Laufband locomotion with body weight support improved walking in persons with severe spinal cord injuries

Abstract

After low transection of the spinal cord mammalian quadrupeds can be trained to walk on a driven surface indicating that coordinating neuronal circuits persist in the spinal cord segments caudal to the lesion. We trained 8 persons with incomplete spinal cord lesion on a Laufband (driven treadmill) for 1! to 7 months (5 days a week, 30-60 minutes daily) starting 5 to 20 months after injury and found significant improvement in the utilisation of the paralysed limbs during locomotion. Locomotion is described in one additional patient who had trained independently on parallel bars for several years.Five patients had complete functional paralysis in one lower limb when tested in a resting position. In EMG recordings voluntary activity (ie activity induced upon command) was absent or residual in the main flexor and extensor muscles of this limb. In contrast, during locomotion flexion and extension movements were performed and phasic EMG activity was present. In these 5 patients, and in all others reported here, skin sensibility and proprioception are preserved to different degrees in all limbs. In the course of locomotive training of 4 severely paralysed patients the initially habituating flexion reflexes could be entrained in the paralysed limbs as was the case for knee extension during stance. Sub sequently, initial body weight support (BWS) of 40% could be reduced to 0%. The distance covered on the Laufband (0-104 m in the first week) increased significantly (200-410 m) in the last week of training as did speed (0-10 to 14-23 m/min). More importantly, this training subsequently allowed patients to walk on a static surface for 100 to 200 meters while voluntary activity remained absent in the paralysed limb when tested at rest.Similar progress was achieved in the 4 less severely paralysed patients. The one patient who had trained independently on parallel bars for several years is described walking on a static surface for 40 meters with the help of a walker, though he had one completely and one near completely paralysed lower limb.It appears that bipedal stepping with consequent knee extension and stabilisa tion can be taught after unilateral complete or near complete loss of voluntary activity, suggesting the manifestation of complex reflex motor patterns at the spinal level.

Maintenance of locomotor abilities following Laufband (treadmill) therapy in para- and tetraplegic persons: follow-up studies

“…An even more striking discrepancy, assessed functionally and electromyographically, was observed in a patient with zero voluntary activity in one limb and a total value of 2 in the other 5 (patient Z). Motor automatisms seem to be evoked when applying`rules of spinal locomotion' (see Wernig and MuÈ ller, 5 Wernig et al 6 and Grillner 13 for reviews) and might thus be of spinal origin, though in primates supraspinal in¯uences might be involved as well. One of these features, limb loading during stance, has recently been shown to dramatically enhance motor output from muscles of this limb in persons with complete (and incomplete) spinal cord transections, supporting the idea that the isolated spinal cord correctly interpretes proprioceptive a erent information in the sense of maintaining upright body position.…”

“…One of these features, limb loading during stance, has recently been shown to dramatically enhance motor output from muscles of this limb in persons with complete (and incomplete) spinal cord transections, supporting the idea that the isolated spinal cord correctly interpretes proprioceptive a erent information in the sense of maintaining upright body position. 9,14 Applying these rules, elements of stepping on the treadmill short of complete step cycles, could recently be evoked in a 13-year old girl completely paralysed below spinal segment Th 6 12 (detailed manuscript in preparation; see also Wernig and MuÈ ller 5 and Wernig et al 6 for further reports on elements of stepping after complete spinal cord transection, and Dobkin et al 16 and Dietz et al 17 for phasic and alternating¯exor and extensor muscle activity during aided stepping).…”

“…In man after complete spinal transection, only elements of stepping but no full step cycles may be evoked on the treadmill. 5,6,12 Improvement of stepping in spinal cord injured cats and monkeys was achieved by intensive treadmill-stepping; 1,2 other training regimes such as daily standing were not successful and even signi®cantly worsened stepping capabilities in cats. 15,18 Translated into strategies for motor rehabilitation of spinal cord injured patients, these observations imply that relearning of walking can be done only by intensive exercise of upright walking.…”

Walking index for spinal cord injury (WISCI): criterion validation

“…9 Recovery of locomotion, therefore, has become a primary goal of both pharmacological and rehabilitative treatment. In the last decade, pharmacological treatment 10 and rehabilitative approaches 11,12 have been initiated to enhance locomotion capacity of SCI patients. Basic science advances 13 in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials.…”

Does the neuronal plasticity exist in elderly patients? report of an unusual clinical case

“…2 Wernig's patient with one completely and one near completely paralysed lower limb is shown walking with the help of a walker, notwithstanding very little voluntary activity. 7 That was possible by applying the observations on activity-related 'learning' of the isolated spinal cord and the 'rules of spinal locomotion' of the lower vertebrates in humans. 8 This principle, utilised in the Laufband therapy, involves both a complex motor reflex activation as the main source for the improvements in locomotion and better utilisation of the remaining muscle function, if present.…”