COCHRANE CORNER
Locomotor Training for Walking After Spinal Cord Injury Nerys Brick
REVIEW QUESTION: What are the effects of locomotor training on improvement in walking in people with traumatic spinal cord injury (SCI)?
Nursing Implications The annual incidence of traumatic SCIs in industrialized nations is approximately 15 to 40 cases per million populations. The extent of the disability resulting from SCI varies greatly and depends on the severity of the injury, the segment of the spinal cord at which the injury occurs, and which nerve fibers are damaged. Many studies have suggested that locomotor training (overground gait training, hybrid strategies using partial bodyweight support, and functional electrical stimulation) after SCI may improve the overall rehabilitation of the patient. This is of relevance to nursing care as it is important to assess the effects and acceptability of locomotor training after SCI.
Study Characteristics This is a summary of a Cochrane systematic review that included 5 randomized controlled trials (RCTs) involving 309 people. The RCTs were parallel-group (n = 4) or cross-over design (n = 1). Analysis only occurred for the first period (precrossover) for the crossover trial. Participants were of any age and gender, with traumatic SCI. The study included people with any level of traumatic incomplete lesion, regardless of the duration of illness or level of initial walking ability. The intervention of interest was locomotor training (as described previously). This could be compared with any other exercise or with a no-treatment control group. The primary outcomes for this review were as follows: • Speed of walking: measured by the 10-m or 15-m walking speed. • Walking capacity: defined as the capacity to cover distance in a defined time. Secondary outcomes included the following: • Level of independence in walking • Safety of exercise • Rate of dropouts or withdrawals The duration of the training intervention ranged from 4 weeks (one study) to 8 weeks (one study) to 12 weeks © 2014 by National Association of Orthopaedic Nurses
(two studies) and the maximum length of follow-up was 6 months (one study). There were methodological differences in the mechanism of randomization and allocation concealment methods used, blinding of primary outcomes, and the use of intention-to-treat analysis.
Summary of Key Evidence BODYWEIGHT-SUPPORTED TREADMILL TRAINING VERSUS ALL OTHER TRAINING APPROACHES • Four trials (274 participants) showed the use of bodyweight-supported treadmill training as locomotor training did not increase walking velocity compared with all other training approaches. Three trials (234 participants) demonstrated that bodyweight-supported treadmill training did not significantly increase walking capacity compared with all other training approaches. • One trial (146 participants) showed that bodyweight-supported treadmill training did not increase the chances of walking independently compared with all other training approaches. • Five trials (309 participants) reported the rates of adverse events as between 0% (three studies) and 4% (two studies). Bodyweight-supported treadmill training did not significantly increase the risk of participants having an adverse event during training compared with all other training approaches. • Five trials (309 participants) reported dropout rates (from any cause) between 0% and 20%. Bodyweightsupported treadmill training did not significantly increase the risk of participants dropping out compared with all other training approaches.
ROBOTIC-ASSISTED LOCOMOTOR TRAINING VERSUS ALL OTHER TRAINING APPROACHES • One study (74 participants) demonstrated that robotic-assisted locomotor training did not significantly increase walking velocity compared with all other training approaches. Nerys Brick, MSc (Renal), BSc (Hons), PGCLT(HE) NMC, RN, member of the Cochrane Nursing Care Field (CNCF), Canterbury Christ Church University, Canterbury, Kent CT1 1QU, United Kingdom. The author has disclosed no conflicts of interest. DOI: 10.1097/NOR.0000000000000037 Orthopaedic Nursing
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• One trial (74 participants) did indicate that people with SCI who used robotic-assisted locomotor training had significantly reduced walking capacity at final follow-up [pooled mean difference (fixed-effect model) 10.29 m less ability to walk compared with the control group (95% confidence intervals: 0.15–20.43)]. • None of the included studies investigated independence in walking. • Two trials (109 participants) showed that the use of robotic-assisted locomotor training did not significantly increase the risk of participants having an adverse event during training. • Two trials (109 participants) indicated that the use of robotic-assisted locomotor training did not significantly increase the risk of participants dropping out.
FUNCTIONAL ELECTRICAL STIMULATION AND BODYWEIGHT-SUPPORTED TREADMILL TRAINING VERSUS ALL OTHER TRAINING APPROACHES • No significant differences in the following outcomes were demonstrated when bodyweight-supported treadmill training in combination with functional electrical stimulation was compared with all other training approaches: walking speed (two trials, 88 participants), walking capacity (one trial, 74 participants), incidence of adverse events (two trials, 88 participants), and dropouts (two trials, 88 participants).
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• None of the included studies investigated independence in walking.
Best Practice Recommendations Currently there is insufficient evidence to conclude that any one approach to locomotor training is more effective than another for improving walking function in people with SCI. This was mostly due to the small number of trials, the small sample sizes of the included trials and the heterogeneity of study design, participants, and interventions. There is a need for further multicentre RCTs with larger sample sizes to be undertaken to evaluate the efficacy of different locomotor training approaches, and especially robotic-locomotor training, for people with SCI. Further research should define subpopulations of people with SCI to find out who is benefiting most from which locomotor training approaches and at which stage of recovery. Furthermore, it is important that further research describes the complete intervention strategy rather than just the modality of treatment, progression of therapy, and the role of the therapist.
BIBLIOGRAPHY Mehrholz, J., Kugler, J., & Pohl, M. (2012). Locomotor training for walking after spinal cord injury. Cochrane Database of Systematic Reviews, 11, Art. No.: CD006676. Doi:10.1002/14651858.CD006676.pub3. Retrieved from http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD006676.pub3/abstract
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
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Locomotor Training for Walking After Spinal Cord Injury Nerys Brick
REVIEW QUESTION: What are the effects of locomotor training on improvement in walking in people with traumatic spinal cord injury (SCI)?
Nursing Implications The annual incidence of traumatic SCIs in industrialized nations is approximately 15 to 40 cases per million populations. The extent of the disability resulting from SCI varies greatly and depends on the severity of the injury, the segment of the spinal cord at which the injury occurs, and which nerve fibers are damaged. Many studies have suggested that locomotor training (overground gait training, hybrid strategies using partial bodyweight support, and functional electrical stimulation) after SCI may improve the overall rehabilitation of the patient. This is of relevance to nursing care as it is important to assess the effects and acceptability of locomotor training after SCI.
Study Characteristics This is a summary of a Cochrane systematic review that included 5 randomized controlled trials (RCTs) involving 309 people. The RCTs were parallel-group (n = 4) or cross-over design (n = 1). Analysis only occurred for the first period (precrossover) for the crossover trial. Participants were of any age and gender, with traumatic SCI. The study included people with any level of traumatic incomplete lesion, regardless of the duration of illness or level of initial walking ability. The intervention of interest was locomotor training (as described previously). This could be compared with any other exercise or with a no-treatment control group. The primary outcomes for this review were as follows: • Speed of walking: measured by the 10-m or 15-m walking speed. • Walking capacity: defined as the capacity to cover distance in a defined time. Secondary outcomes included the following: • Level of independence in walking • Safety of exercise • Rate of dropouts or withdrawals The duration of the training intervention ranged from 4 weeks (one study) to 8 weeks (one study) to 12 weeks © 2014 by National Association of Orthopaedic Nurses
(two studies) and the maximum length of follow-up was 6 months (one study). There were methodological differences in the mechanism of randomization and allocation concealment methods used, blinding of primary outcomes, and the use of intention-to-treat analysis.
Summary of Key Evidence BODYWEIGHT-SUPPORTED TREADMILL TRAINING VERSUS ALL OTHER TRAINING APPROACHES • Four trials (274 participants) showed the use of bodyweight-supported treadmill training as locomotor training did not increase walking velocity compared with all other training approaches. Three trials (234 participants) demonstrated that bodyweight-supported treadmill training did not significantly increase walking capacity compared with all other training approaches. • One trial (146 participants) showed that bodyweight-supported treadmill training did not increase the chances of walking independently compared with all other training approaches. • Five trials (309 participants) reported the rates of adverse events as between 0% (three studies) and 4% (two studies). Bodyweight-supported treadmill training did not significantly increase the risk of participants having an adverse event during training compared with all other training approaches. • Five trials (309 participants) reported dropout rates (from any cause) between 0% and 20%. Bodyweightsupported treadmill training did not significantly increase the risk of participants dropping out compared with all other training approaches.
ROBOTIC-ASSISTED LOCOMOTOR TRAINING VERSUS ALL OTHER TRAINING APPROACHES • One study (74 participants) demonstrated that robotic-assisted locomotor training did not significantly increase walking velocity compared with all other training approaches. Nerys Brick, MSc (Renal), BSc (Hons), PGCLT(HE) NMC, RN, member of the Cochrane Nursing Care Field (CNCF), Canterbury Christ Church University, Canterbury, Kent CT1 1QU, United Kingdom. The author has disclosed no conflicts of interest. DOI: 10.1097/NOR.0000000000000037 Orthopaedic Nursing
•
March/April 2014
•
Volume 33
•
Number 2
115
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
ONJ669R1.indd 115
3/13/14 8:58 AM
• One trial (74 participants) did indicate that people with SCI who used robotic-assisted locomotor training had significantly reduced walking capacity at final follow-up [pooled mean difference (fixed-effect model) 10.29 m less ability to walk compared with the control group (95% confidence intervals: 0.15–20.43)]. • None of the included studies investigated independence in walking. • Two trials (109 participants) showed that the use of robotic-assisted locomotor training did not significantly increase the risk of participants having an adverse event during training. • Two trials (109 participants) indicated that the use of robotic-assisted locomotor training did not significantly increase the risk of participants dropping out.
FUNCTIONAL ELECTRICAL STIMULATION AND BODYWEIGHT-SUPPORTED TREADMILL TRAINING VERSUS ALL OTHER TRAINING APPROACHES • No significant differences in the following outcomes were demonstrated when bodyweight-supported treadmill training in combination with functional electrical stimulation was compared with all other training approaches: walking speed (two trials, 88 participants), walking capacity (one trial, 74 participants), incidence of adverse events (two trials, 88 participants), and dropouts (two trials, 88 participants).
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Orthopaedic Nursing
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March/April 2014
•
Volume 33
•
Number 2
• None of the included studies investigated independence in walking.
Best Practice Recommendations Currently there is insufficient evidence to conclude that any one approach to locomotor training is more effective than another for improving walking function in people with SCI. This was mostly due to the small number of trials, the small sample sizes of the included trials and the heterogeneity of study design, participants, and interventions. There is a need for further multicentre RCTs with larger sample sizes to be undertaken to evaluate the efficacy of different locomotor training approaches, and especially robotic-locomotor training, for people with SCI. Further research should define subpopulations of people with SCI to find out who is benefiting most from which locomotor training approaches and at which stage of recovery. Furthermore, it is important that further research describes the complete intervention strategy rather than just the modality of treatment, progression of therapy, and the role of the therapist.
BIBLIOGRAPHY Mehrholz, J., Kugler, J., & Pohl, M. (2012). Locomotor training for walking after spinal cord injury. Cochrane Database of Systematic Reviews, 11, Art. No.: CD006676. Doi:10.1002/14651858.CD006676.pub3. Retrieved from http://onlinelibrary.wiley.com/ doi/10.1002/14651858.CD006676.pub3/abstract
© 2014 by National Association of Orthopaedic Nurses
Copyright © 2014 by National Association of Orthopaedic Nurses. Unauthorized reproduction of this article is prohibited.
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