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Three Part Question

In [adults with Traumatic Brain Injury] is [body weight supported treadmill training superior to traditional physical therapy] at [improving gait]?

Clinical Scenario

A patient who has suffered a traumatic brain injury (TBI) is admitted to your rehabilitation hospital. Other therapists have used body weight supported treadmill training (BWSTT) with patients post stroke. What evidence supports the use of BWSTT in a TBI population?

Search Strategy

Search of MEDLINE, PEDro, CINHAL, Pubmed and Cochrane Library with key words 'Body weight supported treadmill training', 'TBI', 'partial body weight bearing gait training' returned 2 RCT's
• Inclusion: Studies that investigated the use of body weight supported treadmill training intervention in a population of individuals with traumatic brain injury (TBI) with comparison to conventional physical therapy and at least one outcome related to a gait parameter.
• Exclusion: Single subject studies, no comparison intervention

Search Outcome

(2) relevant studies were located and categorised as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 1998)
Study Design/ Methodology of Articles Retrieved
Individual RCT's of good quality 1b 2
Brown et al (2005); Wilson et al (2006)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Brown TH, Mount J, Rouland B, Kautz K, Barnes R, Kim J. 2005 United States	20 participants (14 men and 6 women) from 20-57 years old with diagnosis of TBI, time since injury varied from 7-23 years.	Randomized controlled trial with two groups (treatment group and control group) rated by 2 independent reviewers regarding gait characteristics, subjects were paired with respect to motor presentation.	Velocity by determining the distance travelled between foot strikes divided by time	No difference between groups	No blinding of assessors and no power anlaysis done
			Step width	No difference
			Step length differential	No difference between groups
			Functional Reach	No difference between groups
			Timed up and Go(TUG	No difference between gorups
			Functional Ambulation Category	No difference between gorups
Wilson DJ, Powell M, Gorham J, Childers M 2006 United States	40 adults with TBI were recruited from the 2 rehab hospitals, recruitment strategy unknown, 35 subjects were men and 3 were women. Mean age was 29.6 with a range from 17 years old to 47. Date since injury ranged from 1 year to 7.5 years.	Randomized controlled trial	Functional Independence Measure (FIM)	Both groups improved, no differences between groups	No blinding of researchers
			Functional Assessment Measure (FAM)	Both improved, no differences between groups
			Standing Balance Scale (SBC)	Both groups improved, no difference between groups
			Functional Ambulation Category (FAC)	both improved, no differences between groups
			Rivermead Mobility Index (RMI)	both improved, no differences between groups
			Gross Motor Subscale (GMS)	both improved, no differences between groupss

Comment(s)

Commercially available body weight supported systems are gaining popularity in physical therapy to aid in gait retraining. They have been used in different patient populations such as spinal cord injury and stroke. Research has shown positive results in the stroke population, but in this review, it was not shown to be superior to conventional therapy in the TBI population. The systems are expensive and require extensive manpower to operate. There is a paucity of literature regarding the effectiveness in TBI and of the studies available, no difference has been found between the body weight supported groups and the conventional physical therapy groups. More studies are warranted before clinics and hospitals should invest in this therapy modality.

Clinical Bottom Line

BWSTT does not appear to be more effective than conventional physical therapy in improving gait and function in patients with TBI.

References

1. Brown TH, Mount J, Rouland B, Kautz K, Barnes R, Kim J. Body weight-supported treadmill training versus conventional gait training for people with chronic traumatic brain injury J Head Trauma Rehabil 2005; 20 (5): 402-415.
2. Wilson DJ, Powell M, Gorham J, Childers M. Ambulation training with and without partial weightbearing after traumatic brain injury: results of a randomized controlled trial Am J Phys Med Rehabil 2006 85 (1): 68-74