Whole-body vibration improves walking function in individuals with spinal cord injury: a pilot study

G ModelGAIPOS-2815; No of Pages 5 Gait & Posture xxx (2009) xxx–xxx Contents lists available at Whole-body vibration improves walking function in individualswith spinal cord injury: A pilot study Lanitia L. Ness ,Edelle C. Field-Fote a The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USAb The Department of Physical Therapy, University of Miami Miller School of Medicine, Miami, FL, USAc The Department of Biomedical Engineering, University of Miami, Coral Gables, FL, USA Injury to the central nervous system often results in impairments that negatively affect walking function.
Received 28 January 2009 Prior evidence suggests that vibration may improve walking function. The purpose of this study was to Received in revised form 20 May 2009 determine whether repeated use of whole-body vibration (WBV) is associated with improvements in Accepted 26 June 2009 walking function in individuals with spinal cord injury (SCI). Subjects were 17 individuals with chronic(1 year), motor-incomplete SCI. Subjects were tested before and after participation in a 12-session (3 days/week for 4 weeks) intervention of WBV. We assessed change in walking function via 3D motion capture, with walking speed as the primary outcome measure. We also assessed the influence of the WBV intervention on secondary gait characteristics, including cadence, step length, and hip-knee Afferent inputHuman movement system intralimb coordination. Walking speed increased by a mean of 0.062  0.011 m/s, a change that wasstatistically significant (p < 0.001). The WBV intervention was also associated with statistically significantincreases in cadence, and both the stronger and weaker legs exhibited increased step length and improvedconsistency of intralimb coordination. Changes in cadence and step length of the stronger leg were stronglycorrelated with improvements in walking speed. The improvement in walking speed observed with the WBVintervention was comparable to that reported in the literature in association with locomotor training. Thismagnitude of change has been identified as being clinically meaningful, even in non-clinical populations.
These findings suggest WBV may be useful to improve walking function with effects that may persist forsome time following the intervention.
ß 2009 Elsevier B.V. All rights reserved.
of vibration placement and direction of progression Inindividuals with Parkinson's disease, vibration applied through Loss of walking function is a common consequence of spinal the soles of the feet during walking increases walking distance, cord injury (SCI), and for these individuals, regaining walking speed, stride length, and improves stride variability Vibration function is a high priority Individuals with SCI, and other may also excite spinal circuitry (i.e., locomotor pattern generators) populations with disorders of the central nervous system, often involved in the production of locomotor output .
have various impairments that negatively impact walking func- Whole-body vibration (WBV) is increasingly being used in tion. For example, muscle weakness and sensory impairment elderly individuals and in clinical populations In result in reduced levels of muscle activation and decreased walking individuals with SCI, our studies offer preliminary evidence that a speed . Spasticity may result in altered muscle timing and co- 12-session intervention of WBV decreases spasticity of the contraction associated with spastic gait patterns Decreased quadriceps muscles . The use of WBV has also been associated walking function results from any one, or a combination, of these with changes in walking function Elderly individuals who received a 2-month WBV intervention in combination with In non-disabled (ND) individuals, vibration to the muscle body balance, muscle strengthening, and walking exercises demon- or tendon increases walking speed, depending on the combination strated increased walking speed and step length compared toindividuals who did the same exercise program without WBV In individuals with Parkinson's disease, a 3-week intervention ofWBV is associated with improvements in walking speed In * Corresponding author at: The Miami Project to Cure Paralysis, University of adults with spastic diplegia due to cerebral palsy, an 8-week Miami Miller School of Medicine, 1095 NW 14 Terr (R-48), Miami, FL 33136, USA.
intervention of WBV is associated with improvements in muscle Tel.: +1 305 243 7119; fax: +1 305 243 3913.
E-mail address: (E.C. Field-Fote).
strength and reductions in spasticity of the knee extensor muscles, 0966-6362/$ – see front matter ß 2009 Elsevier B.V. All rights reserved.
doi: Please cite this article in press as: Ness LL, Field-Fote EC. Whole-body vibration improves walking function in individuals with spinalcord injury: A pilot study. Gait Posture (2009), doi:

G ModelGAIPOS-2815; No of Pages 5 L.L. Ness, E.C. Field-Fote / Gait & Posture xxx (2009) xxx–xxx but the distance walked in 6 min was unchanged In parameters. Information about daily use of medications and assistive devices for individuals with SCI who were unable to stand without long-leg mobility was also recorded.
Demographic data for the subjects are given in All subjects gave written braces, a case series published in an abstract attributed the use of and verbal informed consent to participate in a protocol approved by the Human WBV with the progression of function from standing to walking Subjects Research Office at the institution. All subjects were instructed to maintain . Evidence of the effects of WBV on walking function is limited their regular exercise and medication habits until completion of the study.
in individuals with SCI.
The purpose of this study was to determine whether repeated 2.1. WBV intervention use of WBV is associated with improvements in walking function, Subjects received an intervention consisting of WBV (Power Plate; Northbrook, as defined by changes in walking speed, in individuals with IL) 3 days/week for 4 weeks. Each session included four 45-s bouts with 1 min of chronic, motor-incomplete SCI. In individuals with SCI, increased seated rest without vibration between bouts according to previously published walking speed is a standard benchmark for improvement in protocols (. During each WBV bout, subjects stood on the vibrationplatform with knees flexed approximately 308 from anatomical neutral. Vibration walking function In addition, we assessed changes in was delivered at 50 Hz with a vertical displacement of 2–4 mm (depending on secondary gait parameters including step length, cadence, and subject weight).
consistency of hip-knee intralimb coordination. Our prior studiesof interventions to improve walking function in individuals with 2.2. Testing procedure SCI have focused on locomotor training or nutrient The effects of the 12-session WBV intervention on walking function were supplementation While there is preliminary evidence in that quantified by comparing the kinematic data acquired prior to the intervention WBV may improve walking function in elderly individuals and (initial test) to that collected within 7 days of the last WBV session (final test). One individuals with Parkinson's disease , there are no published subject returned an additional time at 5-week post-WBV for a follow-up test studies related to the influence of WBV on walking function in session to allow assessment of persistence of intervention effects. An array of 21 individuals with SCI, many of whom have a limited ability to reflective markers were placed bilaterally at the lateral malleoli, 5th ray metatarsal-phalangeal joints, heels, lateral knee joints, greater trochanters, anterior superior maintain standing. Based on the prior evidence, we hypothesized iliac spines, shoulders, elbows, and wrists as well as at C7, T10, and the sacrum.
that the 12-session intervention of WBV would be associated with Kinematic data were collected using an 8-camera 3D motion capture system (Peak improvements in walking speed and the secondary gait para- Motus1 Software, Peak Performance, Centennial, CO). Recording of kinematic data meters. In this consideration-of-concept study , our goal was to was performed in a calibrated space with data captured at 60 Hz.
For each walking test session, subjects walked five times across a 10-m walkway determine whether there was value in pursuing this line of study, at their preferred walking speed; subjects were allowed to rest between walking and whether it was feasible to use WBV in individuals with SCI tests. During each walking test, subjects were given 30 s to complete the 10-m walk, relative to subject tolerance and incidence of adverse events.
and all outcome measures were extracted from data captured within the central6 m of the walkway. Subjects used assistive devices as required during testing.
Fourteen subjects used a rolling walker, one subject did not have the necessary 2. Subjects and methods hand function to grip the handles of a standard rolling walker and performed the Seventeen subjects (3 women and 14 men; age 28–65) with SCI enrolled in the test using a rolling walker with bilateral forearm platform supports, and two study. All subjects underwent clinical examination prior to testing. Subject subjects did not require assistive devices. If a subject required an assistive device, inclusion criteria were motor incomplete, chronic (1 year duration) SCI, and the same device was used both for the initial and final test sessions.
ability to rise from sitting to standing with no more than moderate assistance fromone person, and ability to stand (using upper extremity support) for at least 1 min.
2.3. Data analysis and statistics American Spinal Injury Association (ASIA) motor and sensory scores , and ASIAImpairment Scale (AIS) classification were evaluated by a physical therapist Statistical Analysis Software 9.1.3 (Cary, NC) was used for all statistical analyses.
who was not otherwise involved in the study. All individuals had asymmetrical All data were checked and met the parametric assumptions of homogeneity lower extremity motor scores that were used to identify the weaker and stronger (Levene's test for equality of variances) and normality (Kolmogorov–Smirnov Z- extremity. Subject height was recorded for the purpose of normalizing gait test). Significance was set at a = 0.05. Walking speed (SPEED; meters/second; m/s) Table 1Demographics of participants, LEMS = lower extremity motor scores represent the sum of the motor scores for the five key muscles of both legs graded according to ASIAguidelines prior to the WBV intervention.
Antispastic agents Primary daily assistive device Personal transporter Fig. 1. Procedure for a single session of whole-body vibration (WBV). Each session of WBV consisted of four bouts of WBV at a frequency of 50 Hz and an intensity of 2–4 mm(depending on the subject weight). Each vibration bout was separated by a period of 1 min seated rest.
Please cite this article in press as: Ness LL, Field-Fote EC. Whole-body vibration improves walking function in individuals with spinalcord injury: A pilot study. Gait Posture (2009),

G ModelGAIPOS-2815; No of Pages 5 L.L. Ness, E.C. Field-Fote / Gait & Posture xxx (2009) xxx–xxx was calculated from the distance traversed in the direction of forward progressionas measured from the sacral marker. A one-tailed, paired t-test was used to comparethe mean speed of the five walking trials from the initial and final test sessions. Aconvenience sample of one participant (selected because he lived locally) returnedfor a follow-up walking test session 5-week after the last session of WBV. Walkingspeed for this subject was compared to both the initial and final tests to assesspersistence of change in speed associated with the WBV intervention.
Gait parameters were calculated from the kinematic measures. Data were filtered using a Butterworth filter with a 6 Hz cutoff. Bilateral step lengths wereextracted from the coordinates of the heel in the direction of progression. Steplengths (m) were determined by the distance between two consecutivecontralateral heel strikes, and normalized to subject height. A one-tailed, pairedt-test was used to compare the mean initial and final test values of the strong legstep length (SSL) and weak leg step length (WSL). Cadence (CAD; steps/min) wascalculated by dividing the total number of steps by the time needed to complete the Fig. 2. All subjects change in walking speed (SPEED; mean  standard error) steps. A one-tailed, paired t-test was used to compare the mean CAD of the initial associated with 12-session whole-body vibration (WBV) intervention. Change in and final tests. The values of SSL, WSL and CAD are directly derived from a single SPEED values for all subjects (thin lines) and group mean change (thick line). Group reflective marker and may therefore be expected to be interrelated, therefore a mean initial SPEED value (0.259  0.248 m/s) and final SPEED value (0.321  0.260 m/ Bonferroni correction was used to adjust the alpha level for four pair-wise (SPEED, s) were significantly different (*). The y-axis has been broken from 0.6 m/s to 1 m/s CAD, SLL, and WSL) comparisons resulting in a corrected value of a = 0.0083.
because there were no SPEED values measured in this range. One subject returned for a Intralimb coordination was defined as the ability to produce a consistent follow-up test 5-week (dashed line) after the last WBV session, had an initial SPEED of relationship of hip-angle-to-knee-angle coupling over multiple step cycles 0.128 m/s, a final SPEED of 0.215 m/s and a 5-week follow-up SPEED of 0.241 m/s.
The hip angle was defined by the trunk and thigh segments. The knee angle wasdefined by the thigh and shank segments. Vector coding was used to quantifyintralimb coordination wherein the angular component of the coefficient ofcorrespondence (ACC) represents the degree of consistency of the hip-kneerelationship over multiple cycles . It has been suggested that ACC valuesoffer insights into the organization of control mechanisms (i.e., locomotor centralpattern generators) underlying coordination of innate, cyclic behaviours Inindividuals with SCI, changes in the ACC value correlate well with changes inwalking speed associated with locomotor training . ACC was calculated for boththe strong ACC (SACC) and weak ACC (WACC) legs. An increase in ACC value frominitial to final was interpreted as increased consistency of intralimb coordination. Aone-tailed, paired t-test was used to compare the mean SACC and WACC valuesfrom the initial and final tests.
To determine which gait parameters were most closely associated with changes in walking speed, Pearson correlations where used to identify the relationshipbetween SPEED and the parameters of CAD, SSL, WSL, SACC, and WACC. Pearson rvalues were interpreted as follows: 0.00–0.25 was considered little or norelationship, 0.25–0.50 was considered a fair relationship, 0.50–0.75 wasconsidered a moderate relationship, and 0.75–1.0 was considered to be a goodto excellent relationship .
The pooled standard deviation and Cohen's d was used to calculate the effect size Fig. 3. Group mean changes in walking speed (SPEED; m/s), change in walking of the change in SPEED associated with use of the WBV intervention.
cadence (CAD; steps/min), and change in weak (WSL) and strong (SSL) step lengths(m) after a 12-session whole-body vibration (WBV) intervention. CAD, WSL and SSLsignificantly decreased (*) after the 12-session intervention of WBV. These gaitparameters contributed to the increase in SPEED. The y-axis values are dependent on the reported measure and are denoted as group mean  standard error bars. Notethe break in the y-axis from 0.5 to 30 to accommodate for values of cadence.
The group mean walking speed (SPEED) increased by 0.062  0.011 m/s (mean  standard error) (from 0.259  0.248 m/ non-significant, weak, direct correlation with WSL (r = 0.154, s in the initial test to 0.321  0.260 m/s in the final test), an increase p = 0.554), SACC (r = 0.018, p = 0.946), and WACC (r = 0.204, that was statistically significant (p < 0.001) but considered a small effect size (d = 0.249).
All subjects tolerated the 12-session of WBV, were able to Subject 16, who returned for a follow-up test 5-week after the maintain the standing posture for the 45-s bouts of WBV, and last WBV session, had an initial SPEED of 0.128 m/s, a final SPEED of reported no adverse effects. These results suggest that it is feasible 0.215 m/s and a 5-week follow-up SPEED of 0.241 m/s. SPEEDvalues of all subjects, group mean, and subject 16 are illustrated in The 12-session intervention of WBV was also associated with a statistically significant increase in CAD (from 33  5 steps/min[initial] to 36  5 steps/min [final]; p = 0.002). SSL significantlyincreased (from 0.194  0.090 m [initial] to 0.23  0.063 m [final],p = 0.006) and WSL significantly increased (from 0.180  .082 m[initial] to 0.212  0.075 m [final], p = 0.003). The relationshipbetween change in SPEED to changes in, CAD, SSL, and WSL areillustrated in .
There was a statistically significant change in SACC (from 0.68  0.22 [initial] to 0.77  0.12 [final], p = 0.018) and in WACC(from 0.67  0.22 [initial] to 0.74  0.14 in [final], p = 0.026). Therelationship between change in SPEED to changes in SACC and WACC Fig. 4. Group mean changes in walking speed (SPEED; m/s) and the change in strong is illustrated in .
(SACC) and weak (WACC) coefficients of correspondence (ACC) after a 12-sessionwhole-body vibration (WBV) intervention. The y-axis values are dependent on the Changes in SPEED had a significant, moderate, direct correlation reported measure and are denoted as group mean  standard error bars. Note the with CAD (r = 0.528, p = 0.029), and a non-significant, fair, direct break in the y-axis from 0.4 to 0.7 because no values were reported in this range. SACC relationship with SSL (r = 0.344, p = 0.176). Changes in SPEED had a and WACC significantly decreased (*) after the 12-session intervention of WBV.
Please cite this article in press as: Ness LL, Field-Fote EC. Whole-body vibration improves walking function in individuals with spinalcord injury: A pilot study. Gait Posture (2009), doi: G ModelGAIPOS-2815; No of Pages 5 L.L. Ness, E.C. Field-Fote / Gait & Posture xxx (2009) xxx–xxx to use WBV as an intervention in future randomized, controlled speed. The improvements in walking speed and step length are studies that assess interventions to improve walking function in consistent with increases in stride length reported in individuals individuals SCI. All subjects adhered to the study protocol and with Parkinson's disease during vibration . However, this is completed the intervention; many of these individuals indicated contrary to evidence in ND individuals wherein no change in stride they would like to continue with these sessions and would be length during walking was observed with vibration applied to interested in participating in future studies involving WBV.
tibialis anterior, triceps surae, biceps femoris, rectus femoris, orquadriceps femoris Changes in stride length may not be evident in ND individuals because their strides are relatively longercompared to individuals with a neuropathology. For this reason, Our results indicate that consistent use of WBV is associated individuals with neuropathology may have a larger margin for with an increase in walking function, as defined by walking speed, vibration-induced improvement of spatial walking characteristics in individuals with SCI who have some ability to maintain compared to ND individuals.
voluntary standing. While the lack of a control group, the inclusion The degree of consistency of the hip–knee intralimb coordina- of individuals with varying degrees of walking ability, and the fact tion of both legs improved, and the improvement was comparable that it was not possible to blind subjects to the intervention limits to those observed in a 3-month locomotor training wherein the the conclusions that can be drawn from these findings, the fact ACC values improved from 0.56 before to 0.65 after locomotor remains that the observed changes in walking speed associated training However, unlike that prior study wherein the change with WBV were equivalent to those reported for studies of in intralimb coordination was associated with the change in locomotor training . In individuals with SCI who participated in walking speed, in the present study the change walking speed was a 3-month 5-day/week locomotor training intervention, walking only weakly correlated with the change intralimb coordination.
speed changes of 0.023 m/s, 0.05 m/s, 0.05 m/s, and Contrary to our findings, in ND individuals, bilateral Achilles were associated with manually assisted treadmill training, tendon vibration did not change walking speed or leg inter- stimulation-assisted treadmill training, overground training, and segmental coordination Also in ND individuals, changes in robotic-assisted treadmill training, respectively. It is possible that intralimb ankle–knee coordination were not found with vibration participation in a study made the subjects more conscientious of applied to tibialis anterior, triceps surae, biceps femoris, rectus their walking performance or that the pre-, post-test design femoris, or quadriceps femoris . Our findings and other increased familiarity with the test, resulting in an improvement.
evidence in individuals with SCI suggest that the consistent However, we feel these explanations are unlikely, especially in use of afferent input improves the motor output of the control light of comparisons to the locomotor training literature . In mechanisms that have been impaired after a SCI.
healthy elders, a change in walking speed of 0.05 m/s (with asimilar effect size [d = 0.2]) has been judged to be a clinically 5. Implications for function meaningful change . As illustrated in , 10 out of 17 of thesubjects exceeded a change of 0.05 m/s after the 12-session These results provide preliminary support for the use of WBV as intervention of WBV. Subject 13 was unable to take a single step in an intervention to improve walking function in individuals with the initial test. After the 12-session intervention of WBV, the SCI, with changes that appear to be comparable to those achieved subject was able to take four steps. It could be argued that this with some forms of locomotor training. With a 12-session magnitude of change may be even more meaningful in individuals intervention of WBV, we found significant improvements in with SCI than it is in healthy elders. Our findings are consistent walking speed, cadence, step lengths, and intralimb coordination with improvements in walking function observed in elderly over multiple steps. Furthermore, the effect of WBV on walking individuals and in individuals with Parkinson's disease who function may continue to improve walking function even after the received a WBV intervention and therefore provide pre- use of WBV has ended. However, this was assessed in a single liminary evidence that regular use of WBV may be a potent subject and requires further investigation.
intervention for improving walking function in individuals withSCI.
In the single subject who performed a follow-up test session 5 Conflict of interest weeks after the WBV intervention, the effects on walking speed notonly persisted, but increased 5 weeks after the WBV intervention.
There is no conflict of interest with any of the authors.
These are similar to findings in individuals with Parkinson'sdisease who had a persistent change in walking speed 4 weeks after receiving a 3-week WBV intervention . The use of afferentinput to induce positive plastic effects in the nervous system has We gratefully acknowledge the technical contributions of received considerable attention in the recent research literature Stephen Lindley. This study was supported by The Miami Project These plastic changes are most meaningful when they are to Cure Paralysis and the NIH grant #R01HD41487.
associated with a lasting improvement in function . Futurestudies should assess the persistence of effects of WBV through follow-up testing performed some time after the final intervention.
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