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CONV: conventional physical therapy; LEMS: lower extremity motor score.

CONV: conventional physical therapy; LEMS: lower extremity motor score.

observers has been reported, and that revealed no benefit of BWSTT over conventional care in incomplete subjects. The SCI Locomotor Trial (SCILT) randomized 145 subjects with incomplete SCI who could not walk on admission to six regional SCI facilities. Subjects received 12 weeks of BWSTT complemented by over ground training when feasible or an equal amount of conventional over ground training, in addition to usual inpatient and outpatient therapies (Dobkin et al., 2003). Table 3.2 is an overview of the results for ASIA C and D subjects with upper motor neuron impairments. No benefit of the intervention was found for ASIA B subjects, most of whom did not recover any ability to walk, or to ASIA C and D subjects, most of whom did walk at remarkably functional speeds and distances (Dobkin et al., 2004).

In patients who cannot stand and yet have some proximal motor control that may be brought out by an upright posture, BWSTT may enable some loading and foster rhythmic stepping. For example, the patient whose fMRI is shown in Fig. 3.1 was enabled to stand upright, bear some weight in the legs, and activate the iliopsoas and quadriceps muscles reciprocally 3 months after the SCI, when he could not stand or step after routine rehabilitation. The upright posture and leg assistance allowed him to concentrate on finding some motor control over residual descending pathways to surviving motoneu-rons that still innervated these muscles. Training and neuromuscular activity may then drive cerebral control for gait over various surfaces and speeds. Trophic substances produced by activity can increase peripheral axon regeneration to re-innervate muscle. (Dobkin and Havton, 2004). As interesting as this recovery seems, the same result may have been possible using more aggressive conventional therapies.

BWSTT when instituted a mean of 70 days after acute hemiparetic stroke revealed statistically significant gains in gait when compared to treadmill training without BWS (Visintin et al., 1998; Barbeau and Visintin, 2003). This comparison is of interest, but not a clinically useful distinction for evidence-based practices. Also, the outcomes were statistically significant for walking speed, but not clinically significant. Other RCTs of BWSTT during acute inpatient rehabilitation after stroke revealed no clinical benefits for walking independence or speed (Nilsson et al., 2002; Lennihan et al., 2003). RCTs are needed to determine if BWSTT ought to be offered to patients who cannot walk over ground with a reciprocal gait or to those who still walk too slowly to ambulate outside of the home (<50cm/s) more than 6 months after onset of hemiplegic stroke or SCI in ASIA C subjects. Such trials will need to establish training scenarios for the manipulation of BWS and treadmill speeds, along with justifying the duration and intensity of treatment. Even greater attention will be necessary for the design of RCTs of BWSTT augmented by robotic assistive devices (Colombo et al., 2000; Werner et al., 2002), functional electrical stimulation (Hesse et al., 1995; Chaplin, 1996; Barbeau et al., 2002), and pharmacological interventions (Norman et al., 1998; Dobkin, 2003a). Dose-response studies for the amount of training, as is typically required for drug studies, and a demonstration of the reproducibility of training techniques will require considerable pilot data (Dobkin, 2004).

Pulse therapies

The efficacy of a pulse of various training strategies for walking has been demonstrated in well-designed trials from months to years after stroke (Hesse et al., 1994; Sullivan et al., 2002; Ada et al., 2003; Duncan et al., 2003b) and other chronically disabling neurological diseases. The duration of effect will be limited in progressive diseases. That should not dissuade the clinician from attempting to maintain functional walking through a home-based exercise program and a brief course of goal-directed therapy to improve the gait pattern, strengthen leg muscles, or recondition a patient to lessen disability. A home-based program might include sets of practice in sit-to-stand, supine and prone leg lifts, partial squats while braced against a wall, pool exercise, treadmill walking, specified goals for progressive gains in walking distance or walking speed, modest resistance exercises with weights or latex bands, and practice walking on uneven surfaces and stairs.

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