The Use of Bodyweight-Supported Treadmill Training for a 55-Year-Old Male After

Proximal Tibial Plateau and Fibular Fractures

Author: Kelsie B. Turner

Research Advisor: Caroline S. Gwaltney, PT, DPT, CWS

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 5, 2022

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Caroline S. Gwaltney, PT, DPT, CWS

Date of Approval: 04/05/2022
 ABSTRACT

Background and Purpose

Tibial plateau fractures have been found to account for 1% of all bone fractures. Still, these

fractures can be serious and require an open reduction internal fixation procedure followed by

physical rehabilitation to regain strength, joint range of motion and decrease gait impairments. A

Schatzker Type 5 fracture is a type of tibial plateau fracture, involving fracture of both tibial

plateaus, with retained continuity of the diaphysis and metaphysis. Following this type of injury,

muscle weakness and asymmetrical gait patterns with significant deviations are common.

Currently, no guidance is available for rehabilitation following a Schatzker Type 5 fracture.

Bodyweight- supported treadmill (BWSTT) training has been found to improve common

deviations seen in different patient populations. The purpose of this case report was to share the

treatment strategy and outcomes of BWSTT for a patient with impaired gait following a

Schatzker Type 5 fracture.

Case Description

A 55-year-old male was seen in an outpatient orthopedic physical therapy setting 10 weeks after

a comminuted proximal fibular and bicondylar tibial plateau fracture. He presented with

decreased left lower extremity strength and active left knee range of motion as well as impaired

gait. He ambulated with bilateral axillary crutches and demonstrated modified independence with

sit to stand/ stand to sit transfers. The patient performed the Timed Up and Go test in 13.5

seconds and the 10-Meter Walk test in 13.36 seconds. The time needed to complete both of these

outcome measures indicated that he was at an increased risk of falling within the community.

Physical therapy interventions focused on BWSTT for high repetition task specific training as
well as manual therapy for knee range of motion and lower extremity strengthening in open and

closed chain positions.

Outcomes

The patient demonstrated improved active left knee flexion and extension range of motion and

increased muscular strength in all assessed movements. Functional mobility and gait improved,

enabling the patient to ambulate free of an assistive device and navigate stairs with a reciprocal

gait pattern. The patient’s Timed Up and Go test was performed in 10.81 seconds, a 2.69 second

improvement. The 10 Meter Walk test was completed in 9.075 seconds, a 4.285 second

improvement. Quality of gait increased with step length and stance time equivalency achieved,

reciprocal arm swing present, trunk lean absent, and full knee extension present during terminal

stance and swing phase in preparation for heel strike.

Discussion

The patient’s functional improvements were consistent with currently available literature in other

patient populations after the use of BWSTT. He demonstrated improved symmetry in gait both in

step length and stance time, which was consistent with the literature. He demonstrated improved

lower extremity strength which may have been related to lower extremity strengthening

therapeutic exercise, or the task specific training of BWSTT. Although not clinically significant

according to current literature, the patient demonstrated improved gait speed. It appeared that

BWSTT contributed to this patient’s positive functional, but further research is needed to support

the use of BWSTT in orthopedic populations.

1
Background and Purpose

Of all bone fractures, tibial plateau fractures have been found to account for

approximately 1%.1 A Schatzker Type 5 fracture, a type of tibial plateau fracture, involves

fracture of both tibial plateaus, with retained continuity of the diaphysis and metaphysis.2 This

type of injury requires an open reduction internal fixation (ORIF) procedure for stabilization. If

the injury acquisition was high impact in nature, the ORIF may need to be delayed to allow for

healing of the anterior soft-tissue structures of the knee.3 During this time, a temporary external

fixation device may be used to stabilize the fracture.

Weakness of the muscles which control motion of the knee joint are common following

this type of injury, particularly the quadriceps and hamstring muscles. Strength deficits may

remain beyond a full year following the fracture.4 Asymmetrical gait is also prevalent following

this injury in both short and long term. Common deviations include decreased step length and

increased swing time of the injured leg.5,6,7 In addition to this, decreased single leg support time

of the affected leg is common, specifically with terminal stance when quadriceps have leading

muscle function.6

Currently, there is limited and controversial available literature pertaining to

rehabilitation following this type of injury.8 Lliopoulos et al6 suggested the rehabilitation focus

should be on quadriceps muscle strengthening to improve terminal stance when the quadriceps

muscle contracts to bring the femur above the tibia. Improved quadriceps strength would allow

for improved terminal stance and single leg support of the affected extremity during ambulation.6

To date, no literature is available addressing task-specific interventions to improve the

speed or quality of gait in individuals who have had this type of injury. There is also no guidance

1
currently available to clinicians pertaining to effective gait training strategies for this population.

One option available to clinicians is bodyweight- supported treadmill training (BWSTT). While

no literature is available for the use of BWSTT for people after tibial plateau fractures, this

intervention has been studied in a limited number of other orthopedic conditions including

following anterior cruciate ligament rapair9 and total hip arthroplasty.10

In one study, researchers compared outcomes following anterior cruciate ligament repair

between a BWSTT group and a control group which received conventional physical therapy.9

Outcomes were greater for the BWSTT group at week 12 post-operatively, but no significant

difference was present in outcomes between groups at 24 weeks. This study supports the use of

BWSTT to allow early mobilization, based on the improved outcomes in the early phases of

rehabilitation.

In subjects after total hip arthroplasty, Hesse et al10 compared the use of BWSTT plus

passive hip and knee mobilization with a control group which received passive hip and knee

mobilization and hip strengthening as well as overground gait training for 10 days. At both the 3

and 12-month follow up assessments, the treatment group had significantly less hip extension

deficits, greater walking symmetry, greater hip abductor muscle strength on the affected side,

and greater gluteus medius activity than those within the control group. Results from this study

indicate that using BWSTT may yield greater strength improvements in hip abduction and

walking symmetry than overground gait training plus hip strengthening in this population.

The use of BWSTT has been thoroughly studied in populations with a neurologic

diagnosis, such as stroke and Parkinson Disease.11,12 Studies of BWSTT have found

improvements in cadence, stride length and step length as well as decreased stride and step time

2
in patients with subacute stroke.13 Improvements in gait speed have been significantly higher in

BWSTT when compared to traditional treadmill training.13

There is a lack of evidence addressing rehabilitation following a Schatzker Type 5

fracture and the use of BWSTT with lower extremity orthopedic conditions. The purpose of this

case report was to share the treatment strategy and outcomes after use of BWSTT for a patient

with impaired gait following a Schatzker Type 5 fracture.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained within this case report meets the Heath Insurance Portability

Accountability Act (HIPPA) requirements of the clinical agency for disclosure of protected

health information. This case report was completed under the direction of the Department of

Physical Therapy and with oversight of the College of Graduate Studies at Central Michigan

University.

Case Description

Patient History and Review of Systems

A right-hand dominant, 55-year-old male was referred to physical therapy in a rural,

outpatient orthopedic clinic 10 weeks after being involved in a single-rider, all-terrain vehicle

(ATV) accident. The patient was driving the vehicle when it rolled. His left leg was crushed

between his ATV and a metal drain culvert in the accident.

Following the accident, the patient was able to drag himself to a nearby house where the

resident of the home called emergency medical services. The patient was transported by

ambulance to the local emergency department where he was stabilized before being sent to the

nearest level II trauma center, 100 miles away. X-rays of the left lower extremity revealed a

3
comminuted proximal fibular fracture and a bicondylar tibial plateau fracture which was labeled

as a Schatzker 5. Both fractures were displaced.

When he arrived at the level II trauma center, an external fixator was placed on the left

tibia and fibula. The external fixator was removed and an ORIF was performed 20 days after the

injury. He was placed on a 50% weight bearing restriction following the procedure. The patient

underwent physical therapy with a home health therapist for 6 weeks following the ORIF before

beginning outpatient physical therapy to continue to progress his strength, range of motion,

balance, and gait.

The patient’s past medical history was significant for a history of alcohol abuse, a

myocardial infarction 7 years prior, depression, hypertension, and hypercholesterolemia. The

patient had no additional problems with cardiovascular, gastrointestinal, neurological,

respiratory, gastrointestinal, urinary, endocrine, or integumentary systems. All scars secondary to

the injury were well-healed. The patient was a former smoker but ceased smoking 4 years prior

to the accident. His use of smokeless tobacco included chew and snuff. The patient was currently

using alcohol and reported using marijuana one time per week. It was unknown if marijuana use

was for medical or recreational purposes. Refer to Table 1 for the full list of the patient’s

medications.

The patient lived with his significant other and her mother in a 2-story home with 7 steps

to enter. Once inside, the home had a bathroom on the first floor and bedrooms on the second

floor. Prior to the injury, the patient was not formally employed but was watching his young

grandchildren several days a week.

At the start of outpatient physical therapy, the patient was ambulating with bilateral

crutches and was sleeping on the first floor of the home due to inability to navigate the stairs

4
inside the home to reach the second floor. He continued watching his grandchildren with the

assistance of others as he was unable to drive, get down on the floor, or pick up the young

children. Assistance was required for work around the home such as laundry, vacuuming, yard

work, and preparation of meals. His hobby of looking for small “treasures” with his metal

detector while hiking was impossible to continue following the injury. The patient’s goals for

therapy were to return to hiking with his metal detector, regain the ability to sit and stand for

prolonged periods of time so he could ride in a car and help with meal preparation, have the

ability to safely ascend and descend stairs, ambulate in the community independently, and be

able to get down on the floor with his grandchildren.

Clinical Impression #1

At the time of the initial evaluation, the weight bearing restriction of 50% remained to

ensure propper bone healing. Due to these restrictions the patient was limited to ambulation

utilizing bilateral axillary crutches. Dynamic balance capacity, proficiency with transfers,

ambulatory endurance, and ability to navigate stairs were all expected to be impaired. Additional

negative impact was anticipated due to the weight bearing restrictions at the time of the

evaluation. It was expected that the range of motion of the left ankle and knee would be limited

in both flexion in extension based on the nature of nature of the injury, the time spent in the

external fixation device and the overall lack of motion occuring in the joints. It was hypothesized

that gait mechanics may be impaired following lifting of weight bearing restrictions based on

likely range of motion deficits as well as possible hip and knee strength deficits. At the time of

the initial evaluation, the patient confirmed hypotheses made when he reported significant

limitations with functional lower extremity strength, transfers, gait.

5
 Due to the nature of the injury, it was important to assess lower extremity range of

motion and strength at the time of the initial evaluation. The patient denied changes in sensation

other than directly over scar, so a formal sensation assessment was not necessary. No formal gait

or balance outcome measurements were performed at the time of the initial evaluation second to

weight-bearing restrictions, however a visual assessment of transfers, ambulation, and navigation

of stairs was performed by the evaluating physical therapist to assess gait and dynamic balance.

A formal gait assessment to evaluate gait deviations, compensation patterns, and to assess

community access and risk of falling would be performed once his weight-bearing restrictions

were lifted.

Examination

Range of Motion. Active range of motion (AROM) testing of bilateral knee flexion and extension

was performed utilizing a long-arm goniometer to assess the patient’s joint mobility utilizing the

standard test positions as described by Reese and Bandy.14 Active range of motion assessment

using a long-arm goniometer has been found to have excellent inter-rater (ICC= 0.996) and intra-

rater (ICC= 0.993) reliability as well as high validity (ICC- 0.98-0.99) for measuring knee range

of motion.15,16

The patient presented with decreased knee flexion AROM bilaterally, greater on the left

than on the right. There was full knee extension AROM on the right lower extremity, while the

left knee lacked 17 degrees of extension actively and with therapist overpressure. The patient’s

hip and knee range of motion measurements can be found in Table 3. Right ankle ROM was

screened with visual assessment and found to be grossly within normal limits and equal to the

unaffected side, for this reason formal assessment utilizing a goniometer was not performed.

6
Strength Testing. Manual Muscle testing (MMT) of bilateral lower extremities was performed to

assess the patient’s strength with a 5-point scale to assign strength grades to each muscle as

described and defined by Kendall with the exception of left knee.17 Flexion and extension

strength of the left knee was measured within the patient’s available range of motion. A 0 on this

scale indicated no voluntary muscle contraction while a 5 indicated maximum strength of the

muscle being tested. Manual muscle testing of knee and hip flexors have been found to have

good intra-rater reliability, 0.63 and 0.74 reliability coefficients, respectively.18 A definite

relationship exists between MMT and the more objective measurement of hand-held myometer,

although MMT has greater validity when measuring muscles with a strength level below 4/5.19

The patient presented with 5/5 strength on the right lower extremity. Weakness was

present through the left knee and hip musculature. Left hip abduction was graded 3+/5 and left

hip flexion was graded 4/5. When assessing left knee flexion and extension, the patient was able

to maintain the test position against slight manual pressure. For this reason, left knee flexion and

extension strength were graded as a 3+/5 within the available range of motion.

Mobility and Ambulation. The assessing physical therapist noted that the patient was independent

with all bed mobility tasks and modified independent with transfers to and from standing. The

patient required use of bilateral upper extremities with sit-to-stand and stand to sit transfers. The

patient was ambulating safely at a modified independent level utilizing a step-to gait pattern with

bilateral axillary crutches and was able to maintain his 50% weight-bearing status. Ambulation

was slow and only performed for limited distances, less than 500 feet due to fatigue. He was able

to ascend and descend a maximum of 3 stairs safely, at a slowed pace, while maintaining

appropriate weight-bearing status utilizing a non-reciprocal pattern and bilateral axillary

7
crutches. The patient demonstrated significant fatigue following navigation of this limited

number of stairs.

Approximately 10 weeks following the ORIF and 2 weeks following the initial evaluation

in the outpatient physical therapy setting, weight-bearing restrictions were lifted by the surgeon

and ambulation was formally assessed. Gait was analyzed utilizing the Rancho Los Amigos

observational gait system.20 This method was selected because it did not require any instruments

or a great deal of time, yet it offers a systematic way to document deviations in gait. Downfalls

of this method included the requirement of multiple body segments to be observed at one time by

the therapist. Training and observational skills vary between professionals; this technique has no

published reliability or validity.20 Observational analysis with this method revealed that the

patient’s arm swing was decreased bilaterally. With the inability to attain full knee extension, the

patient ambulated with varying degrees of knee flexion of the left lower extremity through the

gait cycle, failing to achieve full knee extension during midstance and during the swing phase in

preparation for initial contact. Decreased time in left stance was accompanied by decreased right

step length. Left trunk lean was present during left stance. The left foot maintained an increased

toe-out position throughout the gait cycle.

Balance. The patient displayed normal seated balance and fair standing balance according to the

Functional Balance Grades.21 He was able to perform all required dynamic tasks in seated,

shifting weight easily through full range. In standing he required upper extremity support

through bilateral axillary crutches due to weight bearing restrictions, but displayed no difficulty

maintaining balance with this support while turning his head.

Outcome Measures. The Timed Up and Go (TUG) test assesses the mobility, walking ability,

and fall risk of an individual. The TUG was performed according to Podsiadlo and Richardson

8
once the weight-bearing restrictions were lifted.22 No normative data is currently available for

individuals who are post-operative following lower extremity orthopedic injury. It was for this

reason that normative data was used pertaining to a non-specific population slightly older than

the patient. In this population, the TUG assessment was found to be 87% sensitive, 87% specific

and have high interrater reliability (ICC=0.98) in predicting probability for falls in community-

dwelling older adults.23 Normative value for community-dwelling adults identified a cut of score

of 13.5 seconds.23 The patient completed the test in 15.6 seconds which is above the cut off

score, indicating he was at an increased risk of falling.

The 10-Meter Walk Test was performed once full weight bearing status was achieved to

quantify the patient’s comfortable walking speed. No literature was available on reliability of this

measure following lower extremity ORIF. However, this test has been found to have excellent

intra-rater reliability in healthy older adults (ICC= 0.98) and in individuals following a hip

fracture (ICC=0.82).24,25 When comparing walking speed measured with a stop watch versus the

gold standard of infrared timing gate measurement procedure it was found to have excelled

concurrent validity.26 The patient performed the test in 13.36 seconds, for a gait speed of 0.748

meters per second. This indicates that the patient was ambulating below the gender and age-

related normative value of 1.433 meters per second.27

Clinical Impression #2

Findings of the examination were largely as hypothesized with both strength and range of

motion deficits present. Decreased left knee range of motion was impairing the patient’s ability

to sit in a standard chair to participate in meal times. Standing dynamic balance was impaired

causing limitations in the patient’s ability to perform functional tasks in a standing position. This

included things such as as aiding in meal preparation, showering, and performing activities of

9
daily living standing at the bathroom vanity. Partial weight bearing status restricted ambulation

to being performed with bilateral axillary crutches. These restrictions in addition to hip and knee

strength deficits played a role in the patients decreased ambulatory endurance within his home

and the community. The patient was unable to safely navigate a full flight of stairs utilizing

crutches to sleep in his own bed. Due to these functional limitations, he was also unable to get on

the floor to play with his grandchildren, prepare meals for his family, work in the yard, or

participate in hobbies such as using his metal detector on hikes.

Once weight bearing restrictions were removed, the patient was still greatly limited due

to hip and knee strength deficits and limited knee range of motion. The also had a new fear of

falling as he reported that he did not trust his affected lower extremity to support his weight.

Reluctance to bear weight in addition to the functional strength and range deficits impaired his

ability to ambulate with propper gait mechanics, and negatively impacted his overall ability to

participate in his prior roles.

The plan of care was developed based on the patient’s performance during the initial

evaluation, the patient’s reported prior level of function, and the patient’s level of desired return

to function. Therapy goals, presented in Table 2, were established with input from the patient and

addressed sleep, knee range of motion, lower extremity strength, and independent ambulation

capacity. Interventions were developed based on deficits in knee range of motion, lower

extremity strength and deficits in independent ambulation.

It was determined that the patient had good rehabilitation potential. The patient

demonstrated willingness to participate in BWSTT and was consistent with home exercise

program compliance. Positive factors for his rehabilitation potential included good support at

home from his significant other who was retired. His motivation to improve as he wanted to

10
return to hiking, playing with his grandkids and cooking meals for his family also played a

positive role in his prognosis. Negative factors contributing to his rehab potential included his

reluctance to ambulate without crutches due to fear of reinjury, failure, and falling. He was a

good candidate for a case report as the traditional overground gait training techniques which

were initially implemented were not successful in improving quality of gait. In addition to this,

the use of BWSTT is not well studied in individuals with proximal tibial plateau and fibular

fractures.

Interventions

The patient was scheduled for outpatient physical therapy 2 times per week for 14 weeks,

but he missed 5 treatments due to scheduling conflicts, resulting in a total of 23 treatments. Each

session was 45 minutes in length. Treatment consisted of a combination of therapeutic exercise

and manual therapy in addition to overground gait training and/or BWSTT.

Treatment Weeks 1-3. During the first 2 weeks of outpatient therapy, partial weight bearing

restrictions remained, allowing interventions to be completed in partial or non-weight bearing

positions only. The patient exercised on a Nu-Step (TRS 4000, NuStep, Inc.) cross trainer

without added resistance for 5-10 minutes at the start of each appointment to facilitate gentle

range of motion of the left knee. Manual therapy interventions included functional massage of

the left distal quadriceps performed with knee flexion in sitting at the edge of the plinth as well

as passive knee flexion and extension range of motion of the left knee performed in supine to

address range of motion deficits.

Therapeutic exercises focused on knee range of motion, lower extremity strengthening,

and stretching of gastrocnemius, quadriceps and hamstring muscles . Exercises included supine

heel slides with a belt for patient self-overpressure and seated knee flexion stretching to facilitate

11
knee flexion, supine straight leg raises for hip flexor strengthening, long arc quads and short arc

quads for knee extensor strengthening, prone knee flexion and standing knee flexion

weightbearing through the unaffected lower extremity for knee flexor strengthening, side lying

hip abduction to strengthen hip abductors, bent knee fall outs in hook lying with a resistance

band for hip external rotation strengthening. Exercises varied from 1-3 sets and 9-15 repetitions

based on the patient’s quality of movement. Once 3 sets of 15 repetitions were achieved with

quality movement throughout, the exercise was progressed with an increase in weight or

resistance. Repetitions and sets were decreased with progression of the exercise to maintain

quality of movement. Repetition and set progression would then begin again. Static stretching of

the gastrocnemius was also introduced at this time to maintain muscle length. This was

performed with a belt in sitting and was held for 3 sets of 1 minute.

Treatment Weeks 3-8. During the third week of outpatient therapy, the patient received clearance

from the surgeon to be weight-bearing as tolerated on the left lower extremity, however he

continued ambulating with partial weight bearing utilizing a unilateral axillary crutch in the

home and 2 in the community because he felt unstable.

Utilization of the Nu-Step for knee range of motion continued to be used at the start of

each appointment to facilitate range of motion. Overground gait training was initiated in the

clinic first using one crutch, ambulating 60 feet with contact guard assistance. During the next

two appointments, gait training progressed to the utilization of a cane in the right upper extremity

with a step-through pattern and contact guard assistance for 60 feet. Verbal cueing from the

treating therapist was required for initiation of appropriate gait pattern. The patient was fatigued

at ready to sit following 60 feet of ambulation.

12
 The patient performed standing weight shifting onto the left lower extremity with the

contralateral leg in toe-touch weight bearing and bilateral upper extremity support for balance

training and to encourage acceptance through the involved side. Additional gait training

exercises included alternating marches, standing end range knee extensions with a ball behind

the knee at the wall, weight shifting in stride stance, and single leg stance on the affected leg

with alternating toe off to heal strike of the unaffected leg. Therapeutic exercises shifted to

closed-chain exercises in standing to facilitate weight-bearing. They included mini squats with

upper extremity support, standing alternating hip abduction at railing with light upper extremity

support, and squats without resistance on the Total Gym (Power Tower, efi Sports Medicine,

Inc.) at its maximum, 34-degree, inclined angle. Additional stretches were added, including

standing gastrocnemius stretch on a slant board and a standing hamstring stretch with the foot

propped on a step.

During week 5, the patient was not feeling well due to significantly elevated levels of

stress within his personal life and only manual therapy was performed at this appointment. The

patient attended therapy for only one appointment that week and the next week, week 6. During

the week 6 appointment, limited weight-bearing exercise was reintroduced. This included using

the Nu-step cross trainer, performing standing hamstring curl bilaterally, and performing mini

squats holding a railing. Manual therapy techniques were performed to address knee range of

motion deficits continued.

During week 7, the patient began expressing frustration and discouragement with

progress toward returning to independent walking. The patient was able to ambulate in the clinic

without the use of an assistive device, but he felt he did not trust his left lower extremity. He was

not confident of his ability to ambulate independently, and he was fearful of falling when he

13
attempted ambulating without his crutches outside of the clinic. He was still ambulating at home

and in the community with bilateral axillary crutches. It became obvious the patient was not

responding to the current treatment approach with overground gait training.

Treatment Weeks 8-14. It was a combination of patient frustration, lack of confidence, reluctance

to discontinue his assistive device, decreased quality of gait and gait symmetry, and continuing

lower extremity weakness which caused the student physical therapist and supervising physical

therapist to consider alternate approaches to traditional overground interventions. An

intervention which allowed for patient success and repetitive practice of the complete gait cycle

without asymmetry was desired.

BWSTT is a repetitive, task-specific approach that allows patients to practice complex

gait cycles in larger quantities than may be possible with overground gait training.(Hesse) Patients

treated with partial BWSTT were found to ambulate without assistive devices sooner and

demonstrate long-lasting, significant improvements in gait symmetry and hip abductor strength

when compared to those treated with traditional treatment of passive joint mobilization, lower

extremity strengthening and gait training on the floor and stairs following total hip

arthroplasty.(Hesse) It was decided to initiate BWSTT with this patient to provide a safe and

controlled environment which allowed for high repetition practive of the full giat cycle while

utilizing propper gait mechanics.

Bodyweight-supported treadmill training was performed utilizing the Biodex (945-480,

Biodex Medical Systems, Inc.) overhead harness unweighting system over a treadmill (CS400,

TRUE Fitness Technology, Inc.) in the clinic. When deciding on the amount of weight

supported, available literature was considered, revealing varying amounts of weight yielding

successful results with a variety of diagnoses. For example, Mao et al13 found significant

14
improvement in kinematic parameters and gait patterns in patients with subacute stroke

beginning at 40% body weight supported and decreasing overtime. Meanwhile, Ganesan et al28

found that significant improvements in walking distance, speed, and step length could be

achieved with 20% bodyweight support continuously throughout treatment in patients with

Parkinson Disease. Continuous, 15% body weight support was utilized by Hesse et al10 with

patients following total hip arthroplasty, finding significant improvements in hip abductor

muscle strength and gait symmetry compared to conventional therapy.

One consideration not mentioned by these authors when selecting the amount of

bodyweight support provided was the confidence of the patient in their ability to successfully

complete the task of walking on the treadmill. The patient in this case report had no weight-

bearing restrictions at this point, but he did not have the strength to ambulate independently or

the necessary confidence in his ability to successfully ambulate without an assistive device. For

this reason, it was decided to unweight the patient to a starting point at which he felt he could

successfully complete the task of walking on the treadmill. The patient slowly ambulated at 0.5

miles per hour with bilateral upper extremity support for balance on the treadmill and was

progressively unweighted starting with 15 pounds to the self-selected amount of 35 pounds

(~15.5% body weight). The treadmill was set at 2.0 miles per hour (mph), the speed at which the

patient selected he was comfortable. Both treadmill speed and amount of body weight support

were initially self-selected by the patient to allow him to feel confident in his ability to succeed.

The selected speed equated to ~70% of the patient’s comfortable walking speed over ground

according to the results from the 10 Meter Walk Test. There was 0% incline on the treadmill.

The patient was able to ambulate 10 minutes at these settings. During the intervention, the

patient required tactile cueing for available terminal knee extension and heel strike on the

15
affected lower extremity. He was able to ambulate ~50% of the time without upper extremity

assistance but displayed difficulty with reciprocal arm swing.

Progression of the intervention was based on concepts outlined by Mao et al13 where the

amount of bodyweight supported gradually decreased as the treadmill speed gradually increased;

however, the two parameters were not changed simultaneously. In the study done by Mao et al13,

the goal was to progress to 0 pounds body weight support before discontinuing treadmill

training.

For this patient, the speed of the treadmill was gradually increased to the patient’s

measured comfortable overground walking speed of 2.9 miles per hour. Consistent heel strike,

maximum available knee extension during stance and swing phases, normalized reciprocal arm

swing, equal step lengths, and the absence of trunk leaning were all required before progressing.

Once the patient demonstrated the ability to ambulate on the treadmill at the current settings for

10 minutes with all the components previously stated, the amount of weight support was

decreased. The amount of body weight support remained at 35 pounds until the fourth session

when it was decreased to 25 pounds. The speed of the treadmill decreased to 2.0 at the new

amount of weight, and the process of progression was repeated. See Table 5 for details on

performance and progression.

During this time, overground gait training was not performed in the clinic. Manual

therapy for knee range of motion and lower extremity strengthening in open and closed chain

positions. Additional strengthening exercises implemented included step-ups on an 8-inch step,

step-downs from an 8-inch step with focus on eccentric control of the knee extensors, and single

leg squats without resistance on the Total Gym at its maximum, 34-degree, inclined angle.

Exercises progression continued based on principles outlined previously.

16
Outcomes

Outcome measurements were taken 14 weeks following the initial evaluation.

Range of Motion. The patient demonstrated improvements in both knee flexion and extension

AROM between the initial evaluation and the re-evaluation 14 weeks later, with normal 0

degrees of extension achieved at this time (See Table 3).

Strength. Following 14 weeks of treatment, lower extremity strength was re-assessed via MMT.

The patient demonstrated improved muscular strength in each movement that was assessed. See

Table 4. The greatest improvements were demonstrated in hip flexion, which improved from a

4/5 to a 5/5, and knee extension strength, which improved from a 3+/5 to a 4+/5

Mobility and Ambulation. The patient was ambulating independently at home and within the

community. He was able to ascend and descend stairs with a reciprocal gait pattern without

hesitation or difficulty. He was independent with all transfers, requiring no upper extremity

support when performing sit-to-stand or stand-to-sit transfers. Observational gait assessment

using the Rancho Los Amigos Gait Evaluation tool revealed that the patient was utilizing

appropriate reciprocal arm swing throughout the gait cycle. He achieved terminal knee extension

during terminal stance and during swing phase in preparation for initial contact with both the

affected and unaffected lower extremities. Time in left stance was equivalent to right stance time

and step length was equal bilaterally. Trunk leaning was no longer present during any portion of

the gait cycle. The increased left toe-out position throughout the gait cycle remained.

The patient reported increased confidence in his ability to safely ambulate at home and in

the community. He stated he was confident in his ability to walk any distance, even on uneven

terrain outside which he would never have dreamed of attempting prior to the initiation of

BWSTT. He reported he had begun walking for exercise with his family and was able to walk

17
with ease in the grocery store, but he reported continued difficulty getting down onto and up off

from the floor independently to play with his young grandchildren as he would have done prior

to the injury.

Balance. Standing balance at the time of the re-evaluation was normal according to the

Functional Balance Grades. (O’Sullicvan et al 18) The patient was able to maintain steady balance with

dynamic balance tasks such as reaching without the need of handheld support since he no longer

had weight bearing restrictions or required an assistive device.

Outcome Measures. The patient completed the TUG test in 10.81 seconds. This was 4.8 seconds

faster than was measured during the patient’s third week of outpatient physical therapy. There

are no published MDC or minimally clinically importance difference values are available for an

orthopedic population with this test, however, cut-off scores are available to aid in identifying

fall risk within various populations. The cut off score for community dwelling adults is 13.5

seconds.23 Since the patient performed the TUG test in less than 13.5 seconds, he was no longer

considered at increased risk of falling in the community due to impaired gait speed.

The 10 Meter Walk Test was also assessed at this time. This test was completed in 9.075

seconds, indicating a comfortable gait speed of 1.10 meters per second, and a 0.352 meter per

second improvement in comfortable gait speed. While this value of improvement is not greater

than the MDC (0.82 meters per second) and he continued to demonstrate a comfortable gait

speed less than the norms for his age (1.393 meters per second), he did report significant

improvement in his day-to-day life.25,29 His score indicated that he had additional need for

continued skilled physical therapy to return to his baseline functional level.

The patient was not discharged due to continued demonstration of progress. Many of the

patient’s initial goals were met, however he continued to have difficulty performing stand to

18
quadruped and quadruped to stand transfers. This prevented him from playing on the floor with

his young grandchildren. See Table 2 for specific goal outcomes. At this point, it was determined

the patient would benefit from continued skilled physical therapy. The patient’s plan of care was

extended an additional 4 weeks, reaching beyond the authoring student physical therapist’s

assigned time within the outpatient clinic and the timeframe of this case report. Gait training

utilizing BWSTT was discontinued following this re-evaluation and the plan of care focused on

overground gait training, lower extremity strengthening, and manual therapy for flexion range of

motion to facilitate achievement of maximum functional capacity of the patient.

Discussion

The purpose of this case report was to share the treatment strategy and outcomes of

BWSTT for a patient with impaired gait following a Schatzker Type 5 fracture. Bodyweight-

supported treadmill training was used exclusively in place of traditional overground gait training

once it was determined the patient was not making sufficient improvements with overground gait

training techniques. Bodyweight- supported treadmill training allowed the patient to participate

in repetitive task specific training utilizing appropriate gait mechanics in a safe environment.

Once the patient demonstrated normalized gait mechanics and reported confidence in his ability

to ambulate independently, gait training was progressed to strictly overground training.

Gait symmetry improvements measured in the current case report are consistent with the

findings of available literature. Hesse et al10 found symmetry of time spent in swing phase of gait

was improved from 72% to 89% in the BSWTT group over the duration of treatment and

achieved 95% swing symmetry between affected and unaffected side at 3-month and 12- month

follow up measurements. This was significantly better than the control group at all 3 post-

treatment measurements. Mao et al13 found step length in BWSTT treatment group increased

19
from 0.30 meters to 0.37 meters. These findings are consistent with the current case report.

Although measurements of the current case report were not quantified into percentages and

distances, they were identified using the Rancho Los Amigos observational gait analysis tool.

The patient did achieve equal time spent in swing and step length bilaterally, contributing to

normalized gait.

The patient’s improvements in hip abductor muscle strength following BWSTT were

consistent with the findings of Hesse et al.10 The authors noted greater improvements in hip

abductor strength and muscle recruitment of gluteus medius following BWSTT than with

traditional physical therapy interventions which included overground gait training and hip

strengthening following total hip arthroplasty. Unlike the treatment group in the Hesse et al10

study, interventions for this patient included both BSWTT and lower extremity strengthening

interventions. Thus, it is possible that BSWTT contributed to the increased strength noted in this

patient, however it is not possible to quantify how much improvement in strength was due to

BWSTT versus the strength-focused therapeutic exercise.

Lliopoulos et al6 concluded that 10-months following injury, individuals with Schatzker

Type 4- Schatzker Type 6 injuries continued to demonstrate gait pattern impairment. Decreased

stance time on the affected lower extremity, when the individual is in single limb support,

remained significantly shorter on the affected limb when compared with that of the unaffected

limb. The authors did not specify what type of gait training was done with the subjects, and

BWSTT was not mentioned. The patient in this case study demonstrated no deviation in stance

time between affected and unaffected lower extremity following BWSTT at only 6 months after

injury. This is a stark contrast to the subjects in the Lliopoulos et al study, suggesting that

BWSTT may lead to greater improvements in functional gait after Schatzker injuries.

20
 Mao et al13 found significant improvement in gait speed following BWSTT 5 days per

week for 3 weeks in patients with subacute stroke. Gait speed for the treatment group in this

study increased by 0.17 meters per second, which is greater than the value identified as the

minimally clinically important difference for this population (0.16 meters per second).30 Ganesan

et al28 also found significant improvements in gait speed utilizing BWSTT with a group of

subjects diagnosed with Parkinsons Disease. Gait speed improvement in this study was 0.26

meters per second after 4 weeks, again greater than the MDC for this population (0.18 meters per

second).31 The patient in the current case report demonstrated gait speed improvements of 0.35

meters per second, a notable improvement. This value is less than the MDC available for the

population post- hip fracture, which is the closest population with this data available (0.82 meters

per second).25 The patient in this case report had not yet reached full recovery, therefore it is

possible his gait speed would continue to improve with continued treatment, eventually

surpassing the MDC. Functionally, the patient reported ability to keep up with his young

grandchildren again and stated that he had started taking evening walks with his significant other

for exercise because he had found so much joy in his ability to walk again.

There were several limitations to the current case report. The design of a case report

limits the ability to determine the causation of outcomes, therefore the interventions and

outcomes cannot be generalized to all patients with this type of lower extremity fracture. The

BWSTT was introduced 5 weeks following clearance for full weight bearing on the affected

extremity and the patient’s recovery may have been improved if this intervention was

implemented sooner.

There are several gaps in available literature regarding gait training following a tibial

plateau fracture. Additional literature is needed on the validity of the 10-meter walk test with

21
lower extremity orthopedic conditions. There is also no data currently available on the

psychometric properties of the Times Up and Go test for the population of those following lower

extremity operations or with orthopedic lower extremity conditions. There is currently no

available reliability or validity for Rancho Los Amigos visual gait analysis. Regarding

interventions, more literature is needed to address interventions which lead to effective results

with outcomes of gait speed or quality of gait in those who have had a tibial plateau fracture.

Finally, additional research is needed to justify the use of BWSTT with lower extremity

orthopedic conditions.

Future research should include randomized controlled trials assessing outcomes of

various physical therapy interventions for patients following lower extremity fractures.

Randomized controlled trials comparing the kinematic parameters of gait in patients with lower

extremity orthopedic conditions treated with BWSTT versus traditional treadmill training versus

overground gait training are also warranted. Future research should also include longitudinal

studies on rates of return to prior level of function in those with a Schatzker Type 5 fracture

when receiving traditional overground training versus BWSTT. Currently available evidence

pertaining to BWSTT has focused on patients with neurological conditions such as stroke and

Parkinson’s Disease but has not addressed its use with patients following a lower extremity

fractures. This intervention has the potential to be a useful tool in an orthopedic clinician’s

toolbox, but more evidence is needed to justify its use.

22
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Table 1.
Patient Medicationsa

Medication Dosage Frequency

Amlodipine 10 mg daily
Aripiprazole 5 mg daily
Aspirin 325 mg daily
Bupropion XL 150 mg daily
Clopidogrel 75 mg daily
Duloxetine 30 mg daily
GNP Softener 100 mg twice daily
Hydrocodone-acetaminophen 7.5-325 mg per every 6 hours as needed
tablet, 1.5 tablets
Lisinopril 5 mg daily
Nitroglycerin 0.4 mg every 5 minutes as needed, not to
exceed 3 doses in 15 min
Rosuvastatin 40 mg daily
Thiamine 100 mg daily
a
mg= milligrams
Table 2.
Physical Therapy Goals

Goal Outcomes
1. The patient will experience decrease in left knee pain to 0/10 to be able to Partially
sleep through the night without waking to symptoms. Met
2. The patient will improve knee flexion range of motion to 90 degrees or Goal Met
greater to allow him to sit for greater than 30 minutes without experiencing
discomfort.
3. The patient’s left quadriceps strength will improve to 4/5 or greater to be Goal Met
able to stand for periods greater than 30 minutes to allow him to return to
meal preparation
4. The patient will achieve knee extension range of motion of 5 degrees or less Goal Met
from full extension ROM to reduce antalgic gait.
5. The patient will be able to return to ambulating 0.50 miles or more without Goal Met
the use of an assistive device or compensation to allow him to return to age-
appropriate activities and hobbies, such as walking in nature and using his
metal detector.
6. The patient will demonstrate ability to get onto and up from the floor Partially
independently to allow him to play with and help care for his young Met
grandchildren.
7. The patient will demonstrate the ability to ascend and descend 10 stairs with Goal Met
a reciprocal gait pattern to allow him safe access to all levels of his home.
Table 3.
Lower Extremity Active Range of Motion

Movement Initial Eval: Initial Eval: 14 Weeks After

Right Lower Left Lower Eval: Left
Extremity Extremity Lower
Extremity
Knee Flexion 130 degrees 60 degrees 91 degrees
Knee Extension 0 degrees -17 degrees 0 degrees
Table 4.
Lower Extremity Manual Muscle Testingb

Movement Initial Eval: Left 14 Weeks After

Strength Grade Eval: Left Strength
Grade
Hip Flexion 4 5
Hip Abduction 3+ 4+
Hip Extension 3+ 4
Knee Flexion 3+ 4-
Knee Extension 3+ 4+
b
3+ = holds test position against slight pressure, 4-= holds test position against slight to moderate
pressure, 4= holds test position against moderate pressure, 4+= holds test position against
moderate to strong pressure, 5= holds test position against strong pressure.
Table 5.
Treadmill Trainingc

Appointment Time Weight Supported Treadmill Incline

Number Speed
13 10 min 35 lbs 2.0 mph 0%
14 10 min 35lbs 2.0 mph 0%
15 10 min 35 lbs 2.5 mph (5 0%
min), 2.9 mph
(5 min)
16 10 min 35 lbs 2.9 mph 0%
17 10 min 25 lbs 2.5 mph 0%
18 10 min 25 lbs 2.5 mph (5 0%
min), 2.7 mph
(5 min)
19 10 min 25 lbs 2.7 mph 0%
20 10 min 25 lbs 2.9 mph 0%
21 10 min 22 lbs 2.7 mph (5 0%
min), 2.9 (5
min)
22 10 min 22 lbs 2.9 mph 0%
c
min= minute, lbs= pounds, mph= miles per hour