Weight-supported treadmill vs over-ground training for walking after acute incomplete SCI

To the Editor: Dobkin et al.1 seemingly failed to detect the superiority of training on the treadmill in acute spinal cord injured (SCI) patients. This outcome is expected considering the study design. In contrast to our controlled trial,2 both the control and the study groups were given the same large amount of specific therapy (i.e., training of upright walking). Without a proper control group, it cannot be determined whether the two procedures were better than no therapy at all. In Dobkin et al.’s “pre-trial” group3 (collected in the same participating clinics before onset of the trial), only 58% of the initial ASIA C and D patients reached independent walking (from table 3)3 but 92% in the trial control (and experimental) group.1 This highlights the significant therapeutic effect of intensive walking over ground and on the treadmill. These data also confirm the superiority of LB therapy we found with 53% comparable success of conventional but 96% of LB therapy (8/15 but 29/30 spastic patients, figure 3).2 The notion concerning our motor score1 is obsolete since the maximum for both limbs is 80 (not 50), and distance to injury is larger. Our data for the first time demonstrated that aggressive task-related training, i.e., intensive upright walking with well defined rules on the treadmill (Laufband-LB-therapy, see www. meb.uni-bonn.de/wernig) or over ground (patient Z), is successful. Dobkin et al.’s study design is not practical for everyday therapy. Previous praxis found treadmill speeds between 0.1 and some 2.0 km/h effective,2 Dobkin et al. used 3.8 km/h and above as adequate without showing an advantage. To the contrary, the robot-like moving of the limbs might hinder the patient’s active contribution and jeopardize activity-related learning.5 With high speeds—as with over-ground walking nonambulating ASIA B and C patients—three therapists are needed to handle a single patient instead of one to two.2 An additional therapist may be available in well-funded trials but difficult in real-life clinical settings. The predictable consequence is a decline in compliance of patients, therapists, and financial officers.