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High-Intensity Variable Stepping Training in Patients With Motor Incomplete Spinal Cord Injury: A Case Series

Holleran, Carey, L., PT, NCS, DHS; Hennessey, Patrick, W., PT, NCS; Leddy, Abigail, L., PT, NCS; Mahtani, Gordhan, B., MS; Brazg, Gabrielle, DPT; Schmit, Brian, D., PhD; Hornby, T., George, PT, PhD

Journal of Neurologic Physical Therapy: April 2018 - Volume 42 - Issue 2 - p 94–101
doi: 10.1097/NPT.0000000000000217
Case Reports and Case Series

Background and Purpose: Previous data suggest that large amounts of high-intensity stepping training in variable contexts (tasks and environments) may improve locomotor function, aerobic capacity, and treadmill gait kinematics in individuals poststroke. Whether similar training strategies are tolerated and efficacious for patients with other acute-onset neurological diagnoses, such as motor incomplete spinal cord injury (iSCI), is unknown. Individuals with iSCI potentially have greater bilateral impairments. This case series evaluated the feasibility and preliminary short- and long-term efficacy of high-intensity variable stepping practice in ambulatory participants for more than 1 year post-iSCI.

Case Series Description: Four participants with iSCI (neurological levels C5-T3) completed up to 40 one-hour sessions over 3 to 4 months. Stepping training in variable contexts was performed at up to 85% maximum predicted heart rate, with feasibility measures of patient tolerance, total steps/session, and intensity of training. Clinical measures of locomotor function, balance, peak metabolic capacity, and gait kinematics during graded treadmill assessments were performed at baseline and posttraining, with more than 1-year follow-up.

Outcomes: Participants completed 24 to 40 sessions over 8 to 15 weeks, averaging 2222 ± 653 steps per session, with primary adverse events of fatigue and muscle soreness. Modest improvements in locomotor capacity where observed at posttraining, with variable changes in lower extremity kinematics during treadmill walking.

Discussion: High-intensity, variable stepping training was feasible and tolerated by participants with iSCI although only modest gains in gait function or quality were observed. The utility of this intervention in patients with more profound impairments may be limited.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1,

Program in Physical Therapy, School of Medicine, Washington University in St Louis, St Louis, Missouri (C.L.H.); Rehabilitation Institute of Chicago, Chicago, Illinois (P.W.H., A.L.L., G.B.M., G.B., and T.G.H.); Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin (B.D.S.); Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois (T.G.H.); and Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana (T.G.H.).

Correspondence: T. George Hornby, PT, PhD, Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 355 West 16th St, Goodman Hall, Ste 4300, Indianapolis, IN 46202 (

Funding for the study was provided by National Institute on Disability and Rehabilitation Research grants H133B031127 and H133B140012, and the Bullock Foundation.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

© 2018 Academy of Neurologic Physical Therapy, APTA