Underwater treadmill training after neural-paralytic injury.
Intro to SCI and Stroke
Patients with neural-paralytic conditions, such as stroke and spinal cord injury (SCI), often experience partial or complete inability to produce a stable, voluntary gait pattern as a result of some level of paralysis [30,10,8,6,51], Additionally, in cases of partial paralysis, namely incomplete SCI and hemiparesis, affected individuals have deficiencies in balance, step initiation, muscle strength, walking speed and cardiovascular function. Improving these physiological characteristics has been shown to be associated with fewer secondary health problems and improvements in quality of life [30,6,51], While patients with SCI often experience complete or incomplete paralysis bilaterally below the level of injury (paraplegia, tetraplegia), stroke patients experience paralysis completely or predominantly on one side of the body (hemiplegia). Like SCI, this hemiplegic state has negative consequences on patient balance, leg strength, mobility, and cardiovascular performance. Due to the unilateral nature of the paralysis, balance is of paramount concern for stroke patients, as they struggle with both upper and lower body posture , Additionally, patients after stroke often exhibit hemiplegic gait during which hip hike and circumduction of the affected leg is produced to compensate for drop foot abnormality, thus increasing the single leg stance phase, decreasing stability, and increasing likelihood of falls [50,16].
Overground Gait Therapies
Over the past two decades, the popularity of body weight supported treadmill walking and electrical stimulation enhanced gait training has increased. Of the therapies utilizing partial body weight supported walking, several additional locomotor aids are utilized to help accomplish a repetitive stepping pattern. These include the use of manual assistance from trainers or therapists, treadmills, neuromuscular electrical stimulation, or the use of robotics. Research in gait restoration has shown that the use of body weight supported treadmill training can produce significant improvements in lower limb strength, walking distance, walking speed, and walking duration in individuals with both SCI and stroke [29,7,31,49]. However this activity also typically necessitates the use of a body harness and straps to aid in body weight support. Recent research has found that the use of such harnesses can adversely affect both cardiovascular performance and range of motion . Additionally, the use of body weight supporting harnesses can produce maladaptive and abnormal muscle recruitment patterns as well as being uncomfortable to the patient and increasing the risk of skin damage . Also to be considered is the relatively high labor intensive nature of body weight supported gait therapies utilizing manual assistance in limb movement, and the subsequent monetary costs to both the patient and the rehabilitation facility. A recent inter-institutional perspective on activity-based restorative therapies reported that the [greater than or equal to] 3 to 1 ratio of therapist to patient required to provide body weight supported treadmill training activities is beyond the staffing capability of some rehabilitation centers . Gait restoration therapies utilizing robotics and electrical stimulation have shown improvements in many gait characteristics, however limitations are still seen in the ability of these individuals to self-initiate a voluntary gait pattern that limits the ability of participants to carry-over gains to non-facilitated ambulation [41,21,15].
Benefits of Aquatic Gait Therapy.
Research in aquatic gait therapy for post-stroke and SCI individuals has shown improvements in balance, leg strength, spasticity, walking performance, pulmonary function, cardiovascular response, and quality of life [54,28,17,34,43]. Similar benefits of aquatic therapies have also been shown for individuals with other severe neurological impairments such as cerebral palsy  and multiple sclerosis . The use of an aquatic environment can provide additional benefits to the rehabilitation process compared to over ground gait therapies. The easily controlled nature of an aquatic environment aids in the therapeutic process by utilizing many of the natural properties of water itself. Of most importance is the provision of the reduced gravitational effects and body weight support provided for the patient. This can reduce or eliminate the reliance on restrictive body harnesses and straps for body weight support. Additionally, and of particular benefit, is the often overlooked fact that an aquatic environment not only lessens the gravitational pull on the patient's entire body, but also on the lower limbs reducing gravitational pull on impaired legs fostering movement. When using harnesses in overground gait therapies, only the weight of the core body is supported, leaving the full gravitational pull remaining on the lower limbs of the paralyzed patient. Employing this natural gravity reduction provided by an aquatic environment can allow for the movement of a limb with less needed strength, possibly allowing a patient to voluntarily move a limb when the ability may not have been present under the effects of full gravity.
Gait therapy that takes place in water also takes advantage of several other aquatic properties that aid in the rehabilitation process. The hydrostatic pressure provided in an aquatic environment has been shown to aid in venous return and cardiac output . This is important as individuals with paralysis often exhibit blood pooling in the lower-extremities as a result of decreased muscle pumping and diminished sympathetic tone . Additionally, both temperature and force provided by the water delivers stimulation to the skin regardless of sensation due to localized paralysis. The thermodynamic properties of the warm water used during therapy help with muscle spasticity and muscle tonicity,  and the viscous resistance of the water is dependent on the velocity of the moving limb . Additionally, aquatic exercise has been shown to aid in regaining gait symmetry, muscle strength, energy efficiency, and endurance [2,14]. Recent gait rehabilitation research has focused on combining a therapeutic aquatic environment with the therapeutic properties of treadmill based gait training. In the limited amount of published literature, underwater treadmill training (UTT) has demonstrated the ability to enhance balance, leg strength, gait performance and cardiovascular performance of individuals after neurological trauma [45,47,35,24,52,19].
UTT and SCI
Stevens et al.  tested the effects of an 8 week long, thrice weekly UTT protocol on leg strength, gait performance, and balance in 11 individuals with SCI. Participant body weight support provided by the water ranged from 29-47% and was held consistent for each of the participants. Each participant performed 3 walking bouts per UTT session (9/week) at a personalized walking speed, and was allowed sufficient time for rest. Walking speed and walking time were systematically increased over the course of the study. The participants included individuals with L2-C2 SCI, and an American Spinal Cord Injury Impairment Scale rating C-D. Compared to pre-test values, individuals that completed the UTT protocol averaged statistically significant improvements in leg strength, balance, and 6-minute walk distance of 57%, 39%, and 82% respectively. Additionally, these participants improved in preferred walking speed, rapid walking speed, and daily step average by 34%, 61%, and 121% respectively. Leg strength and preferred walking speed are especially important due to the correlation of both variables with the daily step activity of individuals with SCI . Considering the known deleterious effects of a sedentary lifestyle, the improvements in leg strength and preferred walking speed may have additional effects on preventing secondary health consequences concomitant with impaired mobility.
Stevens et al.  also examined the effects of the same 8 weeks protocol of 3 times per week UTT on the heart rate response of individuals with SCI. Chest-worn heart rate monitors were used to determine the heart rates of each participant during the final 15 seconds of each walk. After the 8-week protocol, results showed a statistically significant reduction in submaximal heart rate during weeks 2-3, 4-5, and 6-7 of 7%, 14%, and 17% respectively despite the systematically increasing exercise volume.
UTT and Stroke
Similar to SCI, relatively few studies have been performed using UTT as a gait restorative modality for post-stroke individuals. Park et al.  investigated changes in balance for post-stroke individuals completing an UTT protocol. In this study, 22 stroke patients were divided evenly into two groups. Both groups received 4 weeks of 5 times weekly general rehabilitation care with a physical therapist. In addition to the general rehabilitation protocol, one group also completed a 5 times weekly UTT protocol over the same 4 weeks. Both groups exhibited a statistically significant decrease in mediolateral, anteroposterior, and total postural sway, though no statistically significant difference was found between the groups. However, it should be noted that in each of these 3 balance characteristics, the group that completed the additional UTT protocol averaged as well as or better than the control group. For example, those that completed the additional UTT experience a 6% greater decrease in anteroposterior postural sway, and 3% greater decrease in overall postural sway. These findings are supported by Jung et al.  who showed UTT may improve gait symmetry and weight bearing during the stance phase of the gait cycle, however these positive trends were also not statistically significant. However, do to several dissimilarities to other UTT protocols, this study will not be included in Table 1.
Lee et al.  further studied the effects of UTT and lower limb strength examined the differences in peak knee torque after UTT compared with overground treadmill training. In this study, 32 post-stroke patients were evenly matched and divided into 2 groups, each completing 6 weeks of thrice weekly UTT or the same protocol on an overground treadmill. Training for both groups produced significant increases in the peak torque of the knee at 60[degrees]/sec during knee flexion and extension. Additionally, stroke patients in this study that completed the UTT protocol showed significantly greater improvements in peak torque during knee extension compared to patients that performed the same protocol on an overground treadmill. This study further exemplifies that UTT may provide additional benefits over land-based therapies for stroke patients displaying lower-limb weakness.
While few studies have examined the cardiovascular effects of overground treadmill walking in patients with stroke, only two have compared these effects between overground and underwater gait therapies. Yoo et al.  compared the cardiovascular responses of 10 stroke patients that completed two separate sessions of both UTT and land-based treadmill walking. Results from this study showed that blood pressure and heart rate pressure product (systolic blood pressure x heart rate) increased for both aquatic and overground treadmill walking. However, UTT produced significantly lower average maximum increases in heart rate, blood pressure, and rate pressure product compared to overground treadmill walking. Further research by Jung et al.  examining the cardiorespiratory effects of UTT compared to overground treadmill walking included 8 post-stroke and 8 healthy age-matched individuals each completing 8-minute walks on both an overground and underwater treadmill. Results showed that training on an underwater treadmill produced lower mean values for V[O.sub.2], VC[O.sub.2], and overall energy expenditure, resulting in significantly less metabolic cost to the post-stroke individual compared to walking on an overground treadmill. Previous research however, determined that the metabolic costs of walking on an underwater treadmill are highly variable, and dependent on water depth, temperature, and walking speed .
The considerable limitations in physical activity and mobility for patients after both stroke and SCI have been widely shown to lead to decreased quality of life, depression, muscle atrophy, obesity, osteoporosis, urinary tract infections, skin breakdown, as well as multiple other cardiovascular and respiratory comorbidities due to a relatively sedentary lifestyle [32,27,38,39,20,12]. While several previous studies have been performed examining the many benefits of UTT in the healthy [25,26], athletic [4,44], elderly [43,9,42], obese [13,23], and chronically diseased populations [5,40], a small but growing number of studies have examined its rehabilitation benefits for individuals with paralytic conditions [45,47,35,24,52,19]. With the added safety and conducive therapeutic environment of an aquatic setting, UTT combines the benefits of decreased gravity and body weight support with the exercise capabilities of a land-based treadmill.
This review presents research performed on the gait restorative effects of UTT for adults with neural-paralytic injuries, including SCI and stroke. Individuals with SCI and stroke exhibit various degrees of imbalance, muscle weakness, decreased cardiovascular performance, and mobility impairment. The therapeutic aquatic environment is a helpful medium for moderate exercise due to its natural gravity reducing, resistive, and thermodynamic properties which have been shown to both provide mobility assistance and aid in muscle strengthening.
While a moderate amount of documented research on aquatic therapies for patients with neural-paralytic injuries exists, there are a limited number of studies specifically testing the efficacy of UTT exercise in these individuals. No review to date has been performed examining the effects of this specific therapeutic exercise modality in individuals with chronic neurological injury. The common theme among all reviewed studies was the statistically significant improvement of one or more physiological and/or functional variables as a result of UTT in each study. Both studies testing the effects of UTT in individuals with SCI found statistically significant improvements in all of the tested primary outcomes, [45,47] however there were no commonly studied variables between the two studies. One of these studies found significant improvements in all gait parameters including preferred and maximum gait speed, step length, as well as significant improvements in balance and walking endurance . The other study examined the effects of UTT on cardiovascular performance and found a statistically significant decrease in submaximal heart rate despite increasing exercise volume . Both of these studies utilized a 3 sessions per week protocol, maintained over 8 weeks total and included subjects with L2-C2, AISCII scale C-D incomplete spinal cord injuries [29,30]. These two studies did not include follow-up evaluations, so despite short-term improvements, no long-term therapeutic outcomes can be reported.
The studies testing the effects of UTT on post-stroke individuals examined exercise sessions held at 5 times per week for 4 weeks,  3 times per week for 6 weeks,  single 20 minute sessions,  and single 8 minute sessions . Two of these studies compared the use of UTT with other gait therapy modalities including general physiotherapy,  and overground treadmill walking . Park et al. found statistically significant improvements in postural sway both in a group that received UTT and conventional physiotherapy 5x/wk each for 4 weeks and a control group that received only 5x/wk conventional physiotherapy . While both groups showed similarly significant results, it should be noted that the group that completed the additional UTT sessions showed greater decreases in anterolateral and overall sway compared to the group that only completed the conventional physiotherapy protocol . The results of this study suggest that including additional exercise on an underwater treadmill for post-stroke patients may help improve gait balance. Lee et al. found statistically significant improvements in peak knee torque in both groups completing either UTT or overground treadmill exercise protocols performed 3 times per week, for 6 weeks . Interestingly, the group that completed the UTT protocol exhibited statistically greater improvements in peak knee torque than the group that completed the same overground treadmill protocol. These results suggest that the added limb resistance provided by an aquatic environment may aid in improving lower-limb muscle strength during treadmill exercises.
Yoo et al.  and Jung et al.  tested the short-term cardiorespiratory effects of UTT on post-stroke individuals after a single exercise session. Yoo et al. utilized a crossover study design as post-stroke subjects completed single sessions of both UTT and overground treadmill training for 20 minutes each . Results showed that while both UTT and overground treadmill training produced increases in blood pressure and heart rate pressure product, lower average maximum heart rate, blood pressure and heart rate pressure product resulted from UTT. These results suggest that UTT may be a safe alternative for post-stroke individuals considering the decrease cardiopulmonary fitness of these individuals. With a similar crossover design study, Jung et al.  testing single 8-minute sessions of both UTT and overground treadmill training for post-stroke and healthy individuals found that training on an underwater treadmill resulted in significantly less metabolic cost than walking on an overground treadmill for post-stroke individuals. While these results may further suggest a greater benefit for cardiopulmonary compromised post-stroke individuals, previous research shows that the metabolic costs of UTT are highly variable and may be dependent on water height and temperature .
There are considerable limitations to this review. This review was limited to 6 studies, 2 of which included 10 or less subjects with neural-paralytic injury. Due to both the paucity of both performed studies and subjects there within, the results of the studies cannot be generalized to the greater populations of adults with neural-paralytic injury. Of additional limitation to this review is the lack of uniformity of the utilized exercise protocols, and the lack of follow-up assessments. These limitations make it difficult to formulate conclusions based on these study results alone.
While the limited number of studies performed does not allow for specific statements concerning the benefits of UTT for individuals with neural-paralytic injury, the consistent positive results of these studies support the idea that UTT may be a beneficial addition or alternative to traditional rehabilitation. The results reported by the studies in this review show that UTT may be a useful rehabilitation modality for improving cardiovascular health, mobility, balance, and strength for individuals with neural-paralytic conditions. Further studies examining the efficacy of UTT for individuals with neural-paralytic injury is needed to justify integration of UTT protocols into conventional rehabilitation care plans.
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James D. Dolbow
225 Brantley Acres Rd
Speedwell, Tennessee 37870
James D. Dolbow, BS, BA (1), John Gassier, PT, DPT, MS, GCS (2), David R. Dolbow, PhD, DPT, RKT (3), and Sandra L. Stevens, PhD (4)
(1) School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, Tennessee;
(2) DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate Tennessee;
(3) School of Kinesiology, University of Southern Mississippi, Hattiesburg, Mississippi;
(4) Department of Health and Human Performance, Middle Tennessee State University, Murfreesboro, Tennessee
Table 1 UTT studies in individuals with SCI and stroke Study Exercise Protocol Participants Stevens UTT: 3x/wk, 8wks n=11, L2-C2 iSCI et al.  AISCII scale C-D Stevens UTT: 3x/wk, 8wks n=11, L2-C2 iSCI et al.  AISCII scale C-D Park et Gen. Physiotherapy + n=11, 6-24 Months al.  UTT (Exp. Group) Post-Hemiplegic 5x/wk each post-stroke (10 sessions/wk), 4 wks total Gen. Physiotherapy n=11, 6-24 Months (Control) 5x/wk Post-stroke 4 wks total Lee UTT (Exp. Group) n=16, 7.9 months et al.  3x/wk, 6wks post-stroke Overground n=16, 8.0 months Treadmill (Control) post-stroke 3x/wk, 6wks. Yoo UTT (single 20 min n=10, ? months et al.  session) post-stroke Overground (Crossover design) Treadmill (single 20 min session) Jung UTT (single n=8 (Average 5.6 et al.  8 min walk) yrs post-stroke) n=8 (Healthy; Overground Treadmill Average age 56) (single 8 min walk) (Crossover design) Study Results (Stat. Sign. In Bold) Stevens Inc. Leg Strength (57%)# et al.  Inc. Balance (39%)# Inc. 6MWT (En du ran ce) (82%)# Inc. Pref. Walking Speed (34%)# Inc. Rapid Walking Speed (61%)# Inc. Daily Step Average (121%)# Stevens Dec. Submax. Heart Rate: (17%)# et al.  (Despite Inc. in Exercise Volume)# Park et Dec. Mediolateral,# al.  Anteroposterior, and Total# Postural Sway# Dec. Mediolateral,# Anteroposterior, and total# Postural Sway# Lee Inc. Peak Torque at 60[degrees]/sec# et al.  during knee flexion and extension# * Sign. Greater Improvement# than Control Group# Inc. Peak Torque at 60[degrees]/sec# during knee flexion and extension# Yoo Both Exercise: et al.  Inc. Blood Pressure Inc. Heart Rate Pressure Product * Lower Ave. Maximum# Increases in Heart Rate, Blood# Pressure, and Rate Pressure# Product in UTT group than Control# Jung Stroke Group: et al.  Mean V[O.sub.2] dec. (39%) Mean VC[O.sub.2] dec. (42%) Mean Energy Expend. dec (40%) Healthy Group: Mean V[O.sub.2] dec. (21%) Mean VC[O.sub.2] dec. (30%) Mean Energy Expend. dec (25%) * significantly less metabolic cost# to the post-stroke individuals# during UTT compared to walking# on an overground treadmill.# Note: Bold are indicated with #.
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|Title Annotation:||Clinician's Corner|
|Author:||Dolbow, James D.; Gassler, John; Dolbow, David R.; Stevens, Sandra L.|
|Publication:||Clinical Kinesiology: Journal of the American Kinesiotherapy Association|
|Date:||Mar 22, 2016|
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