Comparison of the effects of body-weightsupported treadmill training and tilt-table
standing on spasticity in individuals withchronic spinal cord injury
Melanie M. Adams, Audrey L. Hicks
Department of Kinesiology, McMaster University, Hamilton, ON, Canada
Objective: Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing(TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs inindividuals with chronic spinal cord injury (SCI).
Design: Random cross-over.
Methods: Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks andthrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal
Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn
Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury
Version – III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after
the first training session and within 2 days of completing each training condition.
Results: In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effectsize (ES) = 0.69), flexor spasms (ES = 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79),
clonus (ES = 0.66), and self-reported mobility (ES = 1.27) tended to benefit more from 4 weeks of BWSTT than of
TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor
spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks).
Conclusion: While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics,
data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.
Keywords: Paraplegia, Tetraplegia, Spasticity, Quality of life, Activity-based therapy, Muscle stretching exercises, Treadmill training, Tilt-table training, Spinal
cord injury spasticity evaluation tool, Penn spasm frequency scale

Introduction
Spinal cord injury (SCI) is most commonly sustained byindividuals who are relatively young, making it important to focus on the long-term effective managementof co-morbidities that can impact quality of life. It has
been reported that a majority of individuals withchronic SCI have spasticity1 and that spasticity has
been identified by individuals with SCI as an importantresearch priority.2 Spasticity may be considered beneficial by individuals with SCI for some aspects ofdaily life, such as sitting, standing, transferring, andsome activities of daily living.1,3 There are also,
however, numerous potentially problematic effects ofspasticity, including inhibition of effective walking andCorrespondence to: Audrey L. Hicks, Department of Kinesiology, McMaster
University, Hamilton, ON, L8S 4K1 Canada. Email: hicksal@mcmaster.ca

488© The Academy for Spinal Cord Injury Professionals, Inc. 2011
DOI 10.1179/2045772311Y.0000000028

self-care, pain, fatigue, disturbed sleep, compromised
safety, and negative self-image.1,3 Consequently, many
individuals with SCI seek strategies to manage theirspasticity.
There are various approaches to manage spasticity
following SCI.3 Physical therapy/rehabilitation is considered an essential component both as a first line ofdefense and in a long-term regimen during and after
the implementation of pharmacological or surgicalstrategies.3 There is evidence suggesting that single sessions of active or passive ‘activity-based therapies’,
such as passive standing assisted by a tilt-table, canhave immediate effects on spasticity in individuals with
SCI.4,5 In many cases, however, it has been reported
that the effects of single sessions of activity on spasticity
are short lasting (i.e. <24 hours).5 It is also important tonote that there have been reports of increased spasticity

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by some study participants immediately following asingle session of activity-based therapy.6 Participationin multiple sessions of active or passive movement
activities by individuals with SCI has also been shown
to modify spasticity symptoms.4 There is evidence thatmotor neuron excitability plays a role in spasticity following SCI7 and it has been shown to be modified following single8 and multiple9 sessions of activity-based
intervention.
Body-weight-supported treadmill training (BWSTT)
allows for assisted ambulation by individuals with
impaired mobility. During BWSTT, the lower-limb
musculature of an individual with motor-complete
or -incomplete SCI bears weight, undergoes stretch,and exhibits electromyographic activity.10 BWSTT has
also been reported to reduce the amplitude of thesoleus maximum H-reflex/maximum M-wave ratio(H/M ratio) in people with SCI, which is believed to
be a reflection of reduced motor neuron excitability8.
In comparison, tilt-table standing (TTS) places loadon the lower limbs and imposes stretch on the skeletal
muscles that cross the hip, knee, and ankle joints, but
it is not associated with lower-limb movement or electromyographic activity.
To our knowledge, there are no studies examining
the immediate or longer-term effects of BWSTT and TTS
on multiple measures of spasticity in individuals with
SCI. Therefore, the objective of this pilot study was tocompare the effects of single and multiple sessions of
BWSTT and TTS on clinically assessed and self-reported
spasticity, motor neuron excitability, and related constructs
in individuals with chronic SCI. It was hypothesized that
BWSTT would demonstrate a greater benefit on spasticity-related outcomes compared with TTS.

Methods
Participants
Six males and one female were recruited from the
Hamilton Health Sciences outpatient SCI rehabilitation
program. Eligibility criteria were chronic (>1 year) complete or incomplete paraplegia or tetraplegia (ASIA
A–C), self-reported presence of ‘stable’ spasticity, consistent medication and physical activity/physiotherapy
routines during the previous 6 months, and relianceon a wheelchair as a primary mode of mobility.
Participation in BWSTT during the previous 6 months
and/or any medical contraindications to the performance of BWSTT or TTS were exclusion criteria. This
study received ethics approval from the Hamilton
Health Sciences Research Ethics Board and all participants provided informed consent.

Comparison of the effects of BWSTT and TTS

Study design and overall protocol
A random cross-over design was used to compare intervention effects. Participants were scheduled to perform
12 sessions of BWSTT over 4 weeks and 12 sessions of
TTS over 4 weeks, with a 4-week detraining period
between the two conditions. Each participant served as
his own control, with the order of conditions for eachparticipant determined randomly. Each session wasscheduled to last up to 45 minutes, while aiming tomatch time spent in the two conditions.
Testing was performed in the following order: (1) selfreport questionnaires, (2) maximum H-reflex tomaximum M-wave ratio (H/M ratio), (3) muscle tone,(4) flexor spasms, (5) extensor spasms, and (6) clonus.
Post-testing occurred immediately following the firstsession (30–60 minutes post-activity) and 24–48 hours
following the final session of each 4-week activity condition. All assessments were performed by the same
examiner and at the same time of the day. Participants
were asked to refrain from caffeine, nicotine, marijuana,and physical activity 20 hours before testing and toempty their bladders prior to testing.

Activity conditions
BWSTT was performed using a motor-driven treadmill(Woodway USA Inc., Foster, CT) with a harness andoverhead pulley system capable of supporting a percentage of the participant’s body weight. Body-weightsupport (BWS) and speed of the treadmill were chosen
to enable appropriate gait with full knee extension
during stance. When necessary, lower-limb movement
was assisted by therapists. Participants were encouraged
to place their entire body weight over a fully extended
leg during the stance phase of the walking cycle.
Modifications of the training parameters over the
4-week BWSTT period were made according to ourtraining protocol.11
TTS was performed on a motorized tilt-table(Midland Manufacturing Co., Inc., Columbia, SC,
USA) at the greatest tolerated tilt angle (maximum80°). Velcro straps at the knees, hips, and torso (ifnecessary) were used to support the individual in an
upright position. Participants were allowed to increase
gradually to their maximum tilt angle and to reduce
their tilt angle during a session if they felt light headed.

Outcome measures
The Modified Ashworth Scale (MAS) was used to assesspassive resistance to movement in the left- and right-hip
flexors, extensors, and adductors, knee flexors andextensors, and ankle plantar-flexors and dorsiflexors.
The single scores from the muscle groups of both

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Comparison of the effects of BWSTT and TTS

lower limbs were summed for each participant.12 The
Spinal Cord Assessment Tool for Spastic reflexes wasused to assess spasm and clonus severity.13
The soleus H/M ratio was assessed with participants
seated in their chairs. A single rectangular biphasic pulse
with a pulse width of 500 μs was applied to the tibial
nerve in the popliteal fossa using a constant-voltage
stimulator (Digitimer Devices, Hertfordshire, UK).
The Ag-AgCl gel, self-adhesive recording electrodes(Kendall Meditrace 530, Chicopee, MA, USA) wereplaced in a bi-polar arrangement; one electrode wassecured over the right soleus muscle and the other over
the right Achilles tendon. The data were collectedusing customized LabVIEW software (National
Instruments, Austin, TX, USA). Stimulus intensity
was increased in steps of ∼5 mV until Hmax and Mmax
were approached and then increased in steps of∼1 mV until peak values were obtained. The three greatest measurements of Hmax and the three greatest
measurements of Mmax were averaged. An average ofthe right and left soleus H/M ratios for each participant
was used for all analyses.
Study participants were asked to answer four selfreport questionnaires while considering the previous 7
days. The Spinal Cord Injury Spasticity Evaluation
Tool (SCI-SET) measured the impact of spasticity on
daily life.14 The Penn Spasm Frequency Scale15 assessedspasm frequency. Perceived health and functioning wereassessed with the Quality of Life Index16 SCI Version –III (QLI) and the Motor Subscale of the FIM.17

Data treatment and statistical analyses
A paired samples t-test was used to compare the amountof BWSTT and TTS training time within the singlesession and multiple-session protocols. To check forpossible carryover effects of activity between conditions,
independent samples t-tests were performed for eachoutcome measure, with Bonferroni correction for multiple comparisons. Given the relatively small sample
size, Cohen’s d effect sizes (ESs) were calculated tocompare baseline scores to post-activity scores withincondition and to compare change scores between conditions for each outcome; relevant medium (≥0.50) or
large (≥0.80) ESs are discussed.18 ES calculations
provide an estimate of the strength of a relationship.

Results
Participants
Six men and one woman (age: 37.1 ± 7.7 years) withchronic (5.0 ± 4.4 years post-injury) complete or incomplete paraplegia or tetraplegia and self-reported spasticity participated in this study (Table 1). Current
medication and physical activity/physiotherapy routines had been consistent for at least 6 months prior to
the start of the study and remained consistent throughout the duration of the study.

Activity conditions
All participants completed the activity protocol withattendance at 12 sessions of BWSTT and 12 sessionsof TTS within the respective 4-week training blocks(Tables 2 and 3). Total training time of BWSTT and
TTS did not differ, at 453.7 ± 72.3 and 471.6 ± 52.0
minutes, respectively (P = 0.23). BWSTT training parameters included a group mean treadmill speed of
0.23 ± 0.10 m/second and a group mean provision of
50.7 ± 24.7% BWS. TTS was performed at a groupmean table angle of 68.6 ± 11.3°.

Effects of BWSTT and TTS
The mean scores for all outcome measures are presented
in Table 4. There was no evidence of carryover effects
between activity conditions, nor any statistically significant differences between baseline scores for either
condition.
After the first session, there was a tendency for extensor
spasms to decrease following TTS (ES = 0.68; Fig. 1), but
not following BWSTT. A comparison of the change
scores suggested that there was a greater reduction inpassive resistance to movement (Ashworth; ES = 0.69;
Fig. 2) and flexor spasms (ES = 0.57; Fig. 2) after
BWSTT compared to TTS. It was also suggested that

Table 1 Participant characteristics

490

Participant ID

Sex

Age (years)

Severity

Level

Post-injury (years)

1
2
3

M
M
M

4
5
6
7

F
M
M
M

40
37
32

C
A
B

T2
C6
T5

24
39
49
39

C
A
C
C

C5
T5
T10
T2

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Cause of SCI

Daily spasticity medications

2
14
7

Fall
MVA
MVA

5
3
3
1

MVA
MVA
Bleed
MVA

None
40 mg Baclofen
80 mg Baclofen
Marijuana (2–3 mg/day)
None
None
60 mg Baclofen
80 mg Baclofen
5 mg Tizanidine

Adams and Hicks

Table 2Comparison of the effects of BWSTT and TTSBWSTT and TTS durations and parameters for the single-session protocol
BWSTT

TTS

ID

Duration (minutes)

Avg. speed (minutes/second)

Avg. BWS (%)

Duration (minutes)

Avg. tilt angle (°)

1
2
3
4
5
6
7

30
30
30
25
30
30
30

0.28
0.28
0.33
0.07
0.19
0.17
0.14

8.0
50.3
32.0
40.0
72.0
24.0
40.0

30
30
30
20
30
30
30

70.0
63.3
56.7
43.0
70.0
66.7
70.0

Table 3

BWSTT and TTS durations and parameters for the multiple session protocol
BWSTT

TTS

ID

Duration (minutes)

Avg. speed (minutes/second)

Avg. BWS (%)

Duration (minutes)

Avg. tilt angle (°)

1
2
3
4
5
6
7

487
510
495
320
460
513
391

0.33
0.33
0.33
0.10
0.19
0.17
0.19

4.8
71.7
68.6
55.0
72.9
34.3
47.8

487
515
510
418
456
525
390

78.8
71.6
66.9
46.8
62.8
78.7
74.9

Table 4 Summary of mean ± SD scores for all outcome measures at baseline and post-activity (single session and multiple session)for the BWSTT and TTS conditions
BWSTT
Outcomemeasures
Ashworth
Flexor spasms
Extensor
spasmsClonusSCI-SET
Penn
QLI
FIM motor
H/M ratio

TTS

Baseline

Post-activity(single session)

Post-activity(multiple session)

Baseline

Post-activity(single session)

Post-activity(multiple session)

29.6 ± 16.0
2.9 ± 1.2
3.7 ± 1.5

25.6 ± 13.0
2.7 ± 1.1
3.3 ± 1.6

29.9 ± 8.5
2.4 ± 2.0
4.0 ± 2.1

29.4 ± 14.4
2.4 ± 1.6
4.6 ± 1.1

29.1 ± 13.5
3.0 ± 1.5
3.7 ± 1.4

30.1 ± 14.5
3.0 ± 1.4
3.6 ± 1.0

2.6 ± 2.5
−0.77 ± 0.46
2.6 ± 0.8
62.0 ± 12.4
73.6 ± 11.4
0.61 ± 0.25

2.4 ± 2.3
N/A
N/A
N/A
N/A
0.60 ± 0.22

1.7 ± 1.8
−0.64 ± 0.46
2.3 ± 0.8
68.1 ± 12.6
76.3 ± 11.7
0.63 ± 0.26

1.9 ± 1.7
−0.72 ± 0.36
2.3 ± 1.0
61.7 ± 12.0
77.4 ± 10.2
0.64 ± 0.26

1.7 ± 1.5
N/A
N/A
N/A
N/A
0.66 ± 0.24

2.0 ± 1.3
−0.64 ± 0.41
2.1 ± 0.4
64.7 ± 12.9
76.1 ± 12.5
0.65 ± 0.27

the H/M ratio decreased to a greater extent following asingle session of BWSTT compared to TTS (ES = 0.50;
Fig. 2).
Four weeks of TTS appeared to reduce extensor
spasms (ES = 0.95; Fig. 3). There were also indications
that extensor spasms were affected differently fromflexor spasms depending on the intervention. Extensor
spasms tended to be reduced to a greater extent following TTS compared to BWSTT (ES = 1.32; Fig. 4), while
flexor spasms tended to be reduced to a greater extent
following BWSTT compared to TTS (ES = 0.79;
Fig. 4). Clonus also appeared to be improve more following BWSTT (ES = 0.66; Fig. 4). There were noobserved changes in the H/M ratio following participation in 12 sessions of either BWSTT or TTS, nor

any observed differences in effects between activity conditions (Table 1; Figs 3 and 4).
Participation in 12 sessions of BWSTT or TTS did not
result in group changes in scores on the SCI-SET or thePenn Spasm Frequency Scale. A medium ES supported
the potential beneficial effect of 12 sessions of BWSTT
on quality of life (ES = 0.50; Fig. 3). BWSTT also
resulted in more positive changes in FIM Motor
Subscale scores (ES = 1.24; Fig. 4).

Discussion
To our knowledge, this is the first study comparing theeffects of single and multiple sessions of BWSTT and
TTS on various measures of spasticity in individuals
with chronic ASIA A to C SCI. The group mean activity

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Comparison of the effects of BWSTT and TTS

Figure 1 ESs of the differences between baseline and postactivity outcome measure scores after one session of BWSTT(open bars) and TTS (solid bars) Positive and negative ESs
represent favorable and unfavorable changes, respectively, inthe outcome measures. Absolute ESs greater than 0.50 (dashedline) are discussed in the text.

Figure 2 ESs of the differences in change scores between
outcome measures following a single session of BWSTT and asingle session of TTS. Positive ESs represent a superiority of
BWSTT, whereas negative ESs represent a superiority of TTS interms of the induction of a favorable change. Absolute ESs
greater than 0.50 (dashed line) are discussed in the text.

Figure 3 ESs of the differences between baseline and postactivity outcome measure scores for BWSTT (open bars) andTTS (solid bars) multiple session conditions. Positive andnegative ESs represent favorable and unfavorable changes,
respectively, in the outcome measures. Absolute ESs greaterthan 0.50 (dashed line) are discussed in the text.

492

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Figure 4 ESs of the differences in change scores between
outcome measures following multiple sessions of BWSTT and
of TTS. Positive ESs represent a superiority of BWSTT, whereas
negative ESs represent a superiority of TTS in terms of theinduction of a favorable change. Absolute ESs greater than 0.50
(dashed line) are discussed in the text.

durations and the amount of BWS provided were similar
between conditions for both protocols. Only participant#4 had a notable difference in training duration between
the BWSTT and TTS conditions (98 fewer minutes of
BWSTT). This participant felt that the work required
by BWSTT was greater than with TTS and, therefore,
was consistently unable to match her BWSTT activity
session durations with those of her previously completed
TTS activity sessions.
There was no evidence of change in muscle tone
(MAS) following 4 weeks of BWSTT or TTS. Others
have found similar results following BWSTT or overground locomotor training for 12 weeks.19 This could
reflect limitations of the MAS or a true inability ofactivity to reduce muscle tone. Results did suggest,
however, that participation in single and multiple sessions of TTS-reduced extensor spasms, a finding thathas been reported previously.5 Despite this, the study
results indicated that a single session of BWSTT may
be superior to TTS for several spasticity-related outcomes (reduction of muscle tone, flexor spasms, andmotor neuron excitability). Participation in multiple sessions of BWSTT also appeared to be superior to TTS interms of management of flexor spasms and clonus. We
were unable to detect changes in the soleus H/M ratio
following multiple sessions of activity. A previous
study was also unable to demonstrate a change in the
H/M ratio following 4 months of treadmill walking by
an individual with incomplete SCI.20 Although thismay cast doubt on the role of motor neuron excitabilityin spasticity, it is more likely that various mechanisms
play a role depending on the symptom, the timeline,
and the activity.
It is considered that the best judge of spasticity is theindividual, as he/she is best able to assess the impact ofAdams and Hicks

spasticity on daily life.1 It has also been suggested thatshort-term benefits of a single session of activity may
not be obvious to an examiner beyond a few hours.5
Of note, the majority of participants in the present
study identified smaller problematic effects of spasticity
on daily life following 4 weeks of either BWSTT or
TTS. There was moderately strong evidence, however,that self-reported quality of life improved following
participation in multiple sessions of BWSTT, but not
TTS. This finding is encouraging given the previous
finding of no change in quality of life following 1
year of intrathecal pharmacological treatment for spasticity.21 Therefore, the improvement in quality of life
might have been related to the tendency of BWSTT
to increase self-reported functional mobility compared
to TTS.
Overall, our finding that various outcome measures
did not respond similarly to activity is not surprising
given numerous reports of poor correlations between
different measures of spasticity.7,13,12 The variability of
results within the present study also reflects the generally
inconsistent findings in the literature for the effects ofsingle and multiple sessions of activity-based therapy
on lower-limb spasticity in humans with SCI.4
Although little information exists, it is likely that theheterogeneous nature of spasticity and of SCI contributes to a variable response to activity-based intervention
in this population. Anecdotal reports by the participantsfrom the present study revealed that some participants
perceived short-term decreases in spasticity following a
training session (up to ∼4 hours), whereas others experienced a decrease in spasticity frequency, but an increase
in intensity when spasticity did occur. Because spasticity
exerts different consequences in the lives of different
individuals with SCI, it has been stated that a repertoireof interventions would be beneficial to target the various
issues.2
While the present study identified several interestingfindings related to the effects of BWSTT and TTS on
spasticity-related measures, the small and heterogenous
nature of our sample made it difficult to draw conclusions based on group changes. A limitation of thestudy may have resulted from an inability of the examiner to be blinded to the study intervention. It is also
possible that our multiple-session intervention durations
were not long enough for the benefits to be gained fromBWSTT or TTS. The participants in the present study
exerted efforts that were uncustomary for them and, insome cases, an increase in spasm severity during theintervention period was reported. Perhaps a longer
intervention period would have allowed for the development of favorable physiological adaptations to activity,

Comparison of the effects of BWSTT and TTS

eventually making the activity sessions beneficial tospasticity management.

Conclusion
The results from this pilot study indicate that some individuals with SCI and spasticity may benefit from participation in weight-bearing activity and that BWSTT
and TTS may have different effects for certain outcomes. Compared to more invasive management strategies (e.g. pharmacological, surgical), activity-based
interventions offer the potential for further healthrelated benefits and fewer possible problematic side
effects. Therefore, this area of research would benefit
from investigations of longer activity periods which
address individual characteristics that may affectresponses to participation.

Acknowledgment
Ontario Neurotrauma Foundation (studentship,
M. Adams) and Gatorade Sport Science Foundation(student grant, M. Adams)

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