Comparison of forward versus backward walking using body weight supported treadmill training in an individual with a spinal cord injury: A single subject design

A Backward Walking Training Program to Improve Balance and Mobility in Children with Cerebral Palsy

Background: We studied the effects of motor tasks using backward walking training on balance and gait functions of children with cerebral palsy. This was a single-blinded, randomized controlled trial with a crossover design conducted at a single facility. Methods: Among 12 children with cerebral palsy, the forward (FWG) (n = 6) and backward walking groups (BWG) (n = 6) underwent training three times a week for 4 weeks, 40 min a day. After a 6-week break, the crossover training was conducted. Functional walking variables were measured. Time-Up-and-Go (TUG) test, Figure-8 Walk Test (FW8T), and Pediatric Balance Scale (PBS) were used for measuring balance. Results: Both groups showed significant improvement in walking speed, stride length, and step length. The BWG demonstrated significant improvement in walking speed (p < 0.05) compared with the FWG. The TUG test, FW8T, and PBS showed significant improvement. After the 4-week intervention, both groups displayed a remarkable decrease in TUG duration and FW8T. Both groups also exhibited improvement in the PBS; more so in the BWG. Conclusions: Backward walking training with motor dual tasks could be a more effective interventional approach than forward walking training to improve balance and walking functions of children with spastic hemiplegia.

Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis

BACKGROUND

Backward walking (BW) training is thought to impact balance performance through improving motor system proprioception and gait characteristic, but relevant evidence remains sparse and inconclusive.

OBJECTIVE

This study systematically reviewed and quantified the scientific evidence regarding the effectiveness of BW training on balance performance.

METHODS

Keyword and reference search on BW training interventions was conducted in six electronic databases (PubMed, Web of science, SPORTDiscus, CINAHL, Cochrane Library, and CNKI) for peer-reviewed articles published till November 2017. A standardized form was used to extract data from each selected article that met the pre-specified eligibility criteria. Meta-analysis was conducted to estimate the pooled effects of BW training on balance performance measures.

RESULTS

Eleven studies (nine randomized controlled trials and two pre-post studies) met the eligibility criteria and were included in the review. All studies reported some beneficial effects of BW training on balance performance. Compared to control, BW training was associated with a reduction in overall stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model), medial-lateral stability index score by 0.95 (95% CI = 0.34, 1.57; I² = 0.0%; fixed-effect model), and anterior-posterior stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model). Meanwhile, BW training was associated with an increase in open-eyes single leg standing duration by 0.91 s (95% CI = 0.29, 1.53; I² = 75.9%; random-effect model) in comparison to control.

CONCLUSIONS

BW training could serve as a potentially useful tool to improve balance performance among those with a high risk of fall. However, current evidence remains preliminary due to the small cohort of studies and possible learning effect in pre-post studies. Future work with larger scale and randomized experimental design is warranted to evaluate the effectiveness of BW training on balance performance across diverse population and disease subgroups, and elucidate the underlying biomechanical and neurological pathways.

The Spinal Cord, Not to Be Forgotten: the Final Common Path for Development, Training and Recovery of Motor Function

Research on learning, memory, and neural plasticity has long focused on the brain. However, the spinal cord also exhibits these phenomena to a remarkable degree. Following a spinal cord injury, the isolated spinal cord in vivo can adapt to the environment and benefit from training. The amount of plasticity or recovery of function following a spinal injury often depends on the age at which the injury occurs. In this overview, we discuss learning in the spinal cord, including associative conditioning, neural mechanisms, development, and applications to clinical populations. We take an integrated approach to the spinal cord, one that combines basic and experimental information about experience-dependent learning in animal models to clinical treatment of spinal cord injuries in humans. From such an approach, an important goal is to better inform therapeutic treatments for individuals with spinal cord injuries, as well as develop a more accurate and complete account of spinal cord and behavioral functioning.

Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: A systematic review

CONTEXT

Comprehensive balance measures with high clinical utility and sound psychometric properties are needed to inform the rehabilitation of individuals with spinal cord injury (SCI).

OBJECTIVE

To identify the balance measures used in the SCI population, and to evaluate their clinical utility, psychometric properties and comprehensiveness.

METHODS

Medline, PubMed, Embase, Scopus, Web of Science, and the Allied and Complementary Medicine Database were searched from the earliest record to October 19/16. Two researchers independently screened abstracts for articles including a balance measure and adults with SCI. Extracted data included participant characteristics and descriptions of balance measures. Quality was evaluated by considering study design, sampling method and adequacy of description of research participants. Clinical utility of all balance measures was evaluated. Comprehensiveness was evaluated using the modified Systems Framework for Postural Control.

RESULTS

2820 abstracts were returned and 127 articles included. Thirty-one balance measures were identified; 11 evaluated a biomechanical construct and 20 were balance scales. All balance scales had high clinical utility. The Berg Balance Scale and Functional Reach Test were valid and reliable, while the mini-BESTest was the most comprehensive.

CONCLUSION

No single measure had high clinical utility, strong psychometric properties and comprehensiveness. The mini-BESTest and/or Activity-based Balance Level Evaluation may fill this gap with further testing of their psychometric properties.

Retraining walking adaptability following incomplete spinal cord injury

Introduction

Functional walking requires the ability to modify one’s gait pattern to environmental demands and task goals—gait adaptability. Following incomplete spinal cord injury (ISCI), gait rehabilitation such as locomotor training (Basic-LT) emphasizes intense, repetitive stepping practice. Rehabilitation approaches focusing on practice of gait adaptability tasks have not been established for individuals with ISCIs but may promote recovery of higher level walking skills. The primary purpose of this case series was to describe and determine the feasibility of administering a gait adaptability retraining approach—Adapt-LT—by comparing the dose and intensity of Adapt-LT to Basic-LT.

Case presentation

Three individuals with ISCIs (>1 year, AIS C or D) completed three weeks each (15 sessions) of Basic-LT and Adapt-LT. Interventions included practice on a treadmill with body weight support and practice overground (≥30 mins total). Adapt-LT focused on speed changes, obstacle negotiation, and backward walking. Training parameters (step counts, speeds, perceived exertion) were compared and outcomes assessed pre and post interventions. Based on completion of the protocol and similarities in training parameters in the two interventions, it was feasible to administer Adapt-LT with a similar dosage and intensity as Basic-LT. Additionally, the participants demonstrated gains in walking function and balance following each training type.

Discussion

Rehabilitation that includes stepping practice with adaptability tasks is feasible for individuals with ISCIs. Further investigation is needed to determine the efficacy of Adapt-LT.

The effects of backward walking training on balance and mobility in an individual with chronic incomplete spinal cord injury: A case report

BACKGROUND/PURPOSE

Individuals with incomplete spinal cord injuries (ISCIs) commonly face persistent gait impairments. Backward walking training may be a useful rehabilitation approach, providing novel gait and balance challenges. However, little is known about the effects of this approach for individuals with ISCIs. The purpose of this case report was to describe the effects of backward walking training on strength, balance, and upright mobility in an individual with chronic ISCI.

METHODS

A 28-year-old female, 11-years post ISCI (C4, AIS D) completed 18-sessions of backward walking training on a treadmill with partial body-weight support and overground. Training emphasized stepping practice, speed, and kinematics. Outcome measures included: Lower Extremity Motor Score, Berg Balance Scale (BBS), Sensory Organization Test (SOT), 10-Meter Walk Test (10MWT), 3-meter backward walking test, Timed Up and Go (TUG), and Activities-Specific Balance Confidence (ABC) Scale.

RESULTS

Strength did not change. Improved balance was evident based on BBS (20 to 37/56) and SOT scores (27 to 40/100). Upright mobility improved based on TUG times (57 to 32.7 s), increased 10MWT speed (0.23 to 0.31 m/s), and backward gait speed (0.07 to 0.12 m/s). Additionally, self-reported balance confidence (ABC Scale) increased from 36.9% to 49.6%.

CONCLUSIONS

The results suggest that backward walking may be a beneficial rehabilitation approach; examination of the clinical efficacy is warranted.

Acute and Long-Term Effects of Multidirectional Treadmill Training on Gait and Balance in Parkinson Disease

BACKGROUND

Treadmill training has been shown to be a promising rehabilitation strategy for improving gait and balance in persons with Parkinson disease (PD). Most studies have involved only forward walking as an intervention. The effects of multidirectional treadmill (forward, backward, and left and right sideways) on gait and balance have not been reported.

OBJECTIVE

To investigate the acute and long-term effects of multidirectional treadmill training (MDTT) on gait and balance in persons with PD, and to determine the optimal training duration.

DESIGN

Single group, repeated-measures design.

SETTING

Research laboratory in a hospital.

PARTICIPANTS

Ten persons with PD (mean age 65.9 ± 7.4 years; average disease duration 3.90 ± 2.18 years).

INTERVENTIONS

MDTT was used. Participants walked forward, backward, and left and right sideways for 5-7 minutes in each direction at their fastest tolerated speed. The training was 3 days per week continuously for 8 weeks.

MAIN OUTCOME MEASUREMENTS

Gait speed, cadence, and stride length of forward, backward and sideways walks; time and number of steps to turn 360°; and the timed 5-step test and Timed Up-and-Go (TUG) test were performed after the first session of MDTT and every 2 weeks. Effect size of MDTT on each gait and balance variable was measured every 2 weeks for 8 weeks to determine the optimal training duration. Gait and balance variables after the first session of MDTT were compared to the baseline values (pre-MDTT) to study the acute effect of MDTT.

RESULTS

Stride length of forward, backward, and sideways walks improved immediately after 1 session of MDTT (P = .031, .012, and .001, respectively). The number of steps to turn and the timed 5-step test score decreased after the first session (P = .016, and .010, respectively). Six weeks of training was found to yield the largest mean effect size of all gait and balance variables. At 6 weeks of MDTT, gait speed of all walking directions (P = .001-.031), stride length of backward (P < .005) and sideways (P = .001) walks, cadence of sideways walk (P = .036), number of steps to turn (P = .014), and timed 5-step test (P = .033) improved from pre-MDTT measures.

CONCLUSIONS

MDTT immediately improved gait and balance in persons with PD. Six weeks of MDTT might be the optimal training duration to improve gait and balance in the long term.

LEVEL OF EVIDENCE

IV.

Local dynamic stability of the trunk segments and lower extremity joints during backward walking

Backward walking has become a popular training method in physical exercise and clinical rehabilitation. For the sake of safety, it is important to keep a stable gait during backward walking. However, the gait stability during backward walking was rarely studied. This study investigated the effects of walking direction on local dynamic stability of the trunk segments (neck, torso and pelvis) and lower extremity joints (hip, knee and ankle joint). The maximum Lyapunov exponents (λ(s)) of 17 young healthy male adults were calculated while they were walking under three conditions: backward walking with preferred walking speed (BW), forward walking (FW) with the same speed determined by BW, and forward walking with normal speed (FWN). We found that compared with FW, BW showed significant higher values of λ(s) in the trunk segments in vertical (VT) direction (p<0.05). The torso segment also displayed a higher value of λ(s) in anterior-posterior (AP) direction (p<0.01); Higher values of λ(s) during BW were found in the rotation (RT) motion of hip and knee joint (p=0.036, and p=0.009, respectively), and in the abduction/adduction (AB/AD) motion of knee and ankle joint (p=0.013, and p=0.021, respectively). The significant effect of walking speed was found between FW and FWN condition in VT direction (p<0.01). These findings indicate that backward walking did impair the local dynamic stability in trunk segments and lower extremity joints. Especially, the negative effect of BW on the poor gait stability in the AP direction of torso segment, and AB/AD and RT motion of knee joint should not be neglected.