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A Comparison of the Effects of Overground Gait Training and Treadmill Gait Training According to Stroke Patients’ Gait Velocity
Abstract
[Purpose] The purpose of this study was to compare the effects of overground gait training (OGT) and treadmill gait training (TGT) on walking speed, gait endurance, and balance ability of subjects with stroke. [Subjects and Methods] The study subjects were 40 patients with stroke. They were randomly divided into two groups, the OGT group and the TGT group, and further categorized according to their individual walking speeds (slow <0.5 m/s and fast >0.5 m/s). The groups performed exercises 10 times for a week. Pre- and post-test assessments involved the measurement of walking speed, walking endurance, and balance ability, as assessed by the 10-m walking time, the 6-min walking distance, and the Berg Balance Scale (BBS). [Results] The 10-m walking times, 6-min walking distance, and BBS scores of both the OGT group and the TGT group significantly improved, but there were no significant differences between the two groups. In the slow walking speed group, the OGT subjects showed significant improvement compared to the TGT subjects in the 6-min walk test. [Conclusion] Overall, we conclude that OGT was more effective at improving the gait endurance of stroke patients than TGT. Further research is needed to verify the generalizability of these findings and to identify which stroke patients might benefit from OGT.
... Most studies (73%) utilized TT without BWS. Of the 26 studies included, 15 studies investigated TT versus other physiotherapy interventions such as overground walking training [45,47,53,56,57], BWS overground walking training [49], conventional gait therapy [46,48,58], stepping activities [50], conventional rehabilitation (neurodevelopmental therapy) [52], stretches or range-of-motion exercises [51,55], upper and lower limb exercises [54], or relaxation [44]. The other 11 studies investigated TT versus another type of TT. ...
... The challenge rating for experimental and comparison groups is provided in Table 3 and the information used to classify the challenge is provided in Table 4. For the 15 studies comparing TT versus other physiotherapy, 5 studies compared 2 low-challenge interventions [49,52,53,56,57], 1 study compared 2 moderate-challenge interventions [47], 4 studies compared a moderate-challenge TT intervention against a low-challenge physiotherapy intervention [44,46,51,54], and 5 studies compared a high-challenge TT intervention against a low-challenge physiotherapy intervention [45,48,50,55,58]. For the 11 studies comparing 2 different types of TT, the majority (n = 9) matched the challenge level in the experimental and comparison groups; 5 studies compared 2 low-challenge TT interventions [62,63,[66][67][68], 4 studies compared 2 moderate-challenge TT interventions [59,61,64,65], 1 compared high-challenge TT versus moderate-challenge TT [60], and 1 compared high-challenge TT versus low-challenge TT [36]. ...
... The majority of studies (n = 16) measured both walking endurance with the 6 MWT and walking speed with the 10 mWT [36,[44][45][46][47]49,51,54,56,[59][60][61][62]64,65,67]. Three studies measured walking endurance only [50,55,57] and seven studies measured walking speed only [48,52,53,58,63,66,68]. ...
Intervention parameters such as the challenge, amount, and dosage (challenge × amount) have the potential to alter the efficacy of rehabilitation interventions after stroke. This systematic review investigated the effect of intervention parameters of challenge, amount, and dosage on improvements in walking outcomes following treadmill training (TT) and comparison interventions in people with stroke. Randomized controlled trials were included if they: (i) investigated interventions of TT or bodyweight-supported TT (BWSTT); (ii) made comparisons with other physiotherapy interventions, other types of TT, or no intervention; (iii) studied people with stroke; (iv) reported sufficient data on challenge and amount parameters; and (v) measured walking speed or endurance. Completeness of reporting was evaluated using the TIDieR-Rehab checklist and risk of bias was assessed using the revised Cochrane risk-of-bias tool. The review included 26 studies; 15 studies compared TT or BWSTT with other physiotherapy interventions and 11 studies compared different types of TT. Meta-analyses provided evidence with low to moderate certainty that greater differences in challenge and dosage between treadmill and comparison physiotherapy interventions produced greater effects on walking endurance (p < 0.01). However, challenge and dosage did not influence walking speed outcomes. The analysis of intervention amount was limited by the lack of studies that manipulated the amount of intervention. Overall, the findings indicate that, after stroke, some of the efficacy of TT on walking endurance can be explained by the challenge level during training. This supports the implementation of TT at higher challenge levels in stroke rehabilitation practice.
... Thirty-eight papers failed to meet the inclusion criteria (see Appendix 2 on the eAddenda for a summary of the excluded papers) leaving 17 papers to be included. [16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] Two papers 26,27 had the same sample and were therefore reported as a single trial. One paper 29 reported a trial with three arms, which could be used to answer both clinical questions. ...
... The 16 trials, which included 713 participants, investigated the effects of mechanically assisted walking for improving walking speed (n = 16), [16][17][18][19][20][21][22][23][24][25][26][28][29][30][31][32] walking distance (n = 12), [16][17][18][19][20]22,24,25,[28][29][30][31] and participation (n = 4) [16][17][18]27 after stroke (Table 1). Eight trials 16,17,20,[22][23][24]26,27,29 (n = 422 participants) compared mechanically assisted walking with no/non-walking intervention, and nine trials 18,19,21,25,[28][29][30][31][32] was requested from the authors of five papers 23,28,29,31,32 and received from one author. ...
... The 16 trials, which included 713 participants, investigated the effects of mechanically assisted walking for improving walking speed (n = 16), [16][17][18][19][20][21][22][23][24][25][26][28][29][30][31][32] walking distance (n = 12), [16][17][18][19][20]22,24,25,[28][29][30][31] and participation (n = 4) [16][17][18]27 after stroke (Table 1). Eight trials 16,17,20,[22][23][24]26,27,29 (n = 422 participants) compared mechanically assisted walking with no/non-walking intervention, and nine trials 18,19,21,25,[28][29][30][31][32] was requested from the authors of five papers 23,28,29,31,32 and received from one author. ...
Questions
Does mechanically assisted walking improve walking speed, distance and participation compared with no/non-walking intervention or overground walking after stroke? Are any benefits maintained beyond the intervention period?
Design
Systematic review of randomised trials with meta-analysis.
Participants
Ambulatory adults at any time after stroke.
Intervention
Mechanically assisted walking (treadmill or gait trainer) without body weight support.
Outcome measures
Walking speed, walking distance and participation.
Results
Fifteen trials involving 673 participants were included. The mean PEDro score of the trials was 6.3 (range 4 to 8). Treadmill walking increased walking speed by 0.13 m/s (95% CI 0.08 to 0.19) and distance by 46 m (95% CI 24 to 68) compared with no/non-walking intervention; these effects were largely maintained beyond the intervention. Treadmill walking had a similar or better effect on walking speed (MD 0.07 m/s, 95% CI 0.00 to 0.13) and distance (MD 18 m, 95% CI 1 to 36) compared with overground walking. The estimate of the relative effect of treadmill walking compared with overground walking on participation was very imprecise (SMD 0.16, 95% CI −0.15 to 0.48).
Conclusion
This systematic review provides moderate-quality evidence that the effect of treadmill walking is the same as or better than the effect of overground walking for improving walking speed and distance in ambulatory people after stroke. Long-term effects and carryover benefits to participation remain uncertain.
Review Registration
PROSPERO (CRD42020162778).
... Over-ground walking training with partial body weight support also improves spatio-temporal gait parameters of stroke patients [15]. It increases walking speed, endurance, and balance [16]. A study found that combined treadmill and over-ground walking program was effective in improving functional ambulation after stroke [17]. ...
... Additionally, studies have also compared the effectiveness of treadmill training and over-ground walking exercise on functional ambulation recovery post stroke but up to date there is no consensus on which of the two treatment protocols is the most effective. For instance, it was reported that over-ground walking was more effective in improving gait endurance than treadmill training [16]. Over-ground walking also produced higher muscle activity and activated several muscles during gait cycle compared with robot-assisted treadmill walking [11]. ...
... Another study reported that treadmill exercise improves functional mobility in patients with chronic stroke [13]. In-line with the findings of this study, treadmill training was found to improve walking speed and gait endurance [16]. It also leads to recovery of gait and balance in stroke patients [16,22]. ...
The recovery of ambulation is an important focus of rehabilitation for both stroke survivors and their rehabilitation team. This study was conducted to compare the therapeutic efficacy of treadmill training and combination of bicycle ergometer & over ground walk training on functional ambulation (FA) post stroke. Fifteen stroke survivors participated in a 6-week, 2-group quasi-experimental study which was conducted at the Aminu Kano Teaching Hospital. Walking speed was used to rate FA of participants. Participants were randomly distributed into 2 groups: A (tread-mill training) and B (bicycle ergometer and over ground walking training). The data was analysed with inferential statistics of Wilcoxon sign rank test and Mann-Whitney U test to determine within and between group differences in FA respectively. The mean age and baseline FA of the participants in group A was 47.78 ± 8.17 years and 0.32±0.08 m/s while that of participants in group B was 46.9 ± 7.11 years and 0.34±0.15 m/s. There were a significant within group difference (pre versus post intervention) in the scores of FA in group A (p=0.018) and group B (p=0.043). There was however insignificant between group difference (treadmill versus bicycle ergometer and over ground walking) in FA at baseline (p>0.05) and post intervention periods (p>0.05). This study concluded that both treadmill training and combination of bicycle ergometer and over ground walking are effective in the retraining FA post stroke, however, combination of 2 task-oriented exercises did yield better recovery of FA than using treadmill training alone. Ke y w o rd s : stroke, treadmill, over-ground walk, bicycle ergometer, functional ambulation
... DePaul et al. (44) used a motor-learning-science-based overground walking program, which resulted in an average 0.14 m/s gait speed improvement. Park et al. (45) compared the effects of gait training overground versus treadmills and found the largest gait speed improvement, from any of the training conditions, to be 0.1 m/s. The reported gait speed changes from the present study are approximately two to three times greater than those reported by these gait-focused studies and additionally highlight retention, a critical factor not demonstrated in the prior mentioned studies. ...
... Additionally, a lack of a control group limits direct comparison to standard treatments and does not explore the effect of the device in comparison to the concomitant walking activity. However, while the lack of a control group is a limitation, the effect of simply walking on the outcome of gait speed has been thoroughly investigated in the literature (with varying durations, contexts, and intensities explored) (45,(53)(54)(55). The outcomes of these studies demonstrate a substantially lesser gait speed effect than noted in the present study. ...
Background
Gait impairments after stroke are associated with numerous physical and psychological consequences. Treatment with the iStride® gait device has been shown to facilitate improvements to gait function, including gait speed, for chronic stroke survivors with hemiparesis. This study examines the long-term gait speed changes up to 12 months after treatment with the gait device.
Methods
Eighteen individuals at least one-year post-stroke completed a target of 12, 30-minute treatment sessions with the gait device in their home environment. Gait speed was measured at baseline and five follow-up sessions after the treatment period: one week, one month, three months, six months, and 12 months. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame. Additional analysis included comparison to the minimal clinically important difference (MCID), evaluation of gait speed classification changes, and review of subjective questionnaires.
Results
Participants retained an average gait speed improvement >0.21 m/s compared to baseline at all post-treatment time frames. Additionally, 94% of participants improved their gait speed beyond the MCID during one or more post-treatment measurements, and 88% subjectively reported a gait speed improvement.
Conclusion
Treatment with the gait device may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.
Clinical trial registration
https://clinicaltrials.gov/ct2/show/NCT03649217, identifier NCT03649217.
... There are some other similar studies which have nearly similar effect such as a study conducted by Park et al., (2013) [30] by an RCT where 40 participants of stroke included. They were randomly divided into two groups, the OGT group and the TGT group, and further categorized according to their individual walking speeds. ...
... There are some other similar studies which have nearly similar effect such as a study conducted by Park et al., (2013) [30] by an RCT where 40 participants of stroke included. They were randomly divided into two groups, the OGT group and the TGT group, and further categorized according to their individual walking speeds. ...
Background: Body-weight-supported treadmill training (BWSTT) or herness system is a new approach to treat gait recovery among stroke patients.
Objectives: To explore the effects of gait training using body weight supported treadmill or herness system among
stroke patients.
Methodology: This study aimed to explore the effectiveness of gait training using body-weight-supported treadmill among stroke patients by reviewing of the article. Five articles were reviewed in order to fulfil the purpose of this study. With a PEDro score ranging from 4 to 8, randomized controlled trial was used. Each article is analyzed carefully to find out the effectiveness of the intervention.
Results: In this study found that both BWSTT and conventional overground training has beneficiary effects for
recovery and had impact on parameters related to balance, mobility, and fear of falling among stroke patients.
Conclusion: To determine the intensity and precise number of training sessions that should be carried out to restore normal gait, more and better study is required.
... Treadmills are widely used in exercise, gait analysis, and rehabilitation training (Colombo et al., 2000;Pohl et al., 2002;Pohl et al., 2003;Fung et al., 2006;Park et al., 2013) because they provide a convenient way to walk and run in a relatively narrow indoor space. Meanwhile, a number of studies reported that walking on a treadmill is different from overground walking (Elliott and Blanksby, 1976;Pearce et al., 1983;Dingwell et al., 2001;Nymark et al., 2005;Dasilva et al., 2011). ...
... In actual experiments, it is impossible to change only the body mass while fixing all other factors. The subject should be changed such that a different body mass can be investigated; however, because of the uniqueness of gait kinematics, the gait motion changes while other factors are changed (Park et al., 2021). However, we trained the four gait controllers with each body mass (47, 63, 79, and 95 kg) using identical geometrical models and reference motions. ...
Treadmills are widely used in rehabilitation and gait analysis. However, previous studies have reported differences in terms of kinematics and kinetics between treadmill and overground walking due to physical and psychological factors. The aim of this study was to analyze gait differences due to only the physical factors of treadmill walking. Walking motions of a male participant were captured at 0.63, 1.05, 1.33, and 3.91 m/s. A gait controller of a virtual subject (63 kg) was trained for ground walking at each walking speed via a reinforcement learning method. Additionally, the gait controllers of virtual subjects with different body masses of 47, 79, and 94 kg were trained for ground walking at 1.05 m/s. The gait controllers and virtual subjects were tested for treadmill walking, and their lower-limb joint kinematics were compared with those for ground walking. Treadmill conditions of maximum allowable belt force and feedback control frequency of belt speed were set between 100 and 500 N and between 10 and 50 Hz, respectively. The lower-limb kinematics were identical between the two conditions regardless of the body mass and walking speed when the belt could provide a constant speed regardless of external perturbation in the ideal treadmill. However, kinematic differences were observed when simulation was performed on a non-ideal treadmill with a relatively low belt force and control frequency of belt speed. The root-mean-square differences of the hip, knee, and ankle flexion angles between treadmill and overground running at 3.91 m/s increased by 3.76°, 3.73°, and 4.91°, respectively, when the maximum belt force and control frequency decreased from infinity to 100 N and 10 Hz, respectively. At a maximum belt force exceeding 400 N or a control frequency exceeding 25 Hz, the root-mean-square difference of the joint kinematics was less than 3° for all body masses and walking speeds. Virtual subjects walking on non-ideal treadmills showed different joint kinematics from ground walking. The study identified physical factors that differentiate treadmill walking from overground walking, and suggested the belt forces and control frequencies of a treadmill to achieve the desired limit of kinematic differences.
... Many studies have harnessed VR technology to simulate walking environments, which is crucial for gait rehabilitation [24]. Typically, gait rehabilitation involves walking either overground or on treadmills [41]. Moan et al. [34] developed a fully immersive virtual reality treadmill game for post-stroke rehabilitation. ...
... Gait-specific training interventions, such as overground training [22], treadmill training without or with bodyweight support [23,24] or robotic-assisted gait training [25,26], focus on the automaticity of walking by providing repetitive stepping practice. These modalities have shown several benefits leading to improve walking ability. ...
Corticospinal excitability is subject to alterations after stroke. While the reversal of these alterations has been proposed as an underlying mechanism for improved walking capacity after gait-specific training, this has not yet been clearly demonstrated. Therefore, the objective of this review is to evaluate the effect of gait-specific training on corticospinal excitability in stroke survivors. We conducted an electronic database search in four databases (i.e., Medline, Embase, CINAHL and Web of Science) in June 2022. Two authors screened in an independent way all the studies and selected those that investigated the effect of gait-specific training on variables such as motor-evoked potential amplitude, motor threshold, map size, latency, and corticospinal silent period in stroke survivors. Nineteen studies investigating the effect of gait-specific training on corticospinal excitability were included. Some studies showed an increased MEP amplitude (7/16 studies), a decreased latency (5/7studies), a decreased motor threshold (4/8 studies), an increased map size (2/3 studies) and a decreased cortical silent period (1/2 study) after gait-specific training. No change has been reported in terms of short interval intracortical inhibition after training. Five studies did not report any significant effect after gait-specific training on corticospinal excitability. The results of this systematic review suggest that gait-specific training modalities can drive neuroplastic adaptation among stroke survivors. However, given the methodological disparity of the included studies, additional clinical trials of better methodological quality are needed to establish conclusions. The results of this review can therefore be used to develop future studies to better understand the effects of gait-specific training on the central nervous system.
... The provision of direct feedback about the achievement of desired outcomes improves task performance, and the number of errors is reduced (Salmoni et al. 1984;BaniAsadi and Salehian 2021). Gait training involves multiple interventions such as treadmill training (Park et al. 2013), virtual reality training (de Melo et al. 2018), motor imagery (Heremans et al. 2012), visual and auditory cueing (Ginis et al. 2018), and biofeedback (Tate and Milner 2010). These interventions focus on improving various parameters of gait mainly through repeated practice. ...
This study investigated transfer of training from upper extremity limbs (the index fingers) to the lower extremity limbs (the legs) for performance of three gait sequences of different difficulty. Fifteen subjects participated in the study. Subjects in an iPad training group practiced by sequentially moving their left-and right-hand index fingers across tiles to each of three targets displayed on an iPad for 20 trials. Subjects in a gait training group practiced by sequentially walking across tiles to each of the 3 targets displayed on a screen for 20 trials. A no practice group did not receive practice trials. Immediately following practice of each level of difficulty, a transfer test (20 trials) was given for which subjects walked to the target just practiced. A retention test of 36 trials (12 trials at each difficulty level) was administered 20 min following performance of the last transfer test trial. The retention test showed that reaction times were shorter for the iPad training than gait training and no training groups; anticipatory postural adjustment times were equivalent for the iPad and gait training groups, but shorter than for the no training group; and movement times were shorter for the iPad training group than for the gait training and no training groups. These results suggest that iPad training (upper extremity) followed by performance of gait training (lower extremity) had greater benefits for learning (as measured by the delayed retention test) the gait sequences than practicing the actual gait sequences themselves.
... In stroke survivors, regaining gait function is the most frequent self-stated rehabilitation goal (Bohannon et al., 1988;Maclean et al., 2000) and plays a vital role in regaining independence (Mant and Walker, 2011). Gait rehabilitation is typically performed as over ground walking or treadmill walking (Park et al., 2013). Treadmill walking is an attractive option as it allows for continuous walking of varying lengths in a safe and controlled environment. ...
Use of VR-games is considered a promising treatment approach in stroke rehabilitation. However, there is little knowledge on the use and expectations of patients and health professionals regarding the use of treadmill walking in a fully immersive virtual environment as a rehabilitation tool for gait training for stroke survivors. The objectives of the current study were to determine whether stroke survivors can use fully immersive VR utilizing modern HMDs while walking on a treadmill without adverse effects, and to investigate the experiences of stroke survivors and clinicians after testing with focus on acceptability and potential utilization in rehabilitation. A qualitative research design with semi-structured interviews was used to collect data. Five stroke survivors and five clinicians participated in the study and tested a custom-made VR-game on the treadmill before participating in individual semi-structured interview. Data were analyzed through thematic analysis. The analysis of the interview data identified two main categories: (1) experiencing acceptability through safety and motivation, and (2) implementing fully immersive VR in rehabilitation. Both stroke survivors' and clinicians enjoyed the treadmill-based VR-game and felt safe when using it. The stroke survivors experienced motivation for exercising and achievement by fulfilling tasks during the gaming session as the VR-game was engaging. The clinicians found additional motivation by competing in the game. Both groups saw a potential for use in gait rehabilitation after stroke, on the premise of individual adaptation to each patient's needs, and the technology being easy to use. The findings from this qualitative study suggest that a fully immersive treadmill-based VR-game is acceptable and potentially useful as part of gait rehabilitation after stroke, as it was positively received by both stroke survivors and clinicians working within stroke rehabilitation. The participants reported that they experienced motivation in the game through safety, engagement and achievement. They also saw the potential of implementing such a setup in their own rehabilitation setting. Elements that enable safety and engaging experience are important to maintain when using a fully immersive VR-game in stroke rehabilitation.
... A similar mechanism was validated for haptic feedback to the hand in our prior work [29]. We focus our investigation on overground training because it offers improvements of walking function that are comparable to or greater than training on a treadmill without the cost and space that a treadmill requires [30][31][32]. ...
This paper introduces a new device for gait rehabilitation, the gait propulsion trainer (GPT). It consists of two main components (a stationary device and a wearable system) that work together to apply periodic stance-phase resistance as the user walks overground. The stationary device provides the resistance forces via a cable that tethers the user's pelvis to a magnetic-particle brake. The wearable system detects gait events via foot switches to control the timing of the resistance forces. A hardware verification test confirmed that the GPT functions as intended. We conducted a pilot study in which one healthy adult and one stroke survivor walked with the GPT with increasing resistance levels. As hypothesized, the periodic stance-phase resistance caused the healthy participant to walk asymmetrically, with greatly reduced propulsion impulse symmetry; as GPT resistance increased, the walking speed also decreased, and the propulsion impulse appeared to increase for both legs. In contrast, the stroke participant responded to GPT resistance by walking faster and more symmetrically in terms of both propulsion impulse and step length. Thus, this paper shows promising results of short-term training with the GPT, and more studies will follow to explore its long-term effects on hemiparetic gait.
... Additionally, to hypothesize that the gait speed and balance improvements were caused only by walking, one must hypothesize that the altered step mechanics caused by the gait device did not impact the improvement, which is unlikely given the improvements shown on split-belt treadmills. 17 Further, Park et al. 44 evaluated individuals with chronic stroke who were categorized into either slow (<0.5 m/s) or fast (>0.5 m/s) walking groups. All individuals walked either overground or on a treadmill for 30 minutes twice a day, five days a week, for four weeks for a total of 20 hours of walking. ...
Background
Hemiparesis is a common disabling consequence of stroke that leads to abnormal gait patterns marked by asymmetries in step length, stance, and swing phases. Asymmetric gait patterns are correlated with decreased gait velocity and increased susceptibility to falls that can lead to serious injuries and hospitalizations.
Objective
In this single group, before and after study, treatment with the iStrideTM gait device, designed to improve the gait patterns of individuals with hemiparesis, is adapted to the home environment. Previously tested in clinical settings, this study investigates if using the iStrideTM gait device within the home environment can provide safe and effective gait treatment for individuals with hemiparetic gait impairments caused by stroke.
Methods
Twelve 30-minute sessions of walking on the device were administered in each participant’s home environment. Twenty-one participants who were more than one-year post-stroke received the treatment. The Ten-Meter Walk Test, Timed Up and Go Test, Berg Balance Scale, Functional Gait Assessment, and Stroke Specific Quality of Life Scale were performed before and one week after treatment. Safety, treatment plan compliance, and subjective responses were also recorded during the study period.
Results
Results demonstrate statistically significant improvement on all five outcome measures from before treatment to one week after the last treatment session (p < 0.01) using two-tailed paired t-tests. 76% of participants improved beyond the small meaningful change or minimal detectable change on three or more outcome measures. 67% of participants improved clinically in gait speed and on at least one of the fall risk assessment inventories. 81% of the participants were able to perform the treatment in their home without assistance before the end of week three.
Conclusions
The results indicate that the iStrideTM gait device can facilitate effective, safe, and home-accessible gait treatment opportunities for individuals with hemiparesis from stroke.
... Weight-symmetry, stability index and WS were improved in 10 CSP after action observation training with functional electrical stimulation (FES) during 6 weeks in (I.-M. Park et al., 2013). Improvements in postural stability and gait ability of 20 CSP who performed walking training with action observation during 8 weeks were reported (E. ...
Stroke basically consists in brain-cells death due to lack or excess of blood. Stroke has many important consequences and falls are one of the most concerning. Falls can produce several injures from minor lacerations to fractures and death. It has been found that balance and gait impairments after stroke are important risk factors for fall. Hence, improving balance and gait ability in stroke survivors can significantly reduce falls rate. In this literature review, we review the main characteristic and the therapeutic results of different therapeutic interventions aimed at improving balance and walking ability. The main therapeutic interventions included are the Bobath therapy, exercise-based interventions, orthotic and assistive devices, modality treatments, alternative therapies, robotic-assisted training, and computational-based interventions. The parameters considered as evidence of balance and/or gait recovery after a specific intervention are: walking speed (WS), cadence, endurance, stride/step length, weight/walking symmetry, and sway. Our main findings are: 1) The wide use of the Bobath concept is not well supported by evidence due to its performance has been found to be inferior to some exercises-based interventions such as walking training; 2) exercises-based interventions were classified as strength and task-specific training. The former improves muscular and bone health, aerobic capability, and prepares the patient to perform a more demanding activity. The latter is designed as a repetitive training of a functional activity, mainly walking, and sit to stand exercises, which improve both gait and balance. Orthotic and assistive devices have effects on balance and gait but only while they are worn or used; 3) robotic assisted walking-training presented similar results to overground or treadmill walking training in terms of walking speed and balance recovery. However, the most important advantage lies on the reduction of burden for therapists; 4) thee most important use of motion analysis is as a tool for identify the causes deficits in a patient and the to design a therapy in accordance; 5) motion synthesis can be used as a tool to answer very specific questions related to capabilities/limitations of a patient. For instance, “what would be the effect of increasing hip-torque capability of a stroke survivor on the walking-symmetry?” The answer to this question would either help to design an exercise/intervention or to discard such intervention due to low impact; 6) some treatments are added to a main therapy to increase its effect on a given parameter. Functional electrical stimulation, which is added to cycling training to improve motion patterns. Biofeedback is used during balance training to reduce weight-asymmetry. And virtual reality and video games are used to increase motivation and permanence of patient on a therapy; 7) we found some alternative or no widely used therapies. Among the most promising we can mention Tai-Chi exercises, which integrates physical and mental activities to improve balance and gait and rhythmic auditory stimulation that improves WS and weight-symmetry; and 8) orthotics devices help to reduce falls by extending the base of support but the effect appears only while they are worn. In general, there is not an ultimate therapy able to fit to every patient. The choice should depend on patient’s goals and conditions. Moreover, falls can not be eliminated but they can be substantially reduced by improving balance and gait.
... However, overground gait training delivers a more realistic walking experience for patients with better balance function as obstacles and turns can be more easily introduced to stimulate multiple senses. Recovering stroke patients consume less metabolic energy [38] and improve their gait endurance [39] when walking on real ground rather than on a treadmill. Therefore, individuals with stroke that are capable of unassisted walking can benefit from the use of a system that enables overground gait training. ...
The aim of gait rehabilitation is to achieve independent ambulation. Somatosensory augmentation with external haptic sources can improve the subject’s ability to walk or stand. This paper presents the development and evaluation of a robotic system prototype that delivers haptic forces to aid overground gait rehabilitation. This portable system is based on a compact, mobile robot that is equipped with force and LIDAR sensors. The robot is flexibly linked to the user, which allows the force interaction between the user and machine to be halted when desired. During operation, the system can dynamically transition between modes in which force is applied or distance is maintained to emulate the experience of a human walking a dog on a leash. The haptic feedback from our system was evaluated in a pilot study that involved six young, healthy subjects and one individual recovering from a hemiparetic stroke. The study comprised independent and device-assisted walking trials. When using the device, the subjects walked continuously as it transitioned between distance and force modes. Gait speed and step length increased when force was applied and decreased as the force was removed. The improvements exhibited by an individual suffering from stroke were similar to those exhibited by healthy subjects. The application of haptic forces has a high potential for improving the efficiency of overground gait training with simple interactions.
... Walking ability is instrumental for independence in daily living, and gait rehabilitation is an important part of physiotherapy practice [1]. Gait rehabilitation can be performed as overground walking and as treadmill walking [2]. The latter is an attractive option because it allows for safe and continuous walking of varying lengths, which has been shown to have an impact on rehabilitation outcomes [3,4]. ...
Virtual environments (VE) are increasingly used in rehabilitation settings for gait training, and positive effects are reported. However, little is known about how walking under environmental constraints and solving motor tasks in fully immersive VEs impact gait patterns.
We investigated how gait patterns in healthy adults are impacted by walking under environmental constraints and solving motor tasks on a treadmill, in a fully immersive VE.
Gait patterns were impacted by solving motor tasks, and by environmental constraints, in healthy young adults, suggesting increased need for balance control. We suggest that VE-training on a treadmill holds potential for improving gait and balance control.
... 223 Additional studies that focused on walking training included 3 studies that used rhythmic auditory stimulation during walking [224][225][226] ; 2 that used community-based ambulation training 41,227 ; and studies that incorporated daily stepping feedback with treadmill walking, 228 inclined, 229 turning, 230 obstacle crossing, 231 and combined electrical stimulation with fast and slow treadmill walking. 232 Other studies utilized assisted arm swing with treadmill walking 233 ; incorporated dual task performance 234 ; and compared standard treadmill training without BWS to overground training, 225,235 and 2 studies evaluated treadmill training with postural corrections 236 or provided with feedback of spatiotemporal gait patterns. 237 Many of these studies demonstrated positive findings compared with the control interventions, and future revisions of this CPG may incorporate these findings given sufficient evidence. ...
Background:
Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.
Methods:
A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.
Results:
Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.
Discussion:
The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.
Limitations:
As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.
Summary:
The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.
Disclaimer:
These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.
... Additionally, to hypothesize that the gait speed and balance improvements were caused only by walking, one must hypothesize that the altered step mechanics caused by the gait device did not impact the improvement, which is unlikely given the improvements shown on split-belt treadmills. 17 Further, Park et al. 44 evaluated individuals with chronic stroke who were categorized into either slow (<0.5 m/s) or fast (>0.5 m/s) walking groups. All individuals walked either overground or on a treadmill for 30 minutes twice a day, five days a week, for four weeks for a total of 20 hours of walking. ...
... A study with a larger sample size will provide more details about how these effects generalize across different stroke gait patterns. Another limitation is that this study did not have a matched control group to compare to standard physical therapy or simply walking for a similar amount of time [64]. Despite these limitations, the initial results are promising and suggest that further study is warranted. ...
Background:
Gait impairment is a common consequence of stroke and typically involves a hemiparetic or asymmetric walking pattern. Asymmetric gait patterns are correlated with decreased gait velocity and efficiency as well as increased susceptibility to serious falls and injuries.
Research question:
This paper presents an innovative device worn on a foot for gait rehabilitation post stroke. The device generates a backward motion to the foot, which is designed to exaggerate the existing step length asymmetry while walking over ground. We hypothesize this motion will decrease gait asymmetry and improve functional walking in individuals with chronic stroke.
Methods:
Six participants with chronic stroke, more than one year post stroke, received four weeks of gait training with three sessions per week. Each session included 30 min of walking over ground using the wearable device. Gait symmetry and functional walking were assessed before and after training.
Results:
All participants improved step length symmetry, and four participants improved double limb support symmetry. All participants improved on all three functional outcomes (gait velocity, Timed Up and Go Test, and 6-Minute Walk Test), and five participants improved beyond the minimal detectable change or meaningful change in at least one functional outcome.
Conclusion:
The results indicate that the presented device may help improve stroke patients' walking ability and warrant further study. A gait training approach using this new device may enable and expand long-term continuous gait rehabilitation outside the clinic following stroke.
Trial registration:
NCT02185404. Registered July 9, 2014, https://clinicaltrials.gov/ct2/show/NCT02185404.
... A study reported that lowerextremity muscle strengthening exercises and treadmill walking exercises had positive effects on balance ability and skeletal musclestrength 14) . In addition, walking exercises have positive effects on cardiorespiratory functional capacity 15) , and when stroke patients' walking outside and walking on the treadmill were compared at low and high speeds, statistically significant changes were observed in endurance, walking speed, and balance ability 16) . Another study instructed hemiplegic patients to walk at a speed of 1 km/h for 30 seconds, have a break, and then walk again at a speed of 2 km/h for 30 seconds after adapting to this main walking exercise by initially walking at comfortable speeds. ...
[Purpose] The purpose of this study was to identify whether walking on a treadmill at an adjusted speed is suitable for humans by examining the effects of exercise on the joint functions of white rats with induced knee osteoarthritis. [Subjects and Methods] The subjects were 20 Sprague-Dawley white rats, aged eight weeks, weighing 250 to 300 g. The moderate-speed exercise group performed their exercise at a gradient of 0% and a speed of 15 m/min, and the high-speed exercise group performed their exercise at a gradient of 0% and a speed of 26 m/min. [Results] Statistically significant changes were elicited by the moderate-speed and high-speed exercises. [Conclusion] In conclusion, the results of the present study present the importance of walking exercise. In particular, they demonstrate that changes in knee ROM and stance time are elicited by changes in walking speed.
... Because deterioration of muscular strength and balance ability increases the risk of falling, it is significantly important to perform exercises to promote upper limb muscular strength and training for balance 3) . Regular exercise of walking and for muscular strength and balance may increase muscular strength and balance to prevent falling of patients 4) . Walking, in particular, is known to be a safe type of aerobic exercise for patients, having the merit that it can be performed gradually by considering appropriate intensity, frequency, period, and phases of exercise for abilities of each patient 5) . ...
[Purpose] The purpose of this study is to investigate the effects of virtual reality training using Nintendo Wii on balance and walking for stroke patients. [Subjects and Methods] Forty stroke patients with stroke were randomly divided into two exercise program groups: virtual reality training (n=20) and treadmill (n=20). The subjects underwent their 40-minute exercise program three times a week for eight weeks. Their balance and walking were measured before and after the complete program. We measured the left/right weight-bearing and the anterior/posterior weight-bearing for balance, as well as stance phase, swing phase, and cadence for walking. [Results] For balance, both groups showed significant differences in the left/right and anterior/posterior weight-bearing, with significant post-program differences between the groups. For walking, there were significant differences in the stance phase, swing phase, and cadence of the virtual reality training group. [Conclusion] The results of this study suggest that virtual reality training providing visual feedback may enable stroke patients to directly adjust their incorrect weight center and shift visually. Virtual reality training may be appropriate for patients who need improved balance and walking ability by inducing their interest for them to perform planned exercises on a consistent basis.
... The degree of dyspnea was assessed by the modified Borg scale. The tests were repeated twice, and the highest value was recorded 13,32,33) . The predicted values were calculated by equations of Gibbons et al. 34) that were previously used in patients with SS 11,35) . ...
[Purpose] This study aimed to evaluate the impact of lung function and peripheral muscle function on the six-minute walking distance (6MWD) in systemic sclerosis (SS) patients and, thereby, to develop an explanatory model of functional exercise capacity for these individuals. [Methods] In a cross-sectional study, 31 SS patients underwent pulmonary function testing (including spirometry, diffusing capacity for carbon monoxide [DLCO], and respiratory muscle strength), isometric dynamometry with surface electromyography, and the 6MWD. [Results] There was a significant correlation between the 6MWD (% predicted, 6MWD%) and the following parameters: height (r = 0.427) and DLCO (r = 0.404). In contrast, no other independent variable showed a significant correlation with the 6MWD% (r ≤ 0.257). The final prediction model for 6MWD% (adjusted R2 = 0.456, SE of bias=12%) was 6MWD%Gibbons= −131.3 + 1.16 × heightcm+ 0.33 × DLCO% predicted. [Conclusion] In SS patients, body height and pulmonary diffusion are the main determinants of the 6MWD. Our results justify further investigation of the performance of SS patients during exercise, which may increase the understanding of the pathophysiological mechanisms involved in the disease. The impact of these findings in SS patients may be useful for evaluating the effects of rehabilitation programs. © 2016 The Society of Physical Therapy Science. Published by IPEC Inc.
... Previous studies have shown that walking ability can be improved by various physical therapy interventions [1][2][3][8][9][10][11] . In our study, physical therapy was performed based on movement exercises consisting mainly of general function exercises and walking, without any special procedures. ...
[Purpose] This study aimed to determine the effects of increased amount of physical therapy exercise on improvements in the walking ability of patients with stroke. [Subjects and Methods] The subjects were selected from patients with stroke who were hospitalized in the convalescent rehabilitation ward, and included 91 patients who received physical therapy for 2.5–3 exercise sessions per day during 2005–2006 (PT3unit group), and 86 patients who received physical therapy for 4.5–6 exercise sessions per day during 2010–2015 (PT6unit group). The functional independence measure (FIM) score evaluates the walking ability of patients during hospital admission, 2 and 4 weeks after admission, and at discharge. The FIM score was stratified according to the degree of lower limb motor paralysis and subsequently compared between groups. [Results] Among the patients with complete paralysis and severe paralysis, the FIM-Walking scores at 4 weeks after admission and at discharge were significantly higher in the PT6unit group than in the PT3unit group. No significant differences were found between the PT6unit and PT3unit groups for patients with mild and moderate paralysis. [Conclusion] Higher amounts of physical therapy exercise contributed to improvements in the walking ability of patients with complete and severe lower limb paralysis.
... The American Thoracic Society (ATS) has proposed guidelines for safe and accurate performance of the 6MWT, which has demonstrated high accuracy and reproducibility in the evaluation of endurance in patients with cardiorespiratory disorders 1) . Today, it is used for evaluation of physical endurance in the clinical field of physical therapy [2][3][4] . ...
[Purpose] The purpose of this study was to verify if a periodic sound-based 6-minute walk test with the best periodic sound could be used to evaluate physical endurance more precisely than the conventional 6-minute walk test. [Subjects] The subjects were healthy subjects and 6 ambulant patients with Duchenne muscular dystrophy. [Methods] The subjects initially walked for 1 minute to a long-interval metronome sound, and the walking distance was measured. The sound interval was then gradually shortened, and the subjects walked for 1 minute for each of the intervals. The best periodic sound was considered to be the periodic sound used when the subject walked the longest distance in 1 minute, and the process of determining it was referred to as the period shortening walk test. This study administered the 6-minute walk test with the best periodic sound to twenty healthy subjects and 6 ambulant patients with Duchenne muscular dystrophy and compared the walking distance. [Results] The periodic sound-based 6-minute walk test distances in both the healthy subjects and the patients were significantly longer than the conventional 6-minute walk test distances. [Conclusion] The periodic sound-based 6-minute walk test provided a better indication of ambulatory potential in an evaluation of physical endurance than the conventional 6-minute walk test.
... Regarding rehabilitation of stroke patients, many studies reported improvement of activities of daily living (ADL) and gait [1][2][3] . ...
[Purpose] The motor paralysis-improving effect on the hemiplegic lower limb was compared among mirror therapy, integrated volitional-control electrical stimulation, therapeutic electrical stimulation, repetitive facilitative exercises, and the standard training method in post-stroke hemiplegia patients. [Subjects and Methods] Eighty one stroke patients admitted to a convalescent rehabilitation ward were randomly allocated to the above 5 treatment groups. Each patient performed functional training of the paralytic lower limb for 20 minutes a day for 4 weeks, and changes in the lower limb function were investigated using the Stroke Impairment Assessment Set. [Results] The hip and knee joint functions did not significantly improve in the standard training control group, but significant improvements were observed after 4 weeks in the other intervention groups. Significant improvement was noted in the ankle joint function in all groups. [Conclusion] Although the results were influenced by spontaneous recovery and the standard training in the control group, the hip and knee joints were more markedly improved by the interventions in the other 4 groups of patients with moderate paralysis, compared to the control group. © 2015 The Society of Physical Therapy Science. Published by IPEC Inc.
... Improvement of locomotion is one of the important goals of rehabilitation training for hemiplegic patients after stroke 1,2) . Many researchers have reported the usefulness of treadmill gait training [3][4][5] and have established how to adjust the treadmill speed, the degree of weight bearing and other parameters for setting the level of gait training difficulty based on the patients' walking ability. ...
[Purpose] The purpose of this study was to find whether a fast treadmill gait training speed is effective for the gait training of stroke patients in the early rehabilitation stage. [Subjects and Methods] Thirty-nine stroke patients were the subjects of our investigation. They walked on a treadmill with handrail supports at a fast speed (130% of their comfortable gait speed in the 2nd week). The treadmill gaits of the patients were recorded using a 3-dimensional analysis system at two and six weeks after their admissions. Intraclass Correlation Coefficients (ICC) of the temporal and spatial parameters of the two periods were statistically analyzed. [Results] For all of the patients, the ICCs of the measured parameters were greater than 0.58. In the case of patients whose gait speeds of the two periods were close, the ICC units were greater than 0.7. [Conclusion] The fast gait speed training allowed us to expose the patients to a gait speed that they were expected to acquire at a later stage of their rehabilitation. This training method was found to be beneficial for the mildly paralyzed patients.
... It is the second leading cause of death in the world 1) , and the third leading cause of death in Taiwan 2) . More importantly, it is a leading cause of long-term disability in adults [3][4][5] . It has been recognized that individuals with stroke-related hemiparesis bear most of the body weight on their unaffected limb despite the fact that the affected limb may already be able to bear weight efficiently during the course of recovery [6][7][8][9] . ...
[Purpose] The purpose of this study was to investigate the effects of a forced-use training program on gait, mobility and quality of life of post-acute stroke patients. [Subjects] Twenty-one individuals with unilateral stroke participated in this study. All participants had suffered from first-ever stroke with time since onset of at least 3 months. [Methods] A single-blinded, non-equivalent, pre-post controlled design with 1-month follow-up was adopted. Participants received either a forced-use or a conventional physical therapy program for 2 weeks. The main outcomes assessed were preferred and fastest walking velocities, spatial and temporal symmetry indexes of gait, the timed up and go test, the Rivermead Mobility Index, and the Stroke-Specific Quality of Life Scale (Taiwan version). [Results] Forced-use training induced greater improvements in gait and mobility than conventional physical therapy. In addition, compared to pre-training, patients in the conventional physical therapy group walked faster but more asymmetrically after training. However, neither program effectively improved in-hospital quality of life. [Conclusion] The forced-use approach can be successfully applied to the lower extremities of stroke patients to improve mobility, walking speeds and symmetry of gait.
Background
Corticospinal excitability is subject to alterations after stroke. While the reversal of these alterations has been proposed as an underlying mechanism for improvement walking capacity after gait-specific training, this has not yet been clearly demonstrated. Therefore, the objective of this review is to evaluate the effect of gait-specific training on corticospinal excitability in stroke survivors.
Design
Systematic review of the literature
Methods
We conducted an electronic database search in four databases ( i.e ., Medline, Embase, CINAHL and Web of Science) in June 2022. Two authors independently screened and selected all studies that investigated the effect of gait-specific training in post-stroke individuals on variables such as motor-evoked potential amplitude, motor threshold, map size, latency, and corticospinal silent period.
Results
Nineteen studies investigating the effect of gait-specific training on corticospinal excitability were included. Some studies showed an increased MEP amplitude (7/16 studies), a decreased latency (5/7studies), a decreased motor threshold (4/8 studies), an increased map size (2/3 studies) and a decreased cortical silent period (1/2 study) after gait-specific training. No change has been reported in term of short interval intracortical inhibition after training. Five studies did not report any significant effect after gait-specific training on corticospinal excitability.
Conclusion
The results of this systematic review suggest that gait-specific training modalities can drive neuroplastic adaptation among stroke survivors. However, given the methodological disparity of the included studies, further clinical trials with better methodological quality are needed to draw conclusions. Hence, the findings from this review can serve as a rationale for future studies and continued efforts in investigating the effects of gait-specific training on the central nervous system.
Background: A majority of stroke survivors experience gait impairments, some of which persist into the chronic phase of stroke. Treatment with the iStrideTM gait device has been shown to improve symmetry, gait speed, and functional balance for chronic stroke survivors. In this study, we examine the long-term gait speed changes up to twelve months after treatment with the iStrideTM gait device.
Methods: Eighteen individuals (mean 56.7 years, range 44-77 years) at least one-year post-stroke (mean 59.7 months, range 13-308 months) participated in this single group, before-after study with multiple follow-ups. Participants completed 12 treatment sessions (three times per week over four weeks) with the gait device. During each session, participants ambulated over ground on the gait device for a goal of 30 minutes. Gait speed was measured using the Ten-Meter Walk Test at a comfortable pace at baseline and at five follow-up sessions after the treatment period: one week, one month, three months, six months, and twelve months. All study aspects were performed in the home environment of each participant and under the guidance of a licensed physical therapist. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame, comparison to the minimal clinically important difference threshold, evaluation of functional ambulation category changes, and subjective questionnaires.
Results: Participants retained more than a 0.21 m/s gait speed improvement at all post-treatment time frames, p<0.01. Additionally, 94% of participants improved their gait speed beyond the minimally clinical important difference during one or more post-treatment measurements. 88% of participants subjectively reported a gait speed improvement.
Conclusion: The findings of this study indicate that this four-week treatment protocol using the iStrideTM gait device in the home environment may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.
Trial Registration: NCT03649217. Registered August 28, 2018 – Retrospectively registered for 11 participants who were consented before August 28, 2018; seven participants were consented after August 28, 2018.
A majority of stroke survivors experience gait impairments, some of which persist into the chronic phase of stroke. Treatment with the iStride TM gait device has been shown to improve symmetry, gait speed, and functional balance for chronic stroke survivors with hemiparetic gait impairments. In this study, we examine the long-term gait speed changes up to twelve months after treatment with the gait device. Eighteen individuals (mean 56.7 years, range 44-77 years) at least one-year post-stroke (mean 59.7 months, range 13-308 months) participated in this single group, before-after study with multiple follow-ups. Participants completed approximately 12, 30-minute treatment sessions with the gait device in their home environment. Gait speed was measured using the Ten-Meter Walk Test at a comfortable pace at baseline and five follow-up sessions after the treatment period: one week, one month, three months, six months, and twelve months. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame, comparison to the minimal clinically important difference threshold, evaluation of gait speed classification changes, and subjective questionnaires. Results showed that participants retained more than a 0.21 m/s gait speed improvement compared to baseline at all post-treatment time frames, p<0.01. Additionally, 94% of participants improved their gait speed beyond the minimally clinically important difference during one or more post-treatment measurements, and 88% of participants subjectively reported a gait speed improvement. These study findings indicate that treatment with the gait device may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.
The purpose of this systematic review was to determine the number of treadmill training sessions needed to make a meaningful change in gait speed for chronic stroke survivors. Relevant databases were searched up through February 2020. Articles were included if they fit the following criteria: stroke onset greater than six months, intention to treat with traditional treadmill training, and gait speed included as an outcome. Change in gait speed post intervention was utilized to classify treadmill groups as responders (at least 0.1 meters/second change) or nonresponders (less than 0.1 meters/second change). 17 articles met our criteria, resulting in a total of 19 intervention groups. Ten groups were classified as responders and completed a mean of 30.5 sessions within 6 weeks, while nonresponders completed 20.4 sessions within 10 weeks, indicating that at least 30 treadmill sessions (preferably in a period of 10 weeks and at least 40 minutes per session) is necessary to reach a meaningful change in gait speed. Although these trends were noted between the responder and nonresponder groups, no firm conclusions can be drawn regarding the 'magic' number of sessions chronic stroke survivors should perform given the low correlation between number of sessions and change in gait speed.
In this study, a mobile overground gait-training system (OGTS) was designed, and a prototype was manufactured to determine the feasibility and control stability of the designed system. Approval was received from the Institutional Review Board of Fu Jen Catholic University for conducting experimental testing on healthy individuals with the designed mobile OGTS. The designed system comprises a mobile electric walking aid (EWA), a body weight support system (BWSS), and an exoskeleton gait orthosis (EGO). The system can perform multiple functions for physical overground gait training. The mobile EWA and EGO can be operated separately from the mobile OGTS. An interval type-2 fuzzy sliding controller (IT2FSC) was designed to compensate for disturbances and uncertainties because the mobile OGTS has a coupling issue and potential subjects have different weights and body shapes. The mobile OGTS has one IT2FSC to provide a pulse-width modulation output to regulate two linear actuators for the BWSS, and it adopts four IT2FSCs to produce voltage outputs to control the gait trajectory of the EGO. Three experiments demonstrated that the mobile OGTS provides a stable control force to assist the user in overground gait training as well as assist-as-needed body weight support for gait training.
Objective: To use the Centralized Open-Access Rehabilitation database for Stroke (SCOAR) to explore reporting of both experimental and control interventions in randomized controlled trials (RCTs) for stroke rehabilitation (including upper and lower extremity therapies).
Data Sources: SCOAR was created from a search of MEDLINE, EMBASE, Cochrane CENTRAL, Cochrane-CDSR, and CINAHL from the earliest available date to May 2014.
Study Selection: 2,892 titles were reduced to 514 manuscripts which were screened by full text. This screening left 215 randomized controlled trials (RCTs) in the database (489 independent groups representing 12,847 patients).
Data Extraction: Using a mixture of qualitative and quantitative methods, we conducted a text-based analysis of how the procedures of experimental and control therapies were described. Experimental and control groups were rated by two independent coders according to the Template for Intervention Description and Replication (TIDIER) criteria.
Data Synthesis: Linear mixed-effect regression with a random-effect of study (groups 16 nested within studies) showed experimental groups had statistically greater words in their procedures, M=271.8 words, than did control groups, M=154.8 words, (p < 0.001). Experimental groups had statistically greater references in their procedures, M=1.60 references, than did control groups, M=0.82 references (p < 0.001). Experimental groups also scored significantly higher on the total TIDIER score, M=7.43 points, than the control groups, M=5.23 points (p < 0.001).
Conclusions: Control treatments for stroke motor rehabilitation trials are under described relative to experimental treatments. These poor descriptions are especially problematic for "conventional" therapy control groups. Poor reporting is a threat to internal validity and the generalizability of clinical trial results. We recommend authors use pre-registered protocols and established reporting criteria to improve transparency.
Background
Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking
after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.
Objectives
To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life,
activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training
interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
Search methods
We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled
Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14
February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and
SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research
registers, screened reference lists, and contacted trialists to identify further trials.
Selection criteria
Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in
combination, for the treatment of walking after stroke.
Data collection and analysis
Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary
outcomes investigated were walking speed, endurance, and dependency.
Main results
We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies
were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk
without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other
physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P =
0.94; I2 = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the
walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity
was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I2 = 44%; moderate-quality evidence) and the pooled
MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I2 = 27%; moderate-
quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did
not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model)
for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I2 = 55%; low-quality evidence) and
the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I2 = 47%; low-
quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill
training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95%
CI 0.05 to 0.12; P < 0.00001; I 2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily
living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to
be clinically serious events.
Authors’ conclusions
Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve
their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking
endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are
dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and
walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial
effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed
increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent
walkers.
In this study, treadmill walking and overground walking were compared at the same condition based on kinematics and energy expenditures(EE). In addition, we compared the actual energy expenditure and calculated EE by treadmill. The kinematics of treadmill and overground walking were very similar. The values at each joint were significantly different(P
Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke.
A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used.
In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback.
ClinicalTrials.gov # NCT00561405.
Stroke is the third most common cause of death and the most frequent cause of severe adult disability in Scotland.1 Despite considerable advances in organised stroke care over recent years, improvements are still needed,2 because patients have been reported to spend up to 50% of their time in bed3 and only 20% of their time in treatment.4 Since publication of the previous Scottish Intercollegiate Guidelines Network (SIGN) guideline on rehabilitation after stroke (SIGN 64), several small studies have shown the effectiveness of new therapeutic techniques and technologies.5 This guideline supersedes the earlier guideline and summarises the most recent recommendations from SIGN on rehabilitation after stroke.6 It also complements SIGN guidelines 119 and 108 on other aspects of the management of stroke.7 8
SIGN recommendations are based on systematic reviews of best available evidence. The strength of the evidence is graded as A, B, C, or D (figure⇓), but the grading does not reflect the clinical importance of the recommendations. Recommended best practice (“good practice points”), based on the clinical experience of the guideline development group, is also indicated (as GPP).
Explanation of SIGN grades of recommendations
### Arranging appropriate care
: Overground gait training-observation and cueing of patient's walking pattern along with related exercises-forms a major part of rehabilitation services for individuals with chronic stroke in almost every setting. This report of a Cochrane systematic review assessed the effects of overground gait training on walking ability for individuals with mobility deficits subsequent to chronic stroke.
: We searched the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Science Citation Index Expanded, http://www.clinicaltrials.gov, among other databases through spring 2008. We also searched reference lists and contacted authors and trial investigators.
: Only randomized controlled trials comparing overground physical therapy gait training with a placebo or no treatment condition were included.
: Nine studies involving 499 participants were included. We found no evidence of a benefit on walking function, the primary variable, based on three studies (n = 269). Some performance variables did show significant effects. Walking speed increased by 0.07 m/sec [95% confidence interval (CI), 0.05-0.10] based on seven studies (n = 396), Timed Up and Go test improved by 1.81 seconds (95% CI, -2.29 to -1.33) based on three studies (n = 118), and six-minute walk test increased by 26.06 m (95% CI, 7.14-44.97) based on four studies (n = 181).
: We found insufficient evidence to determine whether overground physical therapy gait training benefits walking function in individuals with chronic stroke, although limited evidence suggests potential benefits for some performance variables. High-quality randomized controlled trials are needed to replicate and extend these findings.
To evaluate spatial and temporal gait characteristics and endurance late after stroke in people who had received two different walking exercises. A secondary aim was to compare the outcomes in relation to length of time exercising and number of exercise occasions between the two.
A randomized controlled trial.
A private rehabilitation centre.
Thirty-nine people with stroke entered the study, and five dropped out.
Treadmill training versus walking outdoors.
Six-Minute Walk Test, a 10-metre walk test and pulse rates at rest and in activity.
There were significant differences in favour of the treadmill group in Six-Minute Walk Test distance (P = 0.04), Six-Minute Walk Test speed (P = 0.03), 10-m walking speed (P = 0.03), bilateral stride length (right leg; P = 0.009, left leg; P = 0.003) and step width (P = 0.01), indicating more symmetrical use of the legs in the treadmill group (1.02-1.10 m versus 0.97-0.92 m). There were no significant differences between groups in cadence (P = 0.78). All participants complied 100% with their respective programmes. Exercise frequency did not differ between the groups but significantly less time was spent exercising on the treadmill compared with walking exercise outdoors (107 versus 316 minutes, P = 0.002). There were no differences in use of assistive aids between the groups on arrival at the clinic or at departure.
The results indicate that treadmill walking improves spatial and temporal gait characteristics more effectively than walking outdoors.
Background and Purpose— Overground gait training can be defined as a physical therapists’ observation and cueing of the patient’s walking pattern along with related exercises, but does not include high-technology aids such as functional electric stimulation or body weight support. This systematic review investigated the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits.
Methods— A comprehensive literature search was performed as per the Cochrane group guidelines. Only randomized controlled trials that compared overground physical therapy gait training to a placebo intervention or no treatment for chronic stroke patients with mobility deficits were included.
Results— Nine studies involving 499 participants matched the inclusion criteria and had moderate methodological quality. Results were mixed with no significant effect on the primary variable, gait function. Small effects for several performance variables were found: gait speed increased by 0.07 meters per second (95% confidence interval [CI]=0.05 to 0.10) based on 7 studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI=−2.29 to −1.33) based on 3 studies and 118 participants, and 6-minute-walk test (6MWT) increased by 26.06 meters (95% CI=7.14 to 44.97) based on 4 studies with 181 participants. No significant differences in adverse events were found.
Conclusions— There is insufficient evidence to determine whether overground gait training directly benefits broad measures of gait function. Results from recent studies, however, suggest that specific training protocols may provide limited benefits for more uni-dimensional performance variables like gait speed, TUG test, and 6MWT.
This study aimed to assess the effectiveness of gait training using body weight support on a treadmill compared with conventional gait training for people with subacute stroke who were unable to walk.
This was a single-blind, randomized, controlled trial with a 6-month follow-up. Ninety-seven subjects were recruited within 6 weeks of stroke onset and were randomly assigned to conventional rehabilitative treatment plus gait training with body weight support on a treadmill (experimental group; n=52) and conventional treatment with overground gait training only (control group; n=45). All subjects were treated in 60-minute sessions every weekday for 4 weeks. Outcome measures were Motricity Index, Trunk Control test, Barthel Index, Functional Ambulation Categories, 10-meter and 6-minute Walk Tests, and Walking Handicap Scale. Assessments were made at baseline, after 20 sessions of treatment, 2 weeks after treatment, and 6 months after stroke.
After treatment, all patients were able to walk. Both groups showed improvement in all outcome measures (P<0.0063) at the end of the treatment and at follow-up. No differences were seen between the 2 groups before, during, and after treatment and at follow-up.
In subacute patients with stroke, gait training on a treadmill with body weight support is feasible and as effective as conventional gait training. However, the need for more personnel for treadmill training makes the use of robotically assisted systems more compelling.
1 fewer than one-third of patients with acute stroke who were admitted to Canadian hospitals received this type of specialized care. 2
The objective of this study was to assess the reliability of the Balance Scale. Subjects were chosen from a larger group of 113 elderly residents and 70 stroke patients participating in a psychometric study. Elderly residents were examined at baseline, and at 3, 6 and 9 months, and the stroke patients were evaluated at 2, 4, 6 and 12 weeks post onset. The Cronbach's alphas at each evaluation were greater than 0.83 and 0.97 for the elderly residents and stroke patients respectively, showing strong internal consistency. To assess inter-rater reliability, therapists treating 35 stroke patients were asked to administer the Balance Scale within 24 hours of the independent evaluator. Similarly, caregivers at the Residence were asked to test the elderly residents within one week of the independent evaluator. To assess intra-rater reliability, 18 residents and 6 stroke patients were assessed one week apart by the same rater. The agreement between raters was excellent (ICC = 0.98) as was the consistency within the same rater at two points in time (ICC = 0.97). The results support the use of the Balance Scale in these groups.
To perform a qualitative systematic overview of the measurement properties of the most commonly utilized walk tests in the cardiorespiratory domain: the 2-min walk test (2MWT), 6-min walk test (6MWT), 12-min walk test (12MWT), self-paced walk test (SPWT), and shuttle walk test (SWT).
MEDLINE (1966 to January 2000) and CINAHL (1982 to December 1999) electronic databases were searched. Bibliographies of the retrieved articles were reviewed.
Clinical trials and observational studies were included if they reported data on the validity, reliability, interpretability, or responsiveness of the 2MWT, 6MWT, 12MWT, SPWT, or SWT. Only studies conducted on patients with cardiac and/or respiratory involvement were included.
Fifty-two studies examining measurement properties of the various walk tests were found: 5 studies on the 2MWT, 29 studies on the 6MWT, 13 studies on the 12MWT, 6 studies on the SPWT, and 4 studies on the SWT. Measurement properties were most strongly demonstrated for the 6MWT. Correlations of 6MWT distance and maximal oxygen consumption ranged from 0.51 to 0.90. A change in distance walked of at least 54 m was found to be clinically significant for the 6MWT. Reliability was shown to be optimized when the administration of walk tests was standardized and at least two practice walks were performed. Patients with increased likelihood of postoperative complications, hospitalization, and death were identified by analysis of distance walked.
Measurement properties of the 6MWT have been the most extensively researched and established. In addition, the 6MWT is easy to administer, better tolerated, and more reflective of activities of daily living than the other walk tests. Therefore, the 6MWT is currently the test of choice when using a functional walk test for clinical or research purposes.
To examine 10-m comfortable walking speed and 6-minute distance in healthy individuals and individuals after stroke and to assess the level of disability associated with poor walking endurance after stroke.
Descriptive study in which comfortable walking speed over 10 m and distance covered in 6 minutes (6-minute walk test) were compared between healthy subjects and subjects after stroke.
Twelve healthy subjects and 14 subjects after stroke.
Walking speed and 6-minute distances were compared between groups. In addition, for each group, actual distance walked in 6 minutes was compared with the distance predicted by the 10-m walking speed test and the distance predicted by normative reference equations.
Subjects after stroke had significant reductions in 10-m speed and 6-minute distance compared with healthy subjects (p < 0.05). Subjects after stroke were not able to maintain their comfortable walking speed for 6 minutes, whereas healthy subjects walked in excess of their comfortable speed for 6 minutes. The average distance walked in 6 minutes by individuals after stroke was only 49.8+/-23.9% of the distance predicted for healthy individuals with similar physical characteristics.
In our subjects after stroke, walking speed over a short distance overestimated the distance walked in 6 minutes. Both walking speed and endurance need to be measured and trained during rehabilitation.
To compare the effect of walking training on a treadmill with body weight support (BWS) and walking training on the ground at an early stage of rehabilitation in patients with hemiparesis after stroke.
Randomized controlled experimental study.
Multicentre design; three departments of rehabilitation medicine.
Seventy-three consecutive first stroke patients admitted to a rehabilitation clinic were randomized into a treatment group and a control group.
The treatment group received walking training on a treadmill with BWS for 30 minutes, 5 days a week. The control group received walking training according to the Motor Relearning Programme (MRP) on the ground for 30 minutes 5 days a week, not including treadmill training. During the time in the rehabilitation department (about two months), all patients in the study also received professional stroke rehabilitation besides the walking training in the two groups.
Functional Independence Measure (FIM), walking velocity for 10 m, Functional Ambulation Classification (FAC), Fugl-Meyer Stroke Assessment and Berg's Balance Scale. The assessments were performed at admission, at discharge and at 10-month follow-up.
There were no statistically significant differences between the groups at discharge or at the 10-month follow-up with regard to FIM, walking velocity, FAC, Fugl-Meyer Stroke Assessment, and Berg's Balance Scale. Patients in both groups improved in these variables from admission to the 10-month follow-up.
Treadmill training with BWS at an early stage of rehabilitation after stroke is a comparable choice to walking training on the ground.
The purpose of the study was to determine the effect of a period of body weight supported treadmill training on gait in a subject with chronic stroke and to see if there was a carry-over to balance, trunk control and function.
A male subject who had suffered a right CVA 30 months previously was selected for the study. A single system ABA design was used. Outcome measures were taken in the 4-week baseline period. This was followed by a 4-week period of body weight support treadmill training and a further 4 weeks of treatment withdrawal. Outcome measures used were the 10-m walk test, Berg Balance Scale (BBS), Trunk Control Test (TCT), a seated lateral reach test (LRT) and the Functional Independence Measure (FIM) and were collected in all phases of the study.
During the intervention phase, there were significant increases in the BBS and the LRT. No significant changes were found in the TCT or the 10-m walk test. The FIM showed a small improvement in the motor score.
A period of treadmill training has significant carry-over to balance in a subject with chronic hemiplegia.
To examine the reliability and validity of the Activities-specific Balance Confidence (ABC) scale among individuals with stroke.
Descriptive measurement study using a 4-week test-retest design. Data were collected at a tertiary rehabilitation centre form a community-dwelling sample of ambulatory older adults who sustained one stroke at least 1 year prior to the study. During the first measurement session, the total sample (n = 77) completed the ABC as well as the Berg Balance Scale (BBS) and gait speed. The reliability sample (n = 24), a subset of the larger data set, completed the ABC again 4 weeks later.
Internal consistency of the ABC was 0.94 and test-retest reliability was ICC = 0.85 (95% CI, 0.68, 0.93). A moderate significant positive, linear correlation with both the BBS (rho = 0.36, P < 0.001) and gait speed (rho = 0.48, P < 0.001) was observed. A factor analysis using principal component analysis indicated that the ABC measures two components of balance self-efficacy (component 1 = perceived low-risk activities; component 2 = perceived high-risk activities).
The ABC has acceptable measurement properties as demonstrated in this sample of individuals with stroke. This study provides further support for the use of the scale.
Comparisons of treadmill and overground walking following stroke indicate that symmetry in temporal-distance measures is better on the treadmill suggestive of better gait economy. We examined this issue by examining the kinematic, kinetic and metabolic demands associated with overground and treadmill walking at matched speeds and also explored the effect of increasing treadmill speed.
Ten people with hemiparesis walked overground at their preferred speed which was matched on the treadmill. Belt speed was then increased 10% and 20% above preferred speed. Temporal-distance outcomes, angular kinematics and vertical ground reaction forces were recorded during steady state (stable heart rate and oxygen uptake).
Step and stance times were longer when walking overground but the degree of symmetry was comparable for both surfaces. In contrast kinematic data revealed significant interlimb asymmetry with respect to all lower limb joint excursions during overground walking accompanied by higher vertical ground reaction forces at push-off. The metabolic demands, however, were lower when walking overground than on the treadmill. Increasing the belt speed increased angular displacements and the vertical forces associated with both limbs such that symmetry remained unchanged. Metabolic demands increased significantly.
People with stroke adopt a more symmetrical kinematic walking pattern on the treadmill which is maintained at faster belt speeds. Surprisingly, at matched speed the metabolic cost was significantly higher with treadmill walking. We suggest further research to explore whether an increased reliance on the hip musculature to compensate lower push-off forces could explain the higher the energy cost.
Elevated energy costs of hemiparetic gait contribute to functional disability after stroke, particularly in physically deconditioned older patients. We investigated the effects of 6 months of treadmill aerobic exercise training on the energy expenditure and cardiovascular demands of submaximal effort ambulation in stroke patients with chronic hemiparetic gait.
Nine older stroke patients with chronic hemiparetic gait were enrolled in a 6-month program of low-intensity aerobic exercise using a graded treadmill. Repeated measures of energy expenditure based on steady state oxygen consumption during a standardized 1-mph submaximal effort treadmill walking task were performed before and after training.
Six months of exercise training produced significant reductions in energy expenditure (n = 9; 3.40 +/- 0.27 versus 2.72 +/- 0.25 kcal/min [mean +/- SEM]; P < .005) during a given submaximal effort treadmill walking task. Repeated measures analysis in the subset of patients (n = 8) tested at baseline and after 3 and 6 months revealed that reductions in energy expenditure were progressive (F = 11.1; P < .02) and that exercise-mediated declines in both oxygen consumption (F = 9.7; P < .02) and respiratory exchange ratio (F = 13.4; P < .01) occurred in a strong linear pattern. These stroke patients could perform the same standardized submaximal exercise task at progressively lower heart rates after 3 months (96 +/- 4 versus 87 +/- 4 beats per minute) and 6 months of training (82 +/- 4 beats per minute; F = 35.4; P < .002).
Six months of low-intensity treadmill endurance training produces substantial and progressive reductions in the energy expenditure and cardiovascular demands of walking in older patients with chronic hemiparetic stroke. This suggests that task-oriented aerobic exercise may improve functional mobility and the cardiovascular fitness profile in this population.
To evaluate the immediate and retention effects of a 4-week training program on the performance of locomotor-related tasks in chronic stroke.
Randomized, controlled pilot study with 2-month follow-up.
Rehabilitation center.
A convenience sample consisting of 12 chronic stroke subjects was used. Subjects were randomly assigned to the experimental or the control group. Three subjects withdrew from the study.
Both experimental and control groups participated in exercise classes three times a week for 4 weeks. The exercise class for the experimental group focused on strengthening the affected lower limb and practicing functional tasks involving the lower limbs, while the control group practiced upper-limb tasks.
Lower-limb function was evaluated by measuring walking speed and endurance, peak vertical ground reaction force through the affected foot during sit-to-stand, and the step test.
The experimental group demonstrated significant immediate and retained (2-month follow-up) improvement (p < or = .05) compared with the control group in walking speed and endurance, force production through the affected leg during sit-to-stand, and the number of repetitions of the step test.
The pilot study provides evidence for the efficacy of a task-related circuit class at improving locomotor function in chronic stroke.
It is widely assumed that only limited improvement in functional mobility is possible beyond the subacute period following ischemic stroke. Contrary to this notion, we studied "neurologically plateaued" stroke patients with chronic hemiparesis to assess whether a "task-oriented" treadmill-training regimen would improve walking speed, cadence, and gait cycle symmetry on a modified "Get-Up and Go" task. Five male patients with a mean age of 60.4 +/- 2.7 years (mean +/- S.D.) status post ischemic stroke (> 6 months prior) participated in this nonrandomized low-intensity treadmill exercise pilot study three times/week for 3 months. All patients had mild to moderate gait asymmetries due to residual hemiparesis. Patients were videotaped before and after 3 months of treadmill aerobic exercise (AEX) while performing a functional task consisting of arising from a chair, walking 3.1 m without an assistive device as fast as safely possible, and returning to sit. Gait events were timed using a 2-D Peak Motus video analysis system. After 3 months AEX training, times for the overall "get-up and return-to-sit" (GURS) task and the "straight-away walk" (SAW) segment decreased from 8.2 +/- 1.4 sec to 6.5 +/- 0.8 sec (mean +/- SEM) (p < 0.05), and from 3.7 +/- 1 sec to 2.8 +/- 0.7 sec (p < 0.05), respectively. These data represent improvements of 21% and 24% for the GURS and SAW segments, respectively. Mean velocity increased from 0.9 +/- 0.2 to 1.2 +/- 0.21 m/sec, a 33% improvement (p < 0.01). Mean cadence (steps/min) increased from 89 +/- 9 to 97 +/- 8, a 9% increase (p < 0.05). Mean stance and swing duration diminished for both paretic (P) and nonparetic (NP) limbs, and the intralimb stance/swing ratio values moved toward normal for both the paretic and nonparetic limbs. However, these latter changes reached significance only for the P limb. Interlimb stance symmetry was unchanged. The more impaired subjects experienced the greatest gains in gait velocity and temporal measures. Collectively, these findings indicate that treadmill exercise improves functional overground mobility in individuals with chronic, stable hemiparesis.
To investigate the hypothesis that treadmill training will improve peak fitness, while lowering the energy cost of hemiparetic gait in chronic stroke patients.
Noncontrolled exercise intervention study with repeated-measures analysis.
Hospital-based senior exercise research center.
Twenty-three patients (mean age +/- standard deviation [SD] 67 +/- 8 yr) with chronic hemiparetic gait after remote (>6 mo) ischemic stroke.
Three 40-minute sessions of treadmill exercise weekly for 6 months.
Peak exercise capacity (VO2peak) and rate of oxygen consumption during submaximal effort treadmill walking (economy of gait) by open circuit spirometry and ambulatory workload capacity before and after 3 and 6 months of training.
Patients who completed 3 months of training (n = 21) increased their VO2peak +/- SD from 15.4 +/- 2.9 mL x kg(-1) x min(-1) to 17.0 +/- 4.4 mL x kg(-1) x min(-1) (p <.02) and lowered their oxygen demands of submaximal effort ambulation from 9.3 +/- 2 mL x kg(-1) x min(-1) to 7.9 +/- 1.5 mL x kg(-1) x min(-1) (p =.002), which enabled them to perform the same constant-load treadmill task using 20% less of their peak exercise capacity (62.3% +/- 17.2% vs 49.9% +/- 19.3%, p <.002). Gains in VO2peak and economy of gait plateaued by 3 months, while peak ambulatory workload capacity progressively increased by 39% (p <.001) over 6 months.
Treadmill training improves physiologic fitness reserve in chronic stroke patients by increasing VO2peak while lowering the energy cost of hemiparetic gait, and increases peak ambulatory workload capacity. These improvements may enhance functional mobility in chronic stroke patients.
To assess the reliability of gait speed in late-stage stroke patients.
Test-retest reliability of three timed walks to 10 metres repeated during two assessments one week apart.
The patient's home.
Twenty-two stroke patients with mobility problems more than one year after stroke.
Gait speed measured in seconds taken to walk 10 metres.
Intraclass correlations (ICCs) with 95% confidence interval (CI) and the Bland and Altman method for assessing agreement by calculating the mean difference between measurements (d); the 95% CI for d; the standard deviation of the difference (SDdiff); a reliability coefficient and the 95% limits of agreement.
There was a trend for decreased times taken to walk 10 metres both within each assessment and between assessments. ICCs for within-assessment reliability were 0.95-0.99. The d (SDdiff) for the second and third walks for assessment 1 was -1.00 (2.63) seconds and for assessment 2 was -0.70 (1.58) seconds. The reliability coefficient was 5.26 for assessment 1 and 3.17 for assessment 2. ICCs for between-assessment reliability were 0.87-0.88. The d (SDdiff) for the comparison of the third walks at assessment 1 and assessment 2 was -0.90 (5.01) seconds. The reliability coefficient was 10.02 and the 95% limits of agreement were -10.92 to +9.12 seconds.
Within-assessment gait speed measured at home is highly reliable. The between-assessment reliability of gait speed measurement is less reliable but comparable with other studies.
The purpose of this study was to assess the reliability of a 6-min walk test in individuals with acquired brain injury.
A total of 23 clients (14 men, 9 women) participated. All participants were clients in a postacute residential rehabilitation facility. The time from injury averaged 12 mo (range, 7-38 mo). Subjects were instructed to walk around a rectangular track as many times as possible during a period of 6 min. The test was performed twice, separated by 1-10 days. Heart rate was monitored continuously throughout the test, and distance traveled was recorded in meters after completion. A physiologic cost index (beats per meter) was calculated. Intraclass correlation coefficients were calculated for distance traveled, heart rate responses, and physiologic cost index.
The mean distance walked was 403 +/- 105 m (trial 1) and 417 +/- 106 m (trial 2). The intraclass correlation coefficient for distance was 0.94. The mean steady-state heart rate was 118 +/- 21 beats/min (trial 1) and 117 +/- 20 beats/min (trial 2), and the intraclass correlation coefficient was 0.65. The mean physiologic cost index was 0.52 +/- 0.19 beats/m (trial 1) and 0.55 +/- 0.22 beats/m (trial 2), and the intraclass correlation coefficient was 0.89.
Distance traveled and the physiologic cost index demonstrated excellent reliability, whereas heart rate responses for individual minutes demonstrated only fair reliability. The individuals studied were very consistent in their efforts, despite a combination of physical and cognitive impairments. The results suggest that the 6-min walk test can be used reliably in the assessment of functional ambulation in persons with acquired brain injury.
To identify the most important impairments determining gait velocity and asymmetry in patients with mild to moderate stroke.
Descriptive analysis of convenience sample.
Outpatient rehabilitation clinic of a hospital in Taiwan.
Twenty-six subjects with mild to moderate spastic hemiparesis after a single onset of stroke, all able to walk independently without any assistance or device.
Not applicable.
Subjects' maximal muscle strength (isokinetic peak torque, total work), motor and sensation function, and ankle plantarflexor spasticity of the affected lower extremity were examined using the Cybex 6000 dynamometry, Fugl-Meyer Assessment, and Modified Ashworth Scale, respectively. Gait velocity, as well as temporal and spatial asymmetry, were evaluated when subjects walked at their comfortable and fast speeds by using the GaitMatII.
Regression analyses revealed that the total work isokinetic measures of the affected hip flexors and knee extensors were the most important independent determinants of the comfortable and fast gait velocities, respectively (R(2)=.57, R(2)=.72). Spasticity of the affected plantarflexors was the most important independent determinant of temporal and spatial gait asymmetry during comfortable-speed (R(2)=.76 for temporal asymmetry; R(2)=.46 for spatial asymmetry) and fast-speed (R(2)=.75 for temporal asymmetry; R(2)=.45 for spatial asymmetry) walking.
Gait velocity and asymmetry of patients with mild to moderate stroke were affected by different physical impairments. Whereas gait velocity was mainly affected by weakness of the affected hip flexors and knee extensors, gait asymmetry was influenced primarily by the degree of the spasticity of the affected ankle plantarflexors. Therapeutic interventions aiming to improve different aspects of gait performance of these patients may emphasize treatment of different impairments.
Within physical therapy, the disablement model has proven useful as a language to delineate the consequences of disease and injury. This perspective provides an update on the changing language of disablement, reviews selected contemporary disablement models, and discusses some challenges that need to be addressed to achieve a universal disablement language that can be used to discuss physical therapy research and clinical interventions. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework has the potential of becoming a standard for disablement language that looks beyond mortality and disease to focus on how people live with their conditions. If widely adopted, the ICF framework could provide the rehabilitation field with a common, international language with the potential to facilitate communication and scholarly discourse across disciplines and national boundaries, to stimulate interdisciplinary research, to improve clinical care, and ultimately to better inform health policy and management.
Effects of treadmill gait training on gait patterns in hemiplegic patients: comparison with conventional gait training
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