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The eects of stepper exercise with visual feedback
on strength, walking, and stair climbing in
individuals following stroke
Munsang Choi, PT, MSc1), Junsang Yoo, PT, MSc1), soonYoung shi n, JD2),
Wanhee Lee, PT, PhD1)*
1) Department of Physical Therapy, Sahmyook Universit y: 26-21 Gongneung 2-dong, Nowon-gu, Seoul
139-742, Republic of Korea
2) Department of English, Sahmyook University, Republic of Korea
Abstract. [Pur pose] This study investigated the effect of stepper exercise with visual feedback on strength, walk-
ing, and stair climbing in stroke patients. [Subjects] Twenty-six stroke patients were divided randomly into the
stepper exercise with visual feedback group (n = 13) or the stepper exercise group (n = 13). [Methods] Subjects
in the experimental group received feedback through the mirror during exercise, while those in the control group
performed the exercise without visual feedback; both groups exercised for the 30 min thrice per week for 6 weeks.
The hip extensor and knee extensor strength, 10-m walking test results, and 11-step stair climbing test results were
evaluated before and after the intervention. [Results] The stepper exercise with visual feedback group showed sig-
nicantly greater improvement for hip extensor strength and the 10-m walking test. The knee extensor strength and
11-step stair climbing in both groups showed signicantly greater improvement after the intervention, but without
any signicant difference between groups. [Conclusion] The ndings of this study indicate that the stepper exercise
with visual feedback can help improve the strength of the hip extensor and the 10-m walking test; the stepper exer-
cise alone may also improve the knee extensor st rength and stair climbing ability.
Key words: Stroke, Stairs, Visual feedback
(This article was submitted Jan. 7, 2015, and was accepted Mar. 7, 2015)
INTRODUCTION
Loss of functional movement is a common consequence
of stroke1). Therefore, the activity level of stroke patients
is reduced, which further reduces muscle tone2–29). The loss
of a normal degree of strength is an important factor that
limits the functional activity of these patients3). Strength-
ening exercises, such as walking and stair climbing, have
been reported to improve functional movement4). Stair
climbing has been used as an important measure in the
evaluation of the active independent and community lives
of stroke patients5). However, when the stair climbing and
walking activities of these patients were evaluated, lack of
strength, coordination, balance, and physical activity were
found to be the most common problems they faced5–28). For
patients to successfully climb stairs, they must strengthen
the appropriate muscles to improve the balance ability of the
lower extremities6). Another method adopted for improving
motor function was that of combining treadmill training
with repetitive training; further, strength training exercises
along with aerobic exercise or task-oriented exercises were
found to lead to improvements in functional behavior, such
as walking or stair climbing7–9).
The most common interventions used for the rehabilita-
tion of stroke patients include training on several exercise
bikes and treadmills10–13). However, when measuring the
exercise intensity (i.e., the rated perceived exertion (RPE)),
the energy consumption ratio of stationary bike training
was found to be lower than that of the stepper exercises
and treadmill training. In other words, stepper or treadmill
training exercises are equally effective14). Strength training
of the muscles is necessary for carrying out the stair climb-
ing function as well as maintaining the correct gait; aerobic
exercise has also been found to improve a person’s stair
climbing ability7).
Therefore, we proposed a training program featuring
a combination of aerobic exercise and strength training
involving stepper training for climbing stairs. Stepper
training engages the hip joint, so it increases lower extrem-
ity strength13). However, stroke patients nd it difcult to
perform new exercises, including stepper training. Stroke
patients may need to relearn various movements15). Learning
efcient movement is an important factor for improving sen-
sory feedback and repetition16). Due to inherent damage to
the intrinsic feedback mechanism in stroke patients, extrin-
sic feedback assumes an important role in motor learning.
J. Phys. Ther. Sci.
27: 1861–1864, 2015
*Corresponding author. Wanhee Lee (E-mail: whlee@syu.
ac. k r)
©2015 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed u nder the terms of the Cre-
ative Commons Attribution Non-Commercial No Derivatives (by-nc-
nd) License <ht tp://creativecommons.org/licenses/by-nc-nd/3.0/>.
Original Article
J. Phys. Ther. Sci. Vol. 27, No. 6, 20151862
Visual feedback and extrinsic feedback improve movement
performance, thereby increasing the efcacy of rehabilita-
tion interventions17, 18).
Thus, the purpose of this study was to investigate the ef-
fect of the stepper exercise with visual feedback on lower
extremity strength and functional movement of patients with
stroke.
SUBJECTS AND METHODS
This study followed a 2-group pre-test-post-test de-
sign. Patients were divided randomly into the 2 groups to
minimize the likelihood of bias. Thirty patients with stroke
were recruited at the Stroke Rehabilitation S Hospital in
Seoul. This study was approved by the Ethics Committee
of Sahmyook University. Before the experiment began,
participants were provided with sufcient explanation about
the study. All participants signed an informed consent form.
The inclusion criteria were as follows: unilateral stroke that
occurred 6 months prior to the study; the ability to perform
10-m independent gait and independent stair climbing; no
sight impairment; and Mini-Mental Status Examination
(MMSE) score of over 24 points. The exclusion criteria were
orthopedic, medical, and/or painful conditions; aphasia; car-
diovascular disease, and previous participation in a similar
experiment.
The pre-tests included a 10-m walking test and the climb-
ing of 11 stairs. The Borg’s scale was used to measure the
intensity of the exercise.
All participants performed the stepper exercise for 30
minutes, thrice per week for 6 weeks. The participants were
divided into the stepper exercise (SE, n = 13) or the stepper
exercise with visual feedback (SEV, n = 13) group. The SEV
group performed the exercise in front of a full-length mirror
and watched their own movements in the mirror; another
mirror was placed behind them so they could view the place-
ment of their foot on the foot pedal. Both groups performed
the exercise for the same amount of time and at the same
intensity. All the participants performed the 30-minute step-
per exercise, thrice per week for 6 weeks.
SPSS version 19.0 software was used for statistical analy-
ses. The pre-test data of the subjects were subjected to nor-
mality tests. The t-test and Mann-Whitney U test were used
to compare the participants’ characteristics. The paired t-test
compared values obtained before and after the intervention
exercise. Data were also analyzed using the independent t-
test to examine differences in the results between the SEV
and SE groups. Statistical signicance was set at p < 0.05.
RESU LT S
While 30 subjects were recruited, only 26 (SEV group,
13; SE group, 13) participated in this study. The demo-
graphic and clinical characteristics of the 2 groups did not
differ signicantly (Table 1). The data regarding hip joint
muscle strength, the 10-m walking test, and stair climbing,
both within groups and between groups, are summarized in
Table 2. Signicant improvements were noted in the non-
paralyzed hip joint strength and also for the paralyzed hip
joint strength of the SEV group (p < 0.05) as well as the
10-m walking and 11-stair climbing tests (p < 0.05).
DISCUSSION
The stepper exercise was performed on the p-bar to en-
sure that the patients were safe, as this method allowed them
to support themselves using both hands. The SEV group
received visual feedback by means of mirrors placed in the
front and rear. The front mirror enabled the participants to
check the alignment of the trunk when performing the exer-
cise, while the rear mirror allowed them to verify that they
were using the stepper pedal correctly7). The SEV group
showed signicant improvements in the hip joint muscle
strength of both the paralyzed and non-paralyzed sides, and
the strength of the hip joint extensor muscle showed more
improvement in the SEV group than the SE group. After the
stepper training, both groups conrmed the activation of the
hip joint extensor muscle13). However, this study only identi-
ed signicant improvement in the hip joint extensor muscle
in the SEV group.
Treatment using the mirror was the result of extensive
research on the recovery of patient upper extremity func-
tion and pain19–21). Only 2 previous studies have reported
the recovery of the exercise capacity of the lower extremity
involving exercises with visual feedback, such as the use of
a mirror22). First, the patients were moved to the non-para-
lyzed side of the mirror to inuence the attack side, which
compensated for the proprioceptive sensory loss23). Second,
watching one’s own movement in the mirror stimulates the
mirror neuron system24). The visual-motor neuron, a neuron
of the mirror neuron system, is activated when observing
motion and motion execution. The mirror-neuron system
generally involves learning through visual observation.
Therefore, the present study aimed to activate the visual
feedback using a mirror, where patients could observe their
movements in the mirror, thereby increasing the efcacy of
the stepper exercise. In particular, the rear mirror’s location
helps patients visualize their exact steps, thereby inducing
the benet of the hip joint extension movement of the step-
per and strengthening the hip joint extensor muscle13).
Tab le 1. Characteristics of study participants
Parameters SEV (n=13) SE (n=13)
Age, years 71.9 (6.92) 69.8 (9.76 )
Weight, kg 55.4 (9.00) 56.5 (6.00)
Height, cm 156.3 (8.44) 156.9 (9.59)
Disease duration, months 13.8 (6.96) 11.2 (5 .35 )
MMSE-K 26.8 (1.74) 25.6 (1.9 4)
Gender Male 3 (23%) 4 (31%)
Female 10 (77%) 9 (69 %)
Case
of disease
Cerebral infarction 8 (62%) 10 (77%)
Cerebral hemorrhage 5 (38%) 3 (23%)
Attack site Right 7 (5 4%) 4 (31%)
Left 6 (46 %) 9 (69%)
Values are mean (SD), MMSE-K: Mini-Mental State Exami-
nation Korea; SEV: stepper exercise with visual feedback; SE:
stepper exercise
1863
After the training, there was a signicant improvement in
the knee joint extensor muscle strength in both the SEV and
SE groups but no signicant difference between the groups
in this regard. In a previous study on stroke patients that in-
volved a stair climbing exercise, the exertion of the hip joint
extensor muscle and muscle strength consumption of both
sides of the knee joint extensor muscle, ankle joint, and plan-
tar exor muscle of the non-paralyzed side were higher than
that reported in our study25). The stepper exercise is similar
to stair climbing, leading to strengthening of the knee joint
extensor muscle. The stepper exercise with visual feedback
was found to be more effective in strengthening the hip joint
extensor muscle than the stepper exercise alone.
Improved muscle strength based upon changes in the
functional activity was examined to investigate the walk test
and the 11-stair climbing task. To determine the effective-
ness of the exercise program, the participants were subjected
to the 10-m walk test; both groups showed a signicant in-
crease in the results compared to the pre-test data. However,
the improvement was higher in the SEV group than in the
SE group. In another study, the increase in the walking speed
of stroke patients was thought to be caused by improved
muscle strength; approximately 75% of the improvement in
walking speed was attributed to muscle strength training and
an increase in the strength of either the hip joint extensor
muscle, the ankle joint planter exor muscle, or both26). The
signicant difference in the walking speed between the SEV
and SE group in the 10-m test is thought to have been caused
by improvement in bilateral hip joint extensor muscle
strength. To examine the different functional changes, the
participants were also subjected to an 11-step stair-climbing
test; both groups showed a signicant increase in the test re-
sults after the exercise program, but there were no signicant
differences in the scores between the 2 groups. In a previous
study on cardiorespiratory capacity reduction of chronic
stroke patients, it was shown that the patients found it ex-
tremely difcult to climb stairs25). Another study reported
that more specialized training was needed in these patients
to improve functional movements, such as climbing stairs27).
In yet another study, stair climbing combined with strength
training was found to improve the patients’ ability to climb
stairs7). However, the stair climbing performance of patients
from a previous study was compared the experimental and
control group. As a result, the hip joint extensor muscle
strength costs were similar. Both sides of the knee joint ex-
tensor muscle and the non-paralyzed side of the dorsiexor
muscle strength costs were also higher25). Thus, in both
groups, a signicant improvement was observed in the 11-
step stair-climbing test results owing to an improvement in
the knee joint extensor muscle and the cardiovascular effects
of the stepper exercise, albeit with no signicant difference
in the scores between the 2 groups. The reason behind this
observation could be that the hip joint extensor muscle was
not improved to a great extent despite the enhanced visual
feedback with the use of the mirror25).
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Val u es Change Values
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Pre Post Pre Post Post-pre Post-pre
Muscle strength (kg)
HJEM NA 7.58 (2.09) 9.15 (3.0 9)* * 8.59 (2 .22) 8.88 (2.08) 1.57 (1.84)* 0.29 (1.21)
A4.32 (1.99) 6.35 (1.99)*** 5.07 (1.94) 5.68 (2.27) 2.03 (1.64)* 0.60 (1.75)
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11 stair climbing test (second) 34.3 9 (16.41) 25.44 (15.15)*** 37.11 (2 0.2 9) 32.62 (19.17 )** −8.95 (8.79) −4.49 (5.76)
Values are mean (SD), *p<0.05, **p<0.01, ***p<0.001
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NA: non paralyzed-side; A: Affected-side
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