REVIEW ARTICLE

Hippokratia 2018, 22(2):51-59

Guzik A, Drużbicki M, Wolan-Nieroda A
Institute of Physiotherapy, Medical Faculty, University of Rzeszów, Rzeszów, Poland

Abstract

Background: Rehabilitation provided to patients after stroke mainly aims at improvement in gait function. The most common gait training strategies include treadmill exercise and traditional overground gait training. The studywas designed to assess the effectiveness of two models of gait re-education in post-stroke patients, namely conventional physical therapy and treadmill training.

Methods: A systematic literature review was performed, taking into account the online databases of Medline (PubMed), Science Direct, Web of Science, Google Scholar, and clinical trials registries. The following inclusion criteria were applied: studies published from 2008 to 2018, written in English, involving treatment and control groups, investigating conventional physical therapy and treadmill training administered for gait re-education after stroke.

Results: Out of 160 articles identified, 23 met the inclusion criteria and were reviewed and analyzed. One hundred fifteen projects involving clinical trials were identified; out of these nine reports from the last five years are included in the review. The number of participants in all the studies totaled at 1,772. The participants in all the studies represented both sexes, and their age ranged from 18 to the late 80s, with an average of 60+ years of age. In most cases, the patients examined were at a chronic stage post-stroke, i.e., more than six months following stroke onset. The most frequently applied types of treadmill training included: high-intensity aerobic treadmill training and treadmill training with or without body weight support. Most interventions involved participation in 30- or 60-minute sessions, from three to five times weekly, for the duration of six to 16 weeks.

Conclusions: Treadmill training seems to be a valuable and effective method of gait re-education, which can be used at various periods following a stroke, and mainly leads to improvement in walking speed and walking capacity. However, no standard has been defined so far with regard to treadmill-supported recovery of gait function in patients after stroke. We still do not know the optimum duration and frequency of exercise. Further study should investigate long-term effects and the way treadmill training impacts on patients’ daily activities. HIPPOKRATIA 2018, 22(2): 51-59.

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Key words: Stroke, gait, treadmill, randomized controlled trials, literature

Corresponding author: Agnieszka Guzik, PhD, Institute of Physiotherapy, University of Rzeszów, 26 a Warszawska, 35-205 Rzeszów, Poland, tel: +48178721930, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Introduction

Walking is one of the most important abilities, necessary for independent functioning and active involvement in social life. It is estimated that gait-related problems are experienced by approximately 60 % of patients after stroke1,2. Although most stroke survivors regain a certain level of independent locomotion, in many cases, they are not able to perform all activities of daily living without assistance. Consequently, rehabilitation programs designed for post-stroke patients primarily focus on gait training3,4. Well-known methods applied in gait re-education after stroke include treadmill training, which presents many advantages compared to overground gait training. Most importantly, treadmill training is based on multiple repetitions of the entire gait cycle, with a greater total number of steps and complete control over the patient’s gait velocity. Furthermore, treadmill training is carried out in a well-defined area; therefore, the therapist has greater control of and can adequately secure the patient1,5.

In the literature, numerous studies are reporting that treadmill training contributes to improved ambulation in patients, both at an early and at a chronic stage after stroke. In addition to such benefits as higher walking speed and longer distance covered, increased endurance, and decreased spasticity, treadmill training seems to support mechanisms of neuroplasticity2,6-13. Likewise, it has been established that overground gait training is effective in post-stroke patients14-24. Therefore, it would be interesting to examine whether or not there are significant differences in the progress achieved by post-stroke patients as a result of treadmill gait training compared to conventional overground gait training. A need to find an answer to the above question was the motivation for this study. The studywas designed to assess the effectiveness of two models of gait re-education after stroke, namely interventions based on a conventional physical therapy or a treadmill training.

Material and Method

The search was carried out, in the period from May 2017 to April 2018, in the following databases: Medline (PubMed), Science Direct, Web of Science, Google Scholar, and in the clinical trials registries (https://www.clinicaltrialsregister.eu, https://clinicaltrials.gov). The following medical subject headings (MeSH) search terms were defined in combination: ‘gait’ and ‘stroke’, and yielded 1,522 articles, and then the terms ‘treadmill training’ (all fields) (505 articles), and ‘conventional gait training’ (all fields) (160 articles) were added to narrow down the search.

Inclusion and exclusion criteria

A detailed search was carried out, and filters were applied to limit the search to randomized control trials published in English, between 2008 and 2018. The articles were taken into account if they met the above criteria and if they focused on gait re-education based on conventional physical therapy or treadmill training administered to patients after stroke. Systematic reviews, meta-analysis, and qualitative studies were excluded from the analysis. Projects involving clinical trials were qualified if their status was identified as ongoing, completed, or terminated and recruiting, within the last five years. Projects based on clinical trials with “unknown” status were excluded from the review. Out of 160 articles identified, 23 met the inclusion criteria and were reviewed and analyzed in the present study. One hundred fifteen projects involving clinical trials were identified; out of these nine reports from the last five years are included in the review.

Data analysis

A systematic review of the research reports was performed in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. The data collected related to the following items: publication date, study type, number of patients, randomization, control, demographics of importance (age, sex, time from a stroke), intervention, training modalities, and main outcome measures. All the potential articles were screened by two independent reviewers and those reports which did not address the research question were excluded.

Results

Relevant information was gathered from the published literature following the PRISMA guidelines and the flow diagram is shown in Figure 1. Titles and abstracts of 1,522 articles were initially screened for inclusion, and 23 articles meeting the eligibility criteria were ultimately selected for the current review (Table 1, Table 2, and Table 3). As for the clinical trials, the screening process took into account 115 projects from 2000-2018, and eventually, nine studies (status: ongoing, completed, terminated, and recruiting) were selected, all published within the last five years (Table 4). All research reports related to randomized controlled studies. All the projects involving clinical trials were interventional/randomized.



Figure 1: Flow diagram according to PRISMA statement of the systematic review conducted to assess the effectiveness of two models of gait re-education in post-stroke patients.

Participants

The participants were assigned randomly to the intervention group or the control group. The number of subjects participating in all the studies totaled at 1,772. The experimental groups and the controls in all the studies represented both sexes (male/female), and their age ranged from 18 to the late 80s, with an average of 60+ years of age. One clinical trial project focused on pediatric stroke at the age of 5-17 years25. In most cases, the patients were at a chronic stage after stroke, i.e., more than six months from stroke onset. Other studies included participants who were one to three months after stroke.

Intervention types

Two major types of interventions applied to improve gait in stroke survivors included treadmill training and conventional physical therapy (Table 1-4). Most interventions involved participation in 30- or 60-minute sessions, three to five times per week, for the duration of six to 16 weeks. Other interventions consisted of 90-minute sessions26,27, 50-minute sessions28,29 or 40(45)-minute sessions30-33. In some cases, the training was conducted with greater intensity for a shorter period of time, e.g., 180-min sessions for two weeks34. The most common types of treadmill training applied included: high-intensity aerobic treadmill training and treadmill training with or without body weight support. Some studies also focused on treadmill training with optic flow, a treadmill based visual cue training, backward walking treadmill training, and asymmetrical treadmill training. Conventional physical therapy (general exercise program/regular physiotherapy) involved stretching, strengthening, endurance, balance, coordination, range of motion activities, and overground walking practice. One study reported a home exercise program, managed by a physical therapist, and focusing on the task-specific walking program, enhancing flexibility, range of motion in joints, the strength of arms and legs, coordination, as well as static and dynamic balance26.

Outcome measures

Different outcome variables adopted by the studies included: spatiotemporal and kinematic gait parameters (gait analysis systems), the 6-minute timed walk or the 10-minute timed walk, the Timed Up and Go test, the Dynamic Gait Index, the Functional Reach Test, the Berg Balance Scale, the Activities-specific Balance Confidence Scale, the Stroke Impact Scale, the Barthel Index, the Functional Independent Measure, the Fugl-Meyer Assessment, the Functional Ambulation Category, the Rivermead Mobility Index, the Motor Assessment Scale, the Falls Efficacy Scale, the Medical Outcomes Study Short Form 12, the International Physical Activity Questionnaire, the Health-related Quality of Life Scale, the Frenchay Activities Index, the Scandinavian Stroke Scale, the Depression Scales, the corticomotor activity and the oscillometric, spirometric, accelerometric, and ergometric methods.

Discussion

Advantages of treadmill training in comparison to conventional gait training

 Research shows that treadmill walking is an alternative for conventional overground walking, which is linked with new opportunities for the analysis of biomechanics and motor control of gait35-41. Kuys et al conducted a comparison of gains achieved by post-stroke patients as a result of treadmill training versus overground gait training. The authors suggested that 30-minute high-intensity treadmill training, three times a week, for six weeks, in addition to a conventional physical therapy produces more significant improvement in walking capacity and walking speed than regular physiotherapy alone. Moreover, these effects were still present after 18 weeks, the patients from the study group on average could walk 0.26 m/s faster than the controls39. Likewise, Dean et al reported that body weight supported treadmill training (BWSTT) leads to greater improvement in walking capacity than overground gait training. The authors showed that 30-minute BWSTT applied in combination with conventional physiotherapy until the patients achieved the ability to walk without assistance or were discharged from hospital, produced a greater increase in walking capacity, compared to assisted overground walking. The findings, however, did not show differences between the groups related to walking speed, length of the gait cycle, number of falls, or community participation40. Mao et al compared changes in balance, lower limb motor function as well as temporospatial and kinematic gait parameters, resulting from BWSTT and conventional overground gait training in patients with subacute stroke. Both types of gait training were conducted on average for 30 minutes per day, five days a week, for three weeks. The authors showed that at the end of the program, both groups achieved improvement in balance and motor function of the lower limb. However, the experimental group presented better temporospatial and kinematic parameters of gait42. The study also showed that the BWSTT (60-minutes per day, five times per week, for six weeks) produced more significant improvements in cardiovascular fitness and walking endurance than conventional physiotherapy during a subacute post-stroke period. Moreover, these gains were largely sustained for one year43. It was also pointed out that, compared to conventional overground walking practice, gait training with robotic gait assistance more successfully decreased gait disturbances, and improved peak torque on the unaffected side and peak aerobic capacity, peak heart rate, and exercise tolerance in subacute hemiplegic stroke patients44,45. On the other hand, Yang et al showed that, in comparison to a general exercise program, the BWSTT (30-minutes per day, three times per week, for four weeks) produced greater increase in cortical reorganization, and consequently more significant improvement in motor control; this effect was observed in the patients both at an early and at a chronic stage after stroke28. Yen et al also investigated changes in corticomotor excitability evoked by gait training in patients with chronic stroke. The researchers reported that following conventional gait training alone, the patients showed improvement in gait velocity and cadence, yet no significant changes were observed in this case in corticomotor excitability. However, after the additional BWSTT, the subjects had significantly better scores on the Berg Balance Scale, and in walking speed and cadence. The map size for tibialis anterior muscle was increased in both hemispheres, while the map size for abductor hallucis muscle was increased only on the affected side29.

Similar effects of treadmill gait training and conventional gait training

The above observations are not consistent with findings reported by Middleton et al, who concluded that BWSTT did not produce better effects in patients with chronic stroke than overground gait training. The entire program comprised one hour of gait training (overground or BWSTT), one hour of balance training, and one-hour exercise session focusing on strength, range of motion, and coordination, and was administered for ten consecutive weekdays. The authors did not find any significant differences in the effects between the groups, either immediately after the training or during the follow-up assessment34. Given the above it was assumed that 10-day training was insufficient; hence there was a need to conduct further study to assess a more intensive training applied for more than ten days, and a resulting improvement of gait, balance, and mobility in individuals with chronic stroke. Srivastava et al assessed the effects of 4-week BWSTT and conventional gait training programs conducted for 30 minutes per day, five times per week. This study also showed no significant differences in the improvement achieved by chronic stroke survivors46. Duncan et al argue that BWSTT is not more effective than progressive exercise at home administered by a physiotherapist. The home exercise program focused on improving flexibility, range of motion in the joints, the strength of upper and lower extremities, coordination, as well as static and dynamic balance. The patients received 36 training sessions, for 12 to 16 weeks, each intervention was 90 minutes long. No significant differences were identified in walking speed, motor control, balance, functional performance and quality of life improvements between the groups (either the early or the late locomotor training)26. Studies carried out by Olawale, Globas, and Kang focused on subjects with chronic stroke (up to 24 months from stroke onset) and reported no significant differences in gait capacity improvements (the 6-minute walk test) achieved by patients as a result of treadmill training, high-intensity aerobic treadmill training and with optic flow as compared to overground training47-49. On the other hand, Baer et al pointed out that treadmill training was feasible in sub-acute stroke patients, but when compared to normal gait re-education showed no significant difference in outcomes33. Bonnyaud et al compared effects of a single treadmill training session and a single overground training session reflected by subjects’ performance in the Timed Up and Go test, assessing independent mobility and risk of falls in patients with hemiparesis after stroke. The authors showed that the time needed for completing the Up and Go test was significantly reduced after the 20-minute training session, to a similar degree in both groups50. Given the above, it can be concluded that hemiparetic patients should be encouraged to regularly walk overground, when possible for 20 minutes without stopping because this is a simple and inexpensive method of rehabilitation to recover functional walking ability. Bonnyaud et al also undertook a comparison of a single overground practice and a single treadmill gait training session to examine short-term effects reflected by biomechanical gait parameters (spatiotemporal, kinematic, and kinetic) in hemiparetic patients. The authors reported that after gait training, there was a considerable increase in such parameters as walking speed, cadence, duration of stance phase, and peak knee extension on the paretic side. Yet, there were no specific changes dependent on the type of gait training performed by the two groups51. Høyer et al investigated the effectiveness of BWSTT combined with traditional gait training in comparison to traditional gait training alone at an early stage after stroke. The authors concluded that the two training strategies (60-minutes per day, five times per week, for ten weeks) lead to similar improvements in walking abilities (speed and capacity) after stroke52. Similar issues were investigated by Franceschini et al. The BWSTT combined with a conventional rehabilitation program and the conventional rehabilitation program alone (60 minutes per day, five times per week, for four weeks) produced the same improvement in gait parameters in patients within six weeks from stroke onset53.  Based on these findings, it can be concluded that, in the case of patients with subacute and with chronic stroke, treadmill training is as effective as a conventional overground gait practice.

Advantage of conventional gait training over equipment assisted gait training 

In the literature, we can also find publications suggesting that conventional gait training presents advantages over devices designed to assist gait training in subacute and chronic stroke. Hidler et al reported that patients who received conventional training showed significantly higher improvement in walking speed and distance walked compared to the patients who trained on the Lokomat (90 minutes per day, three times per week, for 8-10 weeks). The differences were maintained at the follow-up, three months later27. Also, Combs-Miller et al indicated that overground walking was more beneficial than BWSTT in improving self-selected walking speed in patients at least six months post-stroke and able to walk independently54. It was also reported that the step length symmetry ratio was only improved by overground walking practice, which suggested it was essential to integrate overground walking into BWS in individuals with chronic stroke32.

Clinical trials

Research findings published so far do not provide consistent and robust evidence either for or against the effectiveness of treadmill training in recovery of gait by patients after stroke. Further studies, which are being prepared or are in progress25,30,31,55-60, should provide information on the effectiveness of novel treadmill training methods, such as backward walking treadmill training56 and asymmetrical treadmill training25. New research also aims at developing methods of gait re-education after stroke, based on various types of gait training. Kerckhofs et al are conducting a study in which gait re-education program combines robot-assisted gait training (Lokomat), treadmill practice, and overground walking60.

The limitation of the review is the fact that it does not apply strict inclusion criteria taking into account the duration, intensity, and frequency of the programs based on both treadmill training and conventional gait practice.

Conclusions

The present review focuses on the effectiveness of treadmill gait training in comparison to conventional overground gait training in patients with stroke. Studies conducted so far greatly vary in terms of the training methods applied. No standard has been defined yet about the recovery of gait function after stroke. We still do not know the optimum duration and frequency of exercise. The current literature review also allows a conclusion that it is challenging to adopt a uniform definition for the concept of conventional gait training because the relevant studies greatly vary in terms of gait therapy duration as well as the types of exercise applied in gait re-education. Research also seems to suggest that treadmill training mainly produces improvement in walking speed and walking capacity in patients both at an early and at a chronic stage post-stroke. Few of the relevant studies investigated gait changes and the resulting gains in basic and complex activities of daily living. Given the above, further research should focus on assessing long-term effects, and the way they impact the daily activity of subjects after stroke. There is too little evidence confirming that improved gait function (speed and capacity) resulting from treadmill training corresponds to decreased limitations due to disability, and consequently to greater independence and self-reliance.

New studies, which are underway, should provide information on the effectiveness of novel treadmill training methods, such as backward walking treadmill training and asymmetrical treadmill training. New research also aims at developing methods of gait re-education after stroke, based on various types of gait practice.

The problem investigated by these authors remains controversial because the studies published so far provide conflicting information. Some researchers report that treadmill training produces more significant improvement in walking abilities, compared to conventional gait training in patients after stroke, some argue the two methods are equally effective, while others insist conventional gait training presents an advantage over devices designed to assist gait training. Given the above, it can clearly be concluded that the two training strategies produce beneficial effects leading to improved walking abilities in patients after stroke. However, if advanced gait re-education methods, requiring costly equipment, cannot be used for various reasons, a well-designed conventional gait training is an adequate, affordable and straightforward method to achieve the intended effects of rehabilitation after stroke.

Conflict of interest

Authors have no conflict of interest to declare.

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