Effect of an Overground Training Session Versus a Treadmill Training Session on Timed Up and Go in Hemiparetic Patients Céline Bonnyaud, MSc,1,2 Raphael Zory, PhD,1 Johanna Robertson, PhD,1 Djamel Bensmail, PhD, MD,1 Nicolas Vuillerme, PhD,2,3 and Nicolas Roche, PhD, MD1 1 Groupe de Recherche Clinique et Technologique sur le Handicap, Université Versailles Saint Quentin en Yvelines, EA 4497, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, Garches, France; 2Laboratoire AGIM, FRE 3405 CNRS/UJF Grenoble/UPMF/ EPHE, La Tronche, France; 3Institut Universitaire de France, Paris, France
Background: Timed Up and Go (TUG) performance is reduced following stroke. Gait training improves gait-related activities in hemiparetic patients. However, no study has compared the impact of a single overground training session with a treadmill training session on gait-related activities (assessed by TUG). Objective: To compare the immediate effect of a single overground training session versus a single treadmill training session on TUG performance in hemiparetic patients. Methods: In this randomized controlled clinical trial, 56 hemiparetic patients were randomized to 1 or 2 distinct groups: a single gait training session overground (O group) or on a treadmill (T group). Time taken to perform the TUG (in seconds) was assessed before and immediately after the completion of each session. Results: Time taken to perform the TUG decreased significantly, and to a similar extent, in both groups following the training session (O group, 5.9%; T group, 5.2%). Conclusions: An overground training session and a treadmill training session were equally effective in improving TUG performance in hemiparetic patients. Hemiparetic patients should be encouraged to walk regularly overground including turns for 20 minutes without stopping. This is an easy and inexpensive self-rehabilitation method to improve functional gait-related activities involved in the TUG test. Key words: gait training, hemiparesis, self-rehabilitation, Timed Up and Go test
A
pproximately 50% of stroke patients are partly dependent for activities of daily living (ADLs),1 and less than 50% of survivors are able to walk in the community.2 Many stroke patients do not have a gait that allows them to perform all their daily activities.3 Several gait-training techniques have been shown to be effective in improving functional gait capacity. Task-oriented training and treadmill training have both been shown to be effective in improving gait speed and gait-related activities, demonstrated by the Timed Up and Go (TUG) test,4-6 and are more effective than conventional therapy (neurodevelopmental treatment and stretching) in stroke patients.6 However, such training requires equipment and supervision by a therapist. More and more self-rehabilitation programs are being developed, because it has been established that
Corresponding author: Céline Bonnyaud, Université Versailles Saint Quentin en Yvelines, EA 4497, CIC-IT 805, AP-HP, Hôpital Raymond Poincaré, 92380 Garches, France ; e-mail : [email protected]
rehabilitation in the chronic phase of stroke can be effective.7 Therapy at home is also recommended for stroke patients to prevent deterioration in ADLs.8,9 Such programs are important, because stroke patients do not maintain functional gains after the cessation of rehabilitation.10,11 Overground walking is a simple method of gait training available to all patients. However, a recent Cochrane review found that there was insufficient evidence to determine whether overground walking significantly improves gait activity.12 Minimal requirements for efficient mobility require a person to be able to rise from a chair, walk, and turn.13 The TUG test, derived from the Get Up and Go,14 is a very useful test to measure basic gait activities that relate to autonomy in daily life. The TUG test assesses the global time taken to stand up from a chair, walk 3 meters,
Top Stroke Rehabil 2014;21(6):477–483 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2106-477
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turn around, walk back, and sit down.15 This quick and simple test has excellent intrarater reliability and good sensitivity for the detection of clinical changes in stroke patients.3,16 The test was initially developed to assess the risk of falls with a cutoff score of 14 seconds17,18; however, TUG performance has also been shown to be related to independence in ADLs in stroke patients.15 This highlights the importance of defining optimal and efficient protocols to improve TUG performance in hemiparetic patients. Treadmill training appears to be an interesting approach to improve functional gait capacity in stroke patients. Kang et al6 found that 4 weeks (30 min/day) of treadmill training induced a greater improvement of TUG performance than regular therapy of the same duration (neurodevelopmental treatment and stretching) in stroke patients. Nevertheless, it would be easier for patients to perform self-gait training overground than on a treadmill. No study has compared the impact of these 2 training methods (overground and treadmill) on gait-related activities measured by TUG performance in chronic stroke patients. The aim of this randomized controlled study was to compare the immediate effect of a single overground training session, including turning, versus a single treadmill training session on functional gait capacity measured by the TUG in chronic hemiparetic patients. The TUG test is a more complex task than straight walking, including subtasks of standing up, turning, and Table 1.
sitting down. Because the 2 walking phases comprise the greatest portions of this test and treadmill training has been shown to be more effective than overground training on gait speed,19,20 we hypothesized that TUG performance would improve more following the treadmill training session than the overground session. Materials and Methods Subjects
Fifty-six chronic hemiparetic patients (characteristics shown in Table 1) gave written consent and were included in this study. The inclusion criteria were age over 18 years, hemiparesis due to a single hemispheric stroke diagnosed by MRI, and ability to walk 20 minutes without a break and without an assistive device. Patients were not included if they had any comorbid disability such as visual impairment, musculoskeletal or cardiovascular disorders, or other disorders that would affect the assessment. This study was performed in accordance with the ethical codes of the World Medical Association and was approved by the local ethics committee. Experimental set-up
After inclusion, patients were randomized to 1 or 2 distinct gait training protocols performed either (1) on a treadmill (T group, n = 28) or (2) overground
Patient characteristics Time post stroke, years
Barthel, median (range)
NFAC, median (range)
Comfortable gait speed, m/s
TUG baseline, seconds
42 M 14 W
100 (80-100)
7 (6-8)
0.85 ± 0.2
9.3 ± 2.9
5.8 ± 4.6
23 M 5W
100 (80-100)
7 (6-8)
0.8 ± 0.2
9.9 ± 3.5
6.2 ± 8.8
19 M 9W
100 (90-100)
7 (6-8)
0.9 ± 0.2
8.7 ± 2.1
Age, years
Side of hemiparesis
All patients
51.1 ± 12.8
25 right 31 left
6.0 ± 6.8
Overground group
49.7 ± 13.5
13 right 15 left
Treadmill group
52.5 ± 12.6
12 right 16 left
Sex
Note: Timed Up and Go (TUG) and gait speed were not different in both groups in baseline, P > .05. NFAC = New Functional Ambulation Classification.
Gait Training in Hemiparetic Patients
(O group, n = 28). All the gait training sessions were carried out by the same physiotherapist who gave the same encouragements to all patients. Both groups participated in a 20-minute gait training session, during which they were instructed to walk without stopping at a constant speed (ie, their comfortable gait speed previously defined using the 10-meter walking test). For the T group, the speed of the treadmill was progressively increased (over a 1-minute period) to match the patient’s comfortable speed and was maintained constant during the session. For the O group, patients were encouraged by the therapist to maintain a comfortable speed over the time period and the cadence was set by a metronome. The overground gait training session was carried out in a 50-m-long corridor and therefore several turns were included during the session.
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A nonparametric Wilcoxon test was used (P < .05) to assess the effect of gait training, without considering the type (treadmill or overground), on TUG performance. A nonparametric MannWhitney test was used to compare TUG performance in both groups before the gait training and to determine the effect of the type of gait training on changes in TUG performance (P < .05). Results
The TUG test was carried out by the same investigator for each patient, blinded to the group training, just before and immediately after the gait training session. As proposed by several authors,15,17,21 the test was executed as follows: (1) patients were required to stand up from a chair with armrests, walk 3 m, turn around, return to the chair, and sit down again, as fast as possible17,18; (2) the time taken to complete this task was recorded in seconds using a stopwatch; and (3) 3 trials were recorded per patient to reduce the variability.
The 56 patients included in this study (25 with right-sided hemiparesis, 31 with left-sided hemiparesis) had a mean (SD) age of 51.1 (12.8) years and a mean (SD) time since stroke of 6.0 (6.8) years. There was no significant difference in TUG performance between the 2 groups before the gait training (P = .22). In the O group, patients performed an average of 19 half turns in 20 minutes. As illustrated in Figure 1, the time taken to perform the TUG test significantly decreased for all patients following the gait training session (from 9.3 ± 2.9 seconds to 8.7 ± 2.9 seconds; P = .0006, both groups considered together). The analysis of the results showed that this improvement was similar in both groups (from 9.9 ± 3.5 seconds to 9.3 ± 3.6 seconds in the O group [5.9% improvement], and from 8.7 ± 2.1 seconds to 8.2 ± 2.0 seconds in the T group [5.2% improvement]; P = .78). Figure 2 illustrates the percentage of change of TUG performance in each group.
Data analysis and statistical analysis
Discussion
The time taken to perform the TUG test (in seconds) was averaged for each patient.6 The mean values of the TUG test before and after the gait training session were analyzed for each group. The percentage change was calculated for each patient using the following formula: (Post TUG performance – Pre TUG performance)/(Pre TUG performance) × 100 × (-1) Improvements in TUG performance between the pre and post assessments were associated with a positive value. The mean percentage change and its standard error were then calculated for each group (O group and T group).
The aim of this randomized controlled clinical study was to compare the effects of a single overground training session and a treadmill training session on gait-related activities evaluated by the TUG test. The results showed, for the first time, that single overground or treadmill gait training sessions were equally effective in improving gait-related activities (TUG performance) in hemiparetic patients. Firstly, our results showed improvements in TUG performance after a single gait training session in a large sample of chronic stroke subjects. This result is in accordance with studies by Dean
TUG test
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∗
Time to perform TUG test (in sec)
9.8 9.6 9.4 9.2 9 8.8 8.6 8.4 8.2 PRE session
POST session
Figure 1. Mean and standard error of mean of TUG performance (in seconds) measured before (PRE session) and after the gait training session (POST session). *Significant difference between before and after training, P < .05. NS
9
Percentage improvement
8 7 6 5 4 3 2 1 0 Group O
Group T
Figure 2. Mean and standard error of mean of percentage of TUG performance improvement obtained in the 2 groups (group O and group T). NS = no significant difference between group O and group T.
et al5 and Kang et al,6 who assessed the effect of several training sessions. Dean et al5 found an improvement in TUG performance (-7.9 seconds) in 5 chronic stroke subjects following task-oriented training involving overground walking, treadmill walking, and functional tasks carried out 3 times a week for 4 weeks.5 The improvements in TUG performance in our study are smaller (following a single session), but they might be predictive of greater improvements after several sessions. Indeed, Reisman et al22 suggested that immediate adaptations reflect short-term motor learning and that repeated adaptations may result in the learning of a permanent motor pattern. Other
studies showed improvements following a singledose trial on gait parameters23 or on motor skill of the paretic hand24 in stroke patients. Further study is necessary to assess the long-term effects of gait training performed overground or on a treadmill on TUG performance in stroke patients. Our results are in accordance with those of Dean et al, suggesting that a simple gait training session could be as effective as a specific task-oriented program to improve functional gait-related activities assessed by the TUG. Kang et al6 compared the effect of 4 weeks of treadmill training with or without optic flow in 36 persons with chronic hemiparesis. They
Gait Training in Hemiparetic Patients
found a mean improvement of 5.5 seconds following treadmill training with optic flow and of 1.5 seconds following treadmill training without optic flow. Our results are in accordance with their results; they also show that some improvement could be observed after a single treadmill gait training session. Improvement in performance of gait-related activities assessed by the TUG immediately after a single gait training session might therefore constitute a good inclusion criterion for patients who are likely to be highly improved by a training program based on several training sessions. The improvement in TUG performance was independent of the type of gait training – overground or treadmill. This result suggests that, contrary to our expectation, a gait training session performed overground has a similar impact on gait-related activities assessed by the TUG test as gait training performed on a treadmill. This result corroborates the findings of our recent study showing similar improvements in biomechanical gait parameters following a single overground or treadmill training session in hemiparetic patients.23 Encouraging outpatients with hemiparesis to walk for 20 minutes without stopping and to include turns in the walk on a regular basis might at least maintain functional gait capacity and possibly improve other functional gait-related activities.25 Further studies will be necessary to confirm this assumption. Because the 2 walking phases represent the greatest portions of this test and treadmill training has been shown to be more effective than overground training on gait speed,19,20 our initial hypothesis was that TUG performance would be more improved following treadmill training than overground training. One explanation for the lack of difference between the 2 types of gait training on TUG performance may be because the different gait training conditions (overground and treadmill) improve different subphases of the TUG, creating a similar net improvement of the overall test performance. Indeed, we can suppose that the participants in the O group, who performed a mean of 19 turns, improved in the turning subphases of the TUG test more than the T group who did not practice turns, whereas the participants in the T group may have
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improved more in gait speed, thus performing better on the straight walking phases of the TUG test. So even if the net result of the 2 gait training sessions on the TUG performance is similar, the mechanisms underlying these improvements might be different. This hypothesis is supported by the following results. Laufer et al19 and Pohl et al20 showed that treadmill training was more effective than overground training in improving gait speed, and Lam and Luttmann26 found a significant correlation between turning capacity (180° turn) and TUG performance.26 This hypothesis implies that the turning and straight walking phases of the TUG test are likely equally important in overall performance. This is in line with Faria et al27 who suggested that global TUG performance time does not provide sufficient information for clinicians. These results suggest that an optimal gait training program should attempt to improve both turning ability and gait speed to improve functional gait-related activities of stroke patients. We cannot exclude that the sit-to-stand and stand-to-sit subphases of the TUG were also partly improved by the training session. Obviously the overall performance of the TUG does not permit us to determine whether these subphases were really improved. However, because these subtasks were not implied in the training, the overall TUG performance improvement seems not to rely on these subtasks. Further studies are necessary to specifically assess the role of the different subphases (sit to stand, walk, turn, and stand to sit) of the TUG and their respective contribution to the overall TUG performance of patients. Limits
The improvements in TUG performance found in the present study were smaller than those found in other studies (0.6 seconds [5.9%] in the O group and 0.5 seconds [5.2%] in the T group) versus 1.5 seconds following the treadmill training in the study by Kang et al.6 Equally, this change was not clinically significant since the minimum detectable change (MDC) reported in stroke subjects for this test is 7.84 seconds by Hiengkaew et al16 and 23% by Flansbjer et al.3 This
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difference is due to the protocol design involving the assessment of a single gait training session. Moreover, in the present study, subjects were asked to perform the TUG test as quickly as possible,17 whereas the MDC was calculated with the TUG test at comfortable speed.3,16 This may also explain the better TUG performance in our sample (9.3 seconds vs 29 seconds in Hiengkaew et al study16 and 14.3 seconds in Flansbjer et al study3). We can specify that patients included in this study had a TUG test score lower than the cutoff, indicating a risk of falling. It is also possible that the capacity of the patients included in this study to improve (with moderate to good recovery) could be smaller (ceiling effect). Since a learning effect would be similar in both groups, this does not affect the between-group comparison. Moreover, our study was designed to compare treadmill and overground training but not to produce a large change in TUG performance following a single training session. Conclusions
This study documents for the first time that a single 20-minute gait training session improves TUG performance in chronic hemiparetic patients
and that the beneficial effect is similar whether the training was performed overground or on a treadmill. The medical community recommends treadmill training to stroke survivors to reduce their cardiovascular risk and increase their participation in physical activity.23 Our results suggest that hemiparetic patients should also be encouraged to walk overground, including turns and without stopping, for at least 20 minutes. This constitutes an easy and inexpensive selfrehabilitation program to improve functional gait-related activities involved in the TUG test. Further studies should also evaluate the longterm effects of a prolonged self-training program involving regular overground walking, including turns, nonstop for 20 minutes on functional gait capacity. Acknowledgments The authors wish to express their gratitude to the patients who kindly participated in this study. This work was performed in relation with AP-HP, CICIT Garches. The authors report no declarations of interest and no source of funding.
REFERENCES 1. Schaechter JD. Motor rehabilitation and brain plasticity after hemiparetic stroke. Progress Neurobiol. 2004;73:61-72. 2. Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke. 1995;26:982-989. 3. Flansbjer UB, Holmbäck AM, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37(2):75-82. 4. Wevers L, van de Port I, Vermue M, Mead G, Kwakkel G. Effects of task-oriented circuit class training on walking competency after stroke: A systematic review. Stroke. 2009;40:2450-2459. 5. Dean CM, Richards CL, Malouin F. Taskrelated circuit training improves performance of locomotor tasks in chronic stroke: A randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81(4):409-417. 6. Kang HK, Kim Y, Chung Y, Hwang S. Effects of treadmill training with optic flow on balance and gait in individuals following stroke: Randomized controlled trials. Clin Rehabil. 2012;26(3): 246-255.
7. Ferrarello F, Baccini M, Rinaldi LA, et al. Efficacy of physiotherapy interventions late after stroke: A meta-analysis. J Neurol Neurosurg Psychiatry. 2011;82:136-143. 8. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011;377(9778):16931702. 9. Outpatient Service Trialists. Therapy-based rehabilitation services for stroke patients at home. Cochrane Database Syst Rev. 2003;1:CD002925. 10. Richards CL, Malouin F, Wood-Dauphinee S, Williams JI, Bouchard JP, Brunet D. Task-specific physical therapy for optimization of gait recovery in acute stroke patients. Arch Phys Med Rehabil. 1993;74:612-620. 11. Lindmark B, Hamrin E. A five-year follow-up of stroke survivors: Motor function and activities of daily living. Clin Rehabil. 1995;9:1-9. 12. States RA, Pappas E, Salem Y. Overground physical therapy gait training for chronic stroke patients with mobility deficits. Cochrane Database Syst Rev. 2009;(3):CD006075. 13. Isaacs B. Clinical and laboratory studies of falls in old people. Clin Geriatr Med. 1985;1:513.
Gait Training in Hemiparetic Patients
14. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: The “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):387-389. 15. Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-148. 16. Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed “Up & Go” Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees of ankle plantarflexor tone. Arch Phys Med Rehabil. 2012;93(7):1201-1208. 17. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in communitydwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903. 18. Andersson AG, Kamwendo K, Seiger A, Appelros P. How to identify potential fallers in a stroke unit: Validity indexes of 4 test methods. J Rehabil Med. 2006;38(3):186-91. 19. Laufer Y, Dickstein R, Chefez Y, Marcovitz E. The effect of treadmill training on the ambulation of stroke survivors in the early stages of rehabilitation: A randomized study. J Rehabil Res Dev. 2001;38(1):69-78. 20. Pohl M, Mehrholz J, Ritschel C, Rückriem S. Speeddependent treadmill training in ambulatory hemiparetic stroke patients: A randomized controlled trial. Stroke. 2002;33(2):553-558. 21. Ng SS, Hui-Chan CW. The Timed Up & Go test: Its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil. 2005;86:1641-1647. 22. R e i s m a n D S , B a s t i a n A J , M o r t o n S M . Neurophysiologic and rehabilitation insights from the split-belt and other locomotor adaptation paradigms. Phys Ther. 2010;90(2):187-195.
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23. Bonnyaud C, Pradon D, Zory R, Bensmail D, Vuillerme N, Roche N. Does a single gait training session performed either overground or on treadmill induce specific short-term effects on gait parameters in patients with hemiparesis? A randomized controlled study. Top Stroke Rehabil. 2013;20(6):509-518. 24. Zimerman M, Heise KF, Hoppe J, Cohen LG, Gerloff C, Hummel FC. Modulation of training by single-session transcranial direct current stimulation to the intact motor cortex enhances motor skill acquisition of the paretic hand. Stroke. 2012;43(8):2185-2191. 25. Gordon NF, Gulanick M, Costa F, Fletcher G, Franklin BA, Roth EJ, Shephard T; American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Physical activity and exercise recommendations for stroke sur vivors: An American Heart Association scientific statement from the Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation. 2004;109(16):2031-2041. 26. Lam T, Luttmann K. Turning capacity in ambulatory individuals poststroke. Am J Phys Med Rehabil. 2009;88(11):873-883. 27. Faria CD, Teixeira-Salmela LF, Nadeau S. Development and validation of an innovative tool for the assessment of biomechanical strategies: The Timed “Up and Go” - Assessment of Biomechanical Strategies (TUG-ABS) for individuals with stroke. J Rehabil Med. 2013;45(3):232-240.
Background: Timed Up and Go (TUG) performance is reduced following stroke. Gait training improves gait-related activities in hemiparetic patients. However, no study has compared the impact of a single overground training session with a treadmill training session on gait-related activities (assessed by TUG). Objective: To compare the immediate effect of a single overground training session versus a single treadmill training session on TUG performance in hemiparetic patients. Methods: In this randomized controlled clinical trial, 56 hemiparetic patients were randomized to 1 or 2 distinct groups: a single gait training session overground (O group) or on a treadmill (T group). Time taken to perform the TUG (in seconds) was assessed before and immediately after the completion of each session. Results: Time taken to perform the TUG decreased significantly, and to a similar extent, in both groups following the training session (O group, 5.9%; T group, 5.2%). Conclusions: An overground training session and a treadmill training session were equally effective in improving TUG performance in hemiparetic patients. Hemiparetic patients should be encouraged to walk regularly overground including turns for 20 minutes without stopping. This is an easy and inexpensive self-rehabilitation method to improve functional gait-related activities involved in the TUG test. Key words: gait training, hemiparesis, self-rehabilitation, Timed Up and Go test
A
pproximately 50% of stroke patients are partly dependent for activities of daily living (ADLs),1 and less than 50% of survivors are able to walk in the community.2 Many stroke patients do not have a gait that allows them to perform all their daily activities.3 Several gait-training techniques have been shown to be effective in improving functional gait capacity. Task-oriented training and treadmill training have both been shown to be effective in improving gait speed and gait-related activities, demonstrated by the Timed Up and Go (TUG) test,4-6 and are more effective than conventional therapy (neurodevelopmental treatment and stretching) in stroke patients.6 However, such training requires equipment and supervision by a therapist. More and more self-rehabilitation programs are being developed, because it has been established that
Corresponding author: Céline Bonnyaud, Université Versailles Saint Quentin en Yvelines, EA 4497, CIC-IT 805, AP-HP, Hôpital Raymond Poincaré, 92380 Garches, France ; e-mail : [email protected]
rehabilitation in the chronic phase of stroke can be effective.7 Therapy at home is also recommended for stroke patients to prevent deterioration in ADLs.8,9 Such programs are important, because stroke patients do not maintain functional gains after the cessation of rehabilitation.10,11 Overground walking is a simple method of gait training available to all patients. However, a recent Cochrane review found that there was insufficient evidence to determine whether overground walking significantly improves gait activity.12 Minimal requirements for efficient mobility require a person to be able to rise from a chair, walk, and turn.13 The TUG test, derived from the Get Up and Go,14 is a very useful test to measure basic gait activities that relate to autonomy in daily life. The TUG test assesses the global time taken to stand up from a chair, walk 3 meters,
Top Stroke Rehabil 2014;21(6):477–483 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2106-477
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turn around, walk back, and sit down.15 This quick and simple test has excellent intrarater reliability and good sensitivity for the detection of clinical changes in stroke patients.3,16 The test was initially developed to assess the risk of falls with a cutoff score of 14 seconds17,18; however, TUG performance has also been shown to be related to independence in ADLs in stroke patients.15 This highlights the importance of defining optimal and efficient protocols to improve TUG performance in hemiparetic patients. Treadmill training appears to be an interesting approach to improve functional gait capacity in stroke patients. Kang et al6 found that 4 weeks (30 min/day) of treadmill training induced a greater improvement of TUG performance than regular therapy of the same duration (neurodevelopmental treatment and stretching) in stroke patients. Nevertheless, it would be easier for patients to perform self-gait training overground than on a treadmill. No study has compared the impact of these 2 training methods (overground and treadmill) on gait-related activities measured by TUG performance in chronic stroke patients. The aim of this randomized controlled study was to compare the immediate effect of a single overground training session, including turning, versus a single treadmill training session on functional gait capacity measured by the TUG in chronic hemiparetic patients. The TUG test is a more complex task than straight walking, including subtasks of standing up, turning, and Table 1.
sitting down. Because the 2 walking phases comprise the greatest portions of this test and treadmill training has been shown to be more effective than overground training on gait speed,19,20 we hypothesized that TUG performance would improve more following the treadmill training session than the overground session. Materials and Methods Subjects
Fifty-six chronic hemiparetic patients (characteristics shown in Table 1) gave written consent and were included in this study. The inclusion criteria were age over 18 years, hemiparesis due to a single hemispheric stroke diagnosed by MRI, and ability to walk 20 minutes without a break and without an assistive device. Patients were not included if they had any comorbid disability such as visual impairment, musculoskeletal or cardiovascular disorders, or other disorders that would affect the assessment. This study was performed in accordance with the ethical codes of the World Medical Association and was approved by the local ethics committee. Experimental set-up
After inclusion, patients were randomized to 1 or 2 distinct gait training protocols performed either (1) on a treadmill (T group, n = 28) or (2) overground
Patient characteristics Time post stroke, years
Barthel, median (range)
NFAC, median (range)
Comfortable gait speed, m/s
TUG baseline, seconds
42 M 14 W
100 (80-100)
7 (6-8)
0.85 ± 0.2
9.3 ± 2.9
5.8 ± 4.6
23 M 5W
100 (80-100)
7 (6-8)
0.8 ± 0.2
9.9 ± 3.5
6.2 ± 8.8
19 M 9W
100 (90-100)
7 (6-8)
0.9 ± 0.2
8.7 ± 2.1
Age, years
Side of hemiparesis
All patients
51.1 ± 12.8
25 right 31 left
6.0 ± 6.8
Overground group
49.7 ± 13.5
13 right 15 left
Treadmill group
52.5 ± 12.6
12 right 16 left
Sex
Note: Timed Up and Go (TUG) and gait speed were not different in both groups in baseline, P > .05. NFAC = New Functional Ambulation Classification.
Gait Training in Hemiparetic Patients
(O group, n = 28). All the gait training sessions were carried out by the same physiotherapist who gave the same encouragements to all patients. Both groups participated in a 20-minute gait training session, during which they were instructed to walk without stopping at a constant speed (ie, their comfortable gait speed previously defined using the 10-meter walking test). For the T group, the speed of the treadmill was progressively increased (over a 1-minute period) to match the patient’s comfortable speed and was maintained constant during the session. For the O group, patients were encouraged by the therapist to maintain a comfortable speed over the time period and the cadence was set by a metronome. The overground gait training session was carried out in a 50-m-long corridor and therefore several turns were included during the session.
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A nonparametric Wilcoxon test was used (P < .05) to assess the effect of gait training, without considering the type (treadmill or overground), on TUG performance. A nonparametric MannWhitney test was used to compare TUG performance in both groups before the gait training and to determine the effect of the type of gait training on changes in TUG performance (P < .05). Results
The TUG test was carried out by the same investigator for each patient, blinded to the group training, just before and immediately after the gait training session. As proposed by several authors,15,17,21 the test was executed as follows: (1) patients were required to stand up from a chair with armrests, walk 3 m, turn around, return to the chair, and sit down again, as fast as possible17,18; (2) the time taken to complete this task was recorded in seconds using a stopwatch; and (3) 3 trials were recorded per patient to reduce the variability.
The 56 patients included in this study (25 with right-sided hemiparesis, 31 with left-sided hemiparesis) had a mean (SD) age of 51.1 (12.8) years and a mean (SD) time since stroke of 6.0 (6.8) years. There was no significant difference in TUG performance between the 2 groups before the gait training (P = .22). In the O group, patients performed an average of 19 half turns in 20 minutes. As illustrated in Figure 1, the time taken to perform the TUG test significantly decreased for all patients following the gait training session (from 9.3 ± 2.9 seconds to 8.7 ± 2.9 seconds; P = .0006, both groups considered together). The analysis of the results showed that this improvement was similar in both groups (from 9.9 ± 3.5 seconds to 9.3 ± 3.6 seconds in the O group [5.9% improvement], and from 8.7 ± 2.1 seconds to 8.2 ± 2.0 seconds in the T group [5.2% improvement]; P = .78). Figure 2 illustrates the percentage of change of TUG performance in each group.
Data analysis and statistical analysis
Discussion
The time taken to perform the TUG test (in seconds) was averaged for each patient.6 The mean values of the TUG test before and after the gait training session were analyzed for each group. The percentage change was calculated for each patient using the following formula: (Post TUG performance – Pre TUG performance)/(Pre TUG performance) × 100 × (-1) Improvements in TUG performance between the pre and post assessments were associated with a positive value. The mean percentage change and its standard error were then calculated for each group (O group and T group).
The aim of this randomized controlled clinical study was to compare the effects of a single overground training session and a treadmill training session on gait-related activities evaluated by the TUG test. The results showed, for the first time, that single overground or treadmill gait training sessions were equally effective in improving gait-related activities (TUG performance) in hemiparetic patients. Firstly, our results showed improvements in TUG performance after a single gait training session in a large sample of chronic stroke subjects. This result is in accordance with studies by Dean
TUG test
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∗
Time to perform TUG test (in sec)
9.8 9.6 9.4 9.2 9 8.8 8.6 8.4 8.2 PRE session
POST session
Figure 1. Mean and standard error of mean of TUG performance (in seconds) measured before (PRE session) and after the gait training session (POST session). *Significant difference between before and after training, P < .05. NS
9
Percentage improvement
8 7 6 5 4 3 2 1 0 Group O
Group T
Figure 2. Mean and standard error of mean of percentage of TUG performance improvement obtained in the 2 groups (group O and group T). NS = no significant difference between group O and group T.
et al5 and Kang et al,6 who assessed the effect of several training sessions. Dean et al5 found an improvement in TUG performance (-7.9 seconds) in 5 chronic stroke subjects following task-oriented training involving overground walking, treadmill walking, and functional tasks carried out 3 times a week for 4 weeks.5 The improvements in TUG performance in our study are smaller (following a single session), but they might be predictive of greater improvements after several sessions. Indeed, Reisman et al22 suggested that immediate adaptations reflect short-term motor learning and that repeated adaptations may result in the learning of a permanent motor pattern. Other
studies showed improvements following a singledose trial on gait parameters23 or on motor skill of the paretic hand24 in stroke patients. Further study is necessary to assess the long-term effects of gait training performed overground or on a treadmill on TUG performance in stroke patients. Our results are in accordance with those of Dean et al, suggesting that a simple gait training session could be as effective as a specific task-oriented program to improve functional gait-related activities assessed by the TUG. Kang et al6 compared the effect of 4 weeks of treadmill training with or without optic flow in 36 persons with chronic hemiparesis. They
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found a mean improvement of 5.5 seconds following treadmill training with optic flow and of 1.5 seconds following treadmill training without optic flow. Our results are in accordance with their results; they also show that some improvement could be observed after a single treadmill gait training session. Improvement in performance of gait-related activities assessed by the TUG immediately after a single gait training session might therefore constitute a good inclusion criterion for patients who are likely to be highly improved by a training program based on several training sessions. The improvement in TUG performance was independent of the type of gait training – overground or treadmill. This result suggests that, contrary to our expectation, a gait training session performed overground has a similar impact on gait-related activities assessed by the TUG test as gait training performed on a treadmill. This result corroborates the findings of our recent study showing similar improvements in biomechanical gait parameters following a single overground or treadmill training session in hemiparetic patients.23 Encouraging outpatients with hemiparesis to walk for 20 minutes without stopping and to include turns in the walk on a regular basis might at least maintain functional gait capacity and possibly improve other functional gait-related activities.25 Further studies will be necessary to confirm this assumption. Because the 2 walking phases represent the greatest portions of this test and treadmill training has been shown to be more effective than overground training on gait speed,19,20 our initial hypothesis was that TUG performance would be more improved following treadmill training than overground training. One explanation for the lack of difference between the 2 types of gait training on TUG performance may be because the different gait training conditions (overground and treadmill) improve different subphases of the TUG, creating a similar net improvement of the overall test performance. Indeed, we can suppose that the participants in the O group, who performed a mean of 19 turns, improved in the turning subphases of the TUG test more than the T group who did not practice turns, whereas the participants in the T group may have
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improved more in gait speed, thus performing better on the straight walking phases of the TUG test. So even if the net result of the 2 gait training sessions on the TUG performance is similar, the mechanisms underlying these improvements might be different. This hypothesis is supported by the following results. Laufer et al19 and Pohl et al20 showed that treadmill training was more effective than overground training in improving gait speed, and Lam and Luttmann26 found a significant correlation between turning capacity (180° turn) and TUG performance.26 This hypothesis implies that the turning and straight walking phases of the TUG test are likely equally important in overall performance. This is in line with Faria et al27 who suggested that global TUG performance time does not provide sufficient information for clinicians. These results suggest that an optimal gait training program should attempt to improve both turning ability and gait speed to improve functional gait-related activities of stroke patients. We cannot exclude that the sit-to-stand and stand-to-sit subphases of the TUG were also partly improved by the training session. Obviously the overall performance of the TUG does not permit us to determine whether these subphases were really improved. However, because these subtasks were not implied in the training, the overall TUG performance improvement seems not to rely on these subtasks. Further studies are necessary to specifically assess the role of the different subphases (sit to stand, walk, turn, and stand to sit) of the TUG and their respective contribution to the overall TUG performance of patients. Limits
The improvements in TUG performance found in the present study were smaller than those found in other studies (0.6 seconds [5.9%] in the O group and 0.5 seconds [5.2%] in the T group) versus 1.5 seconds following the treadmill training in the study by Kang et al.6 Equally, this change was not clinically significant since the minimum detectable change (MDC) reported in stroke subjects for this test is 7.84 seconds by Hiengkaew et al16 and 23% by Flansbjer et al.3 This
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difference is due to the protocol design involving the assessment of a single gait training session. Moreover, in the present study, subjects were asked to perform the TUG test as quickly as possible,17 whereas the MDC was calculated with the TUG test at comfortable speed.3,16 This may also explain the better TUG performance in our sample (9.3 seconds vs 29 seconds in Hiengkaew et al study16 and 14.3 seconds in Flansbjer et al study3). We can specify that patients included in this study had a TUG test score lower than the cutoff, indicating a risk of falling. It is also possible that the capacity of the patients included in this study to improve (with moderate to good recovery) could be smaller (ceiling effect). Since a learning effect would be similar in both groups, this does not affect the between-group comparison. Moreover, our study was designed to compare treadmill and overground training but not to produce a large change in TUG performance following a single training session. Conclusions
This study documents for the first time that a single 20-minute gait training session improves TUG performance in chronic hemiparetic patients
and that the beneficial effect is similar whether the training was performed overground or on a treadmill. The medical community recommends treadmill training to stroke survivors to reduce their cardiovascular risk and increase their participation in physical activity.23 Our results suggest that hemiparetic patients should also be encouraged to walk overground, including turns and without stopping, for at least 20 minutes. This constitutes an easy and inexpensive selfrehabilitation program to improve functional gait-related activities involved in the TUG test. Further studies should also evaluate the longterm effects of a prolonged self-training program involving regular overground walking, including turns, nonstop for 20 minutes on functional gait capacity. Acknowledgments The authors wish to express their gratitude to the patients who kindly participated in this study. This work was performed in relation with AP-HP, CICIT Garches. The authors report no declarations of interest and no source of funding.
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