supported by differences in CPI item scores between students on early compared with final clinical experiences. Validity also was supported by significant score changes from midterm to final evaluations for students on both early and final internships and by fair to moderate correlations between prior clinical experience and remaining course work. LIMITATIONS: This study did not examine rater reliability. CONCLUSION: The results support the PT CPI: Version 2006 as a valid measure of physical therapist student clinical performance.

A randomized controlled trial of an activity specific exercise program for individuals with Alzheimer disease in long-term care settings.

OBJECTIVE: To determine whether an activity specific exercise program could improve ability to perform basic mobility activities in long-term care residents with Alzheimer disease (AD). DESIGN: Randomized, controlled, single-blinded clinical trial. SETTING: Residents of 7 long-term care facilities. PARTICIPANTS: Eighty-two long-term care residents with mild to severe AD. INTERVENTION: An activity specific exercise program was compared to a walking program and to an attention control. MEASUREMENTS: Ability to perform bed mobility and transfers was assessed using the subscales of the Acute Care Index of Function; functional mobility was measured using the 6-Minute Walk test. RESULTS: Subjects receiving the activity specific exercise program improved in ability to perform transfers, whereas subjects in the other 2 groups declined.

Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial.

BACKGROUND: Impaired walking limits function after spinal cord injury (SCI), but training-related improvements are possible even in people with chronic motor incomplete SCI. OBJECTIVE: The objective of this study was to compare changes in walking speed and distance associated with 4 locomotor training approaches. DESIGN: This study was a single-blind, randomized clinical trial. SETTING: This study was conducted in a rehabilitation research laboratory. PARTICIPANTS: Participants were people with minimal walking function due to chronic SCI. INTERVENTION: Participants (n=74) trained 5 days per week for 12 weeks with the following approaches: treadmill-based training with manual assistance (TM), treadmill-based training with stimulation (TS), overground training with stimulation (OG), and treadmill-based training with robotic assistance (LR). MEASUREMENTS: Overground walking speed and distance were the primary outcome measures. RESULTS: In participants who completed the training (n=64), there were overall effects for speed (effect size index [d]=0.33) and distance (d=0.35). For speed, there were no significant between-group differences; however, distance gains were greatest with OG. Effect sizes for speed and distance were largest with OG (d=0.43 and d=0.40, respectively). Effect sizes for speed were the same for TM and TS (d=0.28); there was no effect for LR. The effect size for distance was greater with TS (d=0.16) than with TM or LR, for which there was no effect. Ten participants who improved with training were retested at least 6 months after training; walking speed at this time was slower than that at the conclusion of training but remained faster than before training. LIMITATIONS: It is unknown whether the training dosage and the emphasis on training speed were optimal. Robotic training that requires active participation would likely yield different results. CONCLUSIONS: In people with chronic motor incomplete SCI, walking speed improved with both overground training and treadmill-based training; however, walking distance improved to a greater extent with overground training.