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Letters and Responses |
In this letter, I would like to address the significance for physical therapy of a recent study by Dobkin et al.1 This randomized clinical trial investigated the effectiveness of a combination of body-weight–supported treadmill training (BWSTT) and over-ground mobility training versus solely over-ground mobility therapy in subjects with an incomplete spinal cord injury (iSCI). A large number of the subjects with iSCI regained walking ability independent of the group to which they were assigned. Compared with historic data, an unexpectedly high percentage (92%) of patients with an American Spinal Injury Association Impairment Scale (ASIA) classification C regained an independent walking ability. In addition, the walking speed of the subjects classified as ASIA C and D did not differ between the groups. The authors concluded that BWSTT was not superior in restoring walking ability compared with over-ground mobility therapy in people with iSCI early after trauma.
From a physical therapist's point of view, the results of the study by Dobkin et al1 could be considered very encouraging. As even a sensitive outcome measure such as walking speed2 did not show any difference, Dobkin and colleagues had evidence that their intervention, which consisted of task-oriented over-ground training, was equally effective when compared with BWSTT. Body-weight–supported treadmill training can be considered an intervention with a thorough theoretical framework based on animal experiments and an impressive amount of animal and (mainly uncontrolled) human evidence indicating effectiveness (for a review, see Dietz3). Because physical therapy interventions often are criticized for their lack of scientific arguments based on theoretical background or treatment effectiveness, the results of Dobkin and colleagues' study are positive findings.
Several ideas might explain the lack of differences found.1,4,5 In my opinion, the 3 prerequisites for improving loco-motor abilities, as identified by Grillner and Wallen,6 are sometimes forgotten, but they might partly explain the findings by Dobkin et al1:
Body-weight–supported treadmill training can be considered a safe and practical intervention that can be applied at an early stage during rehabilitation where body-weight support and physical (or robotic) assistance enable patients with iSCI with partial paresis to perform leg movements. It can also be considered task-specific because it retrains reciprocal leg movements with appropriate sensory inputs.3 Training the CPG improves leg muscle activation, but this cannot be sufficiently transferred into function, because patients who remained classified as ASIA B (motor complete) showed no gain in locomotor function.1 Therefore, supraspinal input appears to be inevitable to restore locomotion, and BWSTT can complement but not replace task-oriented over-ground adaptive locomotor training.
In conclusion, physical therapy, in general, might profit from the results of the study by Dobkin et al1 as these results increase the body of evidence of the effectiveness of task-oriented training and might get physical therapy out of its "not-better-than-placebo" status. The present multidisciplinary approach to treating patients after an iSCI appears to be successful, as a high percentage of patients with iSCI regained walking ability. More specifically for physical therapists, task-oriented over-ground training with or without BWSTT can result in a promising functional outcome for the patient, which is, from the therapist's and patient's point of view, all that matters.
Spinal Cord Injury Center
Balgrist University Hospital
Forchstrasse 340
CH-8008 Zurich, Switzerland
hvanhedel{at}paralab.balgrist.ch
References
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