http://informahealthcare.com/ptp ISSN: 0959-3985 (print), 1532-5040 (electronic) Physiother Theory Pract, 2014; 30(8): 597–602 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.904959
CASE REPORT
Effect of bilateral step-up and -down training on motor function in a person with hemiparesis: a case report Mansoo Ko, PhD1, Sean Hilgenberg, PT2, Scott M. Hasson, EdD, PT, FACSM, FAPTA3, and Heather J. Braden, PhD, PT, GCS1 1
Physical Therapy Program, Angelo State University, San Angelo, TX, USA, 2Department of Physical Medicine, Shannon Medical Center, San Angelo, TX, USA, and 3Department of Physical Therapy, Georgia Regents University, Augusta, GA, USA
Abstract
Keywords
Gait training to facilitate the use of the paretic limb for persons with hemiparesis continues to be of interest to those in the clinical research domain. The purpose of this case report was to assess the outcomes of a repeated step-up and -down treatment, initiating with the paretic limb, on functional mobility, endurance and gait kinematic parameters in a person with hemiparesis. The participant was an 85-year-old female 3 years status post left hemiparesis, who reported overall good health. The participant was asked to step up on a 1-inch height wood box with her paretic limb. Once both feet were on top of the box, the participant initiated descent also with her paretic limb. The height of the box gradually progressed to 5 inches based on the participant’s performance and tolerance. A metronome was used to facilitate rhythmic lower extremity movement patterns. The training duration for each treatment session was 7–15 min/day. The participant completed nine sessions spanning over 3 weeks. The outcome measure used to identify motor recovery was the Fugl-Myer (lower extremity). In addition, the timed up and go (TUG), the 6-min walk test (6 MWT) and gait kinematics were assessed to examine mobility and gait. The Fugl-Myer score and 6 MWT did not reflect a meaningful change (0% and +2.6%, respectively). However, TUG scores did show a meaningful change (+31.9%). With respect to gait kinematics, hip flexion on the paretic limb was improved from 11 to 18 , which indicates the normal range of hip motion during the initial swing phase in post-test.
Functional mobility, gait training, hemiparesis
Introduction Stroke is a major cause of long-term disability, and more than 50% of survivors have residual motor disability (Barnes, Dobkin, and Bogousslavsky, 2005). Even for the individuals with mild to moderate impairment who achieve independent walking, strokerelated balance deficits result in a 73% incidence of falls (Forster and Young, 1995; Keenan, Perry, and Jordan, 1984). The impact of residual deficits following stroke can be characterized by slow walking speed, asymmetrical limb movements, lack of weight transfer and compromised balance (Moseley, Stark, Cameron, and Pollock, 2005; Mudge, Rochester, and Recordon, 2003). In clinical practice, therapists have recognized that persons with hemiparesis have a stopping moment to prepare for the next step (step-through gait), which results in an asymmetrical gait pattern. Therefore, in stroke rehabilitation, gait training in persons with hemiparesis is designed to minimize gait asymmetry (i.e. addressing uneven weight distribution and spatio-temporal asymmetry) (Aruin et al, 2000; Hyndman and Ashburn, 2003). In order to achieve a symmetrical gait pattern, the clinician should be able to provide skilled guidance for inducing a step-through gait in a safe environment. According to the American Physical Therapy Association (APTA) Guide to Physical Therapy Practice (2001), conventional rehabilitation for persons post-stroke is characterized by ‘‘developmental activities training; gait training; implement and device training; perceptual training; standardized Address correspondence to Mansoo Ko, PhD, Physical Therapy Program, Angelo State University, San Angelo, TX, USA. E-mail: mko@ angelo.edu
History Received 26 April 2013 Revised 20 January 2014 Accepted 22 February 2014 Published online 3 April 2014
programmatic, complementary exercise approaches; and wheelchair training’’. However, when employing conventional gait training with traditional therapies including devices such as parallel bars, other assistive devices, and manual guidance, the patients are not allowed to walk with an optimal and consistent sensory input. Assistive devices such as walkers or canes facilitate the compensatory peripheral sensory input creating undesirable motor outcome in persons with hemiparesis (Liston et al, 2000; Plummer et al, 2007). In addition, the current clinical approach requires a relatively large amount of space to facilitate the stepthrough gait pattern for persons with hemiparesis. Over the last decade, treadmill training with partial body weight support has been widely used to enhance the symmetrical gait patterns of people with hemiparesis, because it can provide an appropriate peripheral sensory feedback in a repetitive manner by guiding body alignment, rhythmical step-through gait, body weight support and speed of walking (Combs, Dugan, Ozimek, and Curtis, 2013). However, the high cost of the equipment limits its availability for gait training in persons with hemiparesis (Damiano and DeJong, 2009). Alternative gait protocols involving less physical space and distance as well as inexpensive equipment, such as a step, have not been investigated to facilitate the use of the paretic limb in an upright body posture by physical therapists. The repeated reciprocal step-up and -down training initiated with the paretic limb challenges dynamic balance in a manner similar to the dynamic weight shift required during step-through gait in persons with hemiparesis. In addition, the proposed step training method would allow physical therapists to provide the skilled guidance
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for a repetitive upright mobility intervention in a restricted physical space. This case report evaluated the feasibility and effectiveness of repeated reciprocal step-up and -down training for the purpose of improving functional mobility, endurance and gait kinematic parameters in a person with hemiparesis.
Case description Participant history The participant was an 85-year-old, right-hand dominant female, who experienced a right subcortical ischemic stroke 3 years prior to this intervention. The participant reported she was in overall good health and free from major post-stroke complications (e.g. recurrent stroke, hip fracture and myocardial infarction). This participant lived independently within the community. She was an independent ambulator but had residual balance deficits from the stroke. The participant’s past medical history was significant for hypertension and skin cancer on her face. The participant’s pharmaceutical regimen consisted of Plavix 75 mg, 2/day, and Boniva 150 mg, 1/mos. At the time of this report, the participant lived alone and performed instrumental activities of daily living and activities of daily living independently. The participant reported no history of falls in the previous 6 months, but one fall in the previous 12 months. Examination The participant’s anthropometric measurements were height ¼ 50 200 (157.5 cm) and weight ¼ 118 lbs (53.5 kg). Prior to this intervention, the participant’s vital signs were recorded while sitting at rest: blood pressure ¼ 150/66 mmHg; pulse rate ¼ 73 beats/min and oxygen saturation ¼ 95%. Valid and reliable outcome measures were used to assess functional mobility, endurance and gait kinematics (gait speed, cadence, joint angles during gait and the symmetry ratio of stride length) for pre–post tests. The Fugl–Meyer assessment (FMA) was used to evaluate motor recovery, which has been identified to have high interrater reliability (Duncan, Propst, and Nelson, 1983), and has also been shown to have good correlation with activities of daily living measures (Sanford et al, 1993). Only the lower extremity portion of the FMA was used in this case report, because of its relevance to the report. The timed up and go (TUG) is a tool that reflects functional mobility and has good test–retest reliability (Ng and Hui-Chan, 2005). The 6-min walk test (6 MWT) was used to evaluate functional mobility and walking endurance. The 6 MWT has good interrater and intrarater reliability (Kosak and Smith, 2005; Pohl et al, 2002). Upon observation using the DartfishÕ Video Analysis Software (Fribourg, Switzerland), the participant presented with postural and gait deficits which included increased kyphosis, forward-head posture, decreased hip and knee flexion during initial swing on the paretic limb, diminished knee extension during heel strike on the paretic limb, and asymmetrical stride length (non-paretic vs paretic: 1.17 m vs 1.12 m). Two-D angle analysis of Dartfish software showed that the participant’s hip flexion angle of the paretic limb (11 ) was limited compared to the non-paretic limb (22 ) during initial swing. The knee flexion angle (44 ) of the paretic limb was significantly constrained compared to the non-paretic limb (67 ) during initial swing. The asymmetrical walking patterns became more prominent during her fast walking. The participant ambulated in a normal speed (0.9 m/s) without the use of an assistive device. The cadence was 82 steps/min prior to the intervention. The participant demonstrated a lateral shifted posture onto the non-paretic limb upon walking 10 m. For the right lateral shift walking pattern, the toe out angle of the paretic limb was limited,
Figure 1. (a) Toe clearance of the non-paretic limb during mid-swing and the toe out angle of the paretic limb. (b) Toe clearance of the paretic limb during mid-swing and the toe out angle of the non-paretic limb. The arrow indicates the direction of the toe out during walking.
whereas the toe out angle of the non-paretic limb was greater than the paretic limb. Thus, the right-shifted line of gravity away from the midline of upright posture might lead the body shift to the non-paretic limb. In addition, it was noted that the participant tripped 1–2 times over the ground on the paretic limb at the midswing phase due to limited hip and knee flexion (Figure 1). Evaluation and diagnosis The participant presented with symptoms that commonly occur with residual effects from a cerebrovascular accident (CVA). The results of the pre-intervention outcome measurement scores were as follows: lower extremity FMA ¼ 19/34; TUG ¼ 20.56 s; 6 MWT ¼ 274.32 m. The participant’s problem list included the following: poor motor recovery; decreased functional mobility; decreased dynamic balance; decreased endurance and impaired posture during gait. After initiating walking, the compensatory muscular action by the non-paretic limb played a primary role to move the body forward because of poor coordination of the paretic limb. For instance, in persons with hemiparesis, the non-paretic stance limb gastrocnemius muscle controls forward momentum in preparation for a swing limb heel strike during gait initiation (GI) (Brunt, Vander Linden, and Behrman, 1995; Nichols, 1997). These findings raise the question of whether increasing gait speed may tend to overuse the non-paretic stance limb, resulting in an increased risk for falling (Forster and Young, 1995; Nichols, 1997). Therefore, with respect to weight shifting on the paretic limb during the proposed stepping training, it was important to facilitate the bilateral coordination between the paretic and non-paretic limbs using a metronome in early stages of the step training (Kautz et al, 2005). The participant’s TUG score placed her into a high risk category for falls (Shumway-Cook, Brauer, and Woollacott, 2000). The participant walked 111 m less than a healthy woman her age, according to an age-specific equation for healthy adults to predict the total distance walked during the 6 MWT (Enright and Sherrill, 1998). This translated into decreased functional mobility and endurance. These outcomes in conjunction with the
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Figure 2. Repeated bilateral step-up and -down training initiating with the paretic limb.
participant’s impaired gait mechanics represented functional limitations for the participant. The participant’s medical diagnosis of CVA and problem list were consistent with the Physical Therapy Practice Pattern 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Acquired in Adolescence or Adulthood (American Physical Therapy Association, 2001). Prognosis According to the APTA Guide to Physical Therapy Practice (2001) this patient would require 10–60 visits to achieve anticipated goals and expected outcomes. Previous research investigating body weight support treadmill training (BWSTT) was used as a guide given the absence of research investigating optimal intensity or duration of step training. The duration of BWSTT has varied from as few as 10 to 15 sessions, to as many as 24 or 25 sessions (Barbeau and Visintin, 2003; Visintin, Barbeau, Korner-Bitensky, and Mayo, 1998). When reviewing the literature for 10–15 sessions, mild or moderately impaired patients with stroke responded more quickly than severely impaired patients with BWSTT (Ada et al, 2003; Laufer, Dickstein, Chefez, and Marcovitz, 2001). For this particular case report, the goal for total treatment sessions was directed near the lower end of this spectrum, since the participant was a moderately impaired individual with stroke. The current report included outpatient training for nine sessions (3/week). Intervention Each treatment session required the participant to perform repetitive reciprocal stepping onto a step (Figure 2). The participant led with the paretic limb during ascent and descent of the step, which was derived according to the Kirker, Simpson, Jenner, and Wing (2000) study. A metronome was used to provide cueing for each step. A 1-inch step was used at the beginning of the training to facilitate rhythmic lower extremity movement patterns with a 40 beats/min metronome. Step height was increased according to clinician judgment and participant tolerance. Each session was divided into multiple 1–2-min bouts (3–6 sets) of continuous stepping. The participant received rest breaks between bouts, and the Borg rate of perceived exertion (RPE), which ranges from 6 to 20, was used to determine the participant’s perceived rate of exertion. Each training session ended when the participant reported a 16/20 (feel the heart pounding) on the
Table 1. Progression of a repeated bilateral step-up and -down training.
Sessions 1 2 3 4 5 6 7 8 9
Step heights (in.)
Duration (total mins)
Metronome (beats/min)
Number of steps
1 2 2 3 3 3 4 5 6
7.0 10.0 12.5 13.0 8.25 14.25 11.0 13.25 15.25
40 42 44 42 42 44 40 N/A N/A
280 420 550 546 347 627 440 N/A N/A
Borg RPE scale. During the initial session the participant performed the training protocol with the use of a body weight support system for safety purposes, which was discontinued after the initial session secondary to the participant’s ability to perform the task safely. Outcome measures were recorded during session 1. The participant’s blood pressure, pulse rate and oxygen saturation were recorded at rest prior to the beginning of training and were monitored throughout each session. The participant was provided contact-guard assistance throughout each bout of stepping. No adverse effects were observed with the exception that the participant reported increased fatigue prior to session 5. In addition, the participant reported a fall in the evening a day prior to session 8. The participant did not present with impairments or functional limitations secondary to the fall. The metronome was removed during sessions 8 and 9 secondary to the participant’s complaints of distraction from the attention to the stepping task. Upon observation at this later stage in the stepping intervention, the participant’s step cadence and ability to perform the training successfully was similar with or without the metronome. A summary of the initial and ending step heights, total steps, duration and cadence for each session is summarized in Table 1.
Outcomes The final outcome measurements were recorded after the ninth training session. A total of 10 sessions was the goal of training, however, with scheduling conflicts, a total of 9 were achieved. Table 2 provides the baseline outcome measure results, postintervention scores and percent change for the FMA, TUG and
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Table 2. Outcome measure results.
Fugl-Meyer lower extremity TUG 6-Min Walk Test 6 MWT
Pre-test
Post-test
Percent change
19/34 20.56 s 274.32 m
19/34 14.03 s 281.33 m
0 +31.9 +2.6
6 MWT. The percentage change for the FMA and the 6 MWT are not clinically meaningful, but the 31.9% change in TUG scores does represent a significant attenuation of risk of falls during walking (Shumway-Cook, Brauer, and Woollacott, 2000). With respect to the kinematic components, gait speed, cadence, knee joint angle during gait and the symmetry ratio of stride length were not improved, but hip flexion (the paretic limb) was enhanced from 11 to 18 , which indicates the normal range of motion during the initial swing phase in post-test.
Discussion While the outcome measurements did not reflect a meaningful change in all categories clinically, the results of the training protocol lead to an interesting finding. Functional mobility improved via the TUG scores during only nine sessions of stepping training. The results are not conclusive that this training will have the same effect in all individuals with stroke. However, for post-stroke movement quality, this case report showed the feasibility of the repeated bilateral step-up and -down training as a gait training activity which appeared to effectively challenge the dynamic weight shift onto the paretic limb, to produce symmetrical transition and stepping coordination in this participant with hemiparesis. The task of stepping challenges dynamic balance in a manner similar to the balance required during GI, since initiating gait requires a transition from a relatively large base of support in double stance to a small base of support in single limb stance. Particularly, GI is known as a well-defined motor task often used to assess the effects of sensorimotor deficits as it involves a stereotyped pattern of muscle activity (Brunt et al, 1991, 1999). Ko, Bishop, and Behrman (2011) indicated that the impaired tibialis anterior (TA) muscle on the paretic limb of persons with hemiparesis was activated in a normal sequence of muscle excitation, with greater amplitude, when the paretic limb was loaded to allow the nonparetic limb to initiate the first step. This finding suggests that good weight shifting onto the paretic limb allows the non-paretic limb to execute a good stepping event without any early or delayed response of toe-off. The task of stepping up and down from a step incorporates reciprocal, rhythmic lower extremity movement patterns similar to the mechanics of gait. Mercer, Freburger, Chang, and Purser (2009) indicated that the step test is a valid clinical measure of the paretic limb loading, which may indicate important functional implications in people recovering from stroke. Jaffe et al (2004) studied a training methodology which required participants to step over objects with each foot for a total of 10 steps; the control group stepped over ‘‘real objects’’ and the study group had to step over virtual. Twenty participants having a mean duration of 3.7 years poststroke were included in the study. Gait speed, step length, the ability to step over objects and walking endurance were compared before and after 2 weeks of training and again 2 weeks after cessation of training. Improvements in most outcome measures were noted in both training groups. This study suggests that improvements in walking mechanics are derived from a steppingbased intervention. According to Kirker, Simpson, Jenner, and Wing (2000) a normal pattern of hip muscle activation was
identified in stepping, whereas the response of these muscles to a perturbation while standing remained grossly impaired and was compensated by increased activity of the contralateral muscles. This finding suggests that achieving static balance while standing may not be a prerequisite to start dynamic balance training in persons with hemiparesis. The participant’s post-intervention TUG scores were at the threshold of ‘‘not a high risk for falls’’ category, according to Shumway-Cook, Brauer, and Woollacott (2000) which found a score of 514 s a low risk for falls with 87% sensitivity and specificity. Regarding patient-specific populations, Andersson, Kamwendo, Seiger, and Appelros (2006) found the cut-off for fall risk of older people with stroke to be 514 s likewise. The participant’s post-intervention TUG scores also fell between the normative values for her age, 5–17 s, according to Steffen, Hacker, and Mollinger (2002). This change of TUG score is meaningful and provides confidence to the clinician that this training protocol could be beneficial in improving functional mobility of a participant with stroke (Steffen, Hacker, and Mollinger, 2002). Although TUG scores were improving from her baseline as evidenced by the final session 9 TUG score, the participant had a fall in the late evening at home prior to session 8. According to Rubenstein and Josephson (2006) environmental hazards account for 25–45% of most accidental falls and are considered as the largest fall cause among older adults. The participant was unable to report the reason for falling. Environmental factors, such as poor lighting, time of day and unlevel terrain may have impacted the participant’s fall at home, in which she was uninjured, prior to session 8. The participant did not achieve a minimally clinical important change for the 6 MWT, which is 177 ft (54 m) (Redelmeier, Bayoumi, Goldstein, and Guyatt, 1997). These results could be attributed to various factors. Compensatory motor programs developed by the participant may have allowed her to remain independent at this stage post-CVA (Chen et al, 2003). Faster gait and ability to walk longer distance has likely been the focus for the participant since the CVA. Therefore, abnormal synergies that continue to exist, as evidenced by no improvements or change in the FMA, are overcome via compensatory movement. According to Perry, Garrett, Gronley, and Mulroy (1995) participants that are able to ambulate at speeds 40.8 m/s are classified as unlimited community walkers. In addition, Bohannon (2008) indicated that a comfortable gait speed between 80 and 89 female older adults was 0.78 m/s. Based on the previous studies, the participant’s gait speed was at this threshold prior to training. Accordingly, a ceiling effect of gait speed may have occurred. Significant improvements in gait speed and capacity have been reported after 12 sessions of locomotor training in participants with chronic stroke, but there were no improvements after 12 sessions in acute stroke participants (Plummer et al, 2007). These findings indicate that improving gait speed faster than 0.8 m/s and endurance in this participant with chronic hemiparesis may have required longer bouts of training. The FMA for lower extremity did not change from pre- to post-step training. Possible reasoning for no change in FMA components such as reflex activity, speed, sensation, passive joint motion or pain may be due to the participant being 3 years s/p injury and in the chronic stroke phase. Milovanovic and Popovic (2012) concluded that no significant differences in the FMA were found between people with acute and chronic stroke and that both groups continue to have abnormal synergies. The finding that the participant’s TUG score improved significantly, while the 6 MWT did not, may be due to differences in the components of the two tests. Both the TUG and 6 MWT contain gait components. The kinematic components of gait speed, stride length and knee joint angles during gait, showed no
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significant change from pre- to post-intervention. Only the TUG contains functional mobility components including transitioning from sit to stand and GI. These may be the components that benefited most from the step training. The stepping task intervention allowed for training in the following similar motions as required for sit to stand and GI transitions in the TUG: (1) weight shift for the trunk to move forward to step up in the step training and to stand in the TUG; (2) coactivation of the hip and knee extensors to stand vertically in the step training and in the TUG and (3) stabilization and weight shift in the upright position in preparation for stepping in both step training and in the TUG. Individuals with hemiparesis following stroke frequently have difficulty transferring the appropriate body weight onto the paretic lower limb. Inefficient weight shifting during walking contributes greatly to slower walking and imbalance in persons with hemiparesis. With respect to weight shifting on the paretic limb during bipedal walking, it is important to note that the neural circuitry controlling lower limbs is organized bilaterally to produce coordinated movements (Kautz et al, 2005). Ko, Bishop, and Behrman (2011) indicated that the absent or delayed TA muscle on the paretic limb was activated in a normal sequence of muscle excitation when the paretic limb was loaded to allow the non-paretic limb to initiate the first step in persons with moderate hemiparesis. This case report demonstrates that the proposed step training is feasible, it is capable of repeating weight shifting on the paretic limb, and the results are likely to have important clinical implications for how to repeat a good sensory input with an upright posture and how to facilitate lower limb movements associated with step height. Previous studies did not provide any evidence-based principles of step training regarding the efficacy of bilateral coordination. Thus, the current step training protocol could be adapted by clinicians as a gait training tool to facilitate symmetrical limb loading for persons with hemiparesis. Despite limited outcome measurement changes, the participant did report feeling more balanced and confident while walking within the community. The participant’s perception of balance changes was not objectively measured. The examiners believe recording this information would provide more confidence to the clinician that this training protocol could have an effect on a participant’s perception of improved functional mobility. One of the challenges in the proposed training was to keep consistent, rhythmical movements by the participant. The speed of step training was determined by the metronome, which produces a regulated audible pulse for the performance of stepping up and down. Step height increased according to clinician judgment and participant tolerance. Although metronome pacing and reciprocal stepping may be thought to have an anchoring effect, whereby the participant focuses primarily on the audible cue and steps to it thus stabilizing performance, increasing step height to more than 4 in. increased the intensity and distracted the participant’s attention from performing step up and down with the paretic limb first. Bowen et al (2001) indicated that the simultaneous performance of two tasks can have a dual task decrement on stroke participants’ balance and gait speed. Therefore, it is important to note that the level of dual task may have a considerable impact or interfere with the performance of motor tasks in persons with hemiparesis at a certain point of physical difficulty or intensity of the task. In addition, 6 MWT or TUG has been the most frequently mentioned to quantify gait function in a clinic or laboratory setting, but may not fully represent the functional improvement of walking performance outside the clinic (Bowden and Behrman, 2007). The step activity monitor (SAM) (Cyma Corporation, Seattle, WA) has been known as an effective clinical tool to assess
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not only the overall physical activity measured by the total number of steps but also the intensity of step activity measured by step numbers per minute (Bowden and Behrman, 2007; Brandes and Rosenbaum, 2004; McDonald et al, 2005). The SAM may be better suited to identify the effectiveness of the proposed training as an outcome measure in the home and community. Plautz, Milliken, and Nudo (2000) indicated that the functional reorganization of motor cortex is altered by motor skill acquisition, but not by repetitive use alone. For future research, the repetitive step-up and -down training may need to consider how to enhance the accuracy of a stepping movement (e.g. foot position, speed, trajectory of movement and body alignment) as a prerequisite factor for functional improvement of walking performance in people with hemiparesis.
Conclusion The TUG functional mobility scale showed a meaningful change after step training in a participant with chronic stroke of 3 years. Neither the 6 MWT nor the FMA showed changes from pre- to post-step training. Kinematic components of gait, such as gait speed, stride length and knee joint angle during gait, failed to show a significant change from pre- to post-intervention. However, hip flexion on the paretic limb was improved to the normal range of motion during the initial swing phase in post-test. The TUG may have unique components, that include dynamic weight shifting, which are improved with step training. The proposed step training is feasible for clinicians to provide an intervention for patients that maintain an upright posture and reciprocal stepping while encouraging dynamic weight shifting onto the paretic limb in a restricted physical space.
Declaration of interest The authors report no declarations of interest.
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McDonald CM, Widman L, Abresch RT, Walsh SA, Walsh DD 2005 Utility of a step activity monitor for the measurement of daily ambulatory activity in children. Archives of Physical Medicine and Rehabilitation 86: 793–801. Mercer VS, Freburger JK, Chang SH, Purser JL 2009 Measurement of paretic-lower-extremity loading and weight transfer after stroke. Physical Therapy 89: 653–664. Milovanovic I, Popovic DB 2012 Principal component analysis of gait kinematics data in acute and chronic stroke patients. Computational and Mathematical Methods in Medicine 2012: 649–743. Moseley AM, Stark A, Cameron ID, Pollock A 2005 Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews: CD002840. Mudge S, Rochester L, Recordon A 2003 The effect of treadmill training on gait, balance and trunk control in a hemiplegic subject: A single system design. Disability and Rehabilitation 25: 1000–1007. Ng SS, Hui-Chan CW 2005 The timed up & go test: Its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Archives of Physical Medicine and Rehabilitation 86: 1641–1647. Nichols DS 1997 Balance retraining after stroke using force platform biofeedback. Physical Therapy 77: 553–558. Perry J, Garrett M, Gronley JK, Mulroy SJ 1995 Classification of walking handicap in the stroke population. Stroke 26: 982–989. Plautz EJ, Milliken GW, Nudo RJ 2000 Effects of repetitive motor training on movement representations in adult squirrel monkeys: Role of use versus learning. Neurobiology of Learning and Memory 74: 27–55. Plummer P, Behrman AL, Duncan PW, Spigel P, Saracino D, Martin J, Fox E, Thigpen M, Kautz SA 2007 Effects of stroke severity and training duration on locomotor recovery after stroke: A pilot study. Neurorehabilitation and Neural Repair 21: 137–151. Pohl PS, Duncan PW, Perera S, Liu W, Lai SM, Studenski S, Long J 2002 Influence of stroke-related impairments on performance in 6-minute walk test. Journal of Rehabilitation Research and Development 39: 439–444. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH 1997 Interpreting small differences in functional status: The six minute walk test in chronic lung disease patients. American Journal of Respiratory and Critical Care Medicine 155: 1278–1282. Rubenstein LZ, Josephson KR 2006 Falls and their prevention in elderly people: What does the evidence show? Medical Clinics of North America 90: 807–824. Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C 1993 Reliability of the Fugl–Meyer assessment for testing motor performance in patients following stroke. Physical Therapy 73: 447–454. Shumway-Cook A, Brauer S, Woollacott M 2000 Predicting the probability for falls in community-dwelling older adults using the Timed up & go test. Physical Therapy 80: 896–903. Steffen TM, Hacker TA, Mollinger L 2002 Age- and gender-related test performance in community-dwelling elderly people: Six-minute walk test, berg balance scale, timed up & go test, and gait speeds. Physical Therapy 82: 128–137. Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE 1998 A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke 29: 1122–1128.
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CASE REPORT
Effect of bilateral step-up and -down training on motor function in a person with hemiparesis: a case report Mansoo Ko, PhD1, Sean Hilgenberg, PT2, Scott M. Hasson, EdD, PT, FACSM, FAPTA3, and Heather J. Braden, PhD, PT, GCS1 1
Physical Therapy Program, Angelo State University, San Angelo, TX, USA, 2Department of Physical Medicine, Shannon Medical Center, San Angelo, TX, USA, and 3Department of Physical Therapy, Georgia Regents University, Augusta, GA, USA
Abstract
Keywords
Gait training to facilitate the use of the paretic limb for persons with hemiparesis continues to be of interest to those in the clinical research domain. The purpose of this case report was to assess the outcomes of a repeated step-up and -down treatment, initiating with the paretic limb, on functional mobility, endurance and gait kinematic parameters in a person with hemiparesis. The participant was an 85-year-old female 3 years status post left hemiparesis, who reported overall good health. The participant was asked to step up on a 1-inch height wood box with her paretic limb. Once both feet were on top of the box, the participant initiated descent also with her paretic limb. The height of the box gradually progressed to 5 inches based on the participant’s performance and tolerance. A metronome was used to facilitate rhythmic lower extremity movement patterns. The training duration for each treatment session was 7–15 min/day. The participant completed nine sessions spanning over 3 weeks. The outcome measure used to identify motor recovery was the Fugl-Myer (lower extremity). In addition, the timed up and go (TUG), the 6-min walk test (6 MWT) and gait kinematics were assessed to examine mobility and gait. The Fugl-Myer score and 6 MWT did not reflect a meaningful change (0% and +2.6%, respectively). However, TUG scores did show a meaningful change (+31.9%). With respect to gait kinematics, hip flexion on the paretic limb was improved from 11 to 18 , which indicates the normal range of hip motion during the initial swing phase in post-test.
Functional mobility, gait training, hemiparesis
Introduction Stroke is a major cause of long-term disability, and more than 50% of survivors have residual motor disability (Barnes, Dobkin, and Bogousslavsky, 2005). Even for the individuals with mild to moderate impairment who achieve independent walking, strokerelated balance deficits result in a 73% incidence of falls (Forster and Young, 1995; Keenan, Perry, and Jordan, 1984). The impact of residual deficits following stroke can be characterized by slow walking speed, asymmetrical limb movements, lack of weight transfer and compromised balance (Moseley, Stark, Cameron, and Pollock, 2005; Mudge, Rochester, and Recordon, 2003). In clinical practice, therapists have recognized that persons with hemiparesis have a stopping moment to prepare for the next step (step-through gait), which results in an asymmetrical gait pattern. Therefore, in stroke rehabilitation, gait training in persons with hemiparesis is designed to minimize gait asymmetry (i.e. addressing uneven weight distribution and spatio-temporal asymmetry) (Aruin et al, 2000; Hyndman and Ashburn, 2003). In order to achieve a symmetrical gait pattern, the clinician should be able to provide skilled guidance for inducing a step-through gait in a safe environment. According to the American Physical Therapy Association (APTA) Guide to Physical Therapy Practice (2001), conventional rehabilitation for persons post-stroke is characterized by ‘‘developmental activities training; gait training; implement and device training; perceptual training; standardized Address correspondence to Mansoo Ko, PhD, Physical Therapy Program, Angelo State University, San Angelo, TX, USA. E-mail: mko@ angelo.edu
History Received 26 April 2013 Revised 20 January 2014 Accepted 22 February 2014 Published online 3 April 2014
programmatic, complementary exercise approaches; and wheelchair training’’. However, when employing conventional gait training with traditional therapies including devices such as parallel bars, other assistive devices, and manual guidance, the patients are not allowed to walk with an optimal and consistent sensory input. Assistive devices such as walkers or canes facilitate the compensatory peripheral sensory input creating undesirable motor outcome in persons with hemiparesis (Liston et al, 2000; Plummer et al, 2007). In addition, the current clinical approach requires a relatively large amount of space to facilitate the stepthrough gait pattern for persons with hemiparesis. Over the last decade, treadmill training with partial body weight support has been widely used to enhance the symmetrical gait patterns of people with hemiparesis, because it can provide an appropriate peripheral sensory feedback in a repetitive manner by guiding body alignment, rhythmical step-through gait, body weight support and speed of walking (Combs, Dugan, Ozimek, and Curtis, 2013). However, the high cost of the equipment limits its availability for gait training in persons with hemiparesis (Damiano and DeJong, 2009). Alternative gait protocols involving less physical space and distance as well as inexpensive equipment, such as a step, have not been investigated to facilitate the use of the paretic limb in an upright body posture by physical therapists. The repeated reciprocal step-up and -down training initiated with the paretic limb challenges dynamic balance in a manner similar to the dynamic weight shift required during step-through gait in persons with hemiparesis. In addition, the proposed step training method would allow physical therapists to provide the skilled guidance
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for a repetitive upright mobility intervention in a restricted physical space. This case report evaluated the feasibility and effectiveness of repeated reciprocal step-up and -down training for the purpose of improving functional mobility, endurance and gait kinematic parameters in a person with hemiparesis.
Case description Participant history The participant was an 85-year-old, right-hand dominant female, who experienced a right subcortical ischemic stroke 3 years prior to this intervention. The participant reported she was in overall good health and free from major post-stroke complications (e.g. recurrent stroke, hip fracture and myocardial infarction). This participant lived independently within the community. She was an independent ambulator but had residual balance deficits from the stroke. The participant’s past medical history was significant for hypertension and skin cancer on her face. The participant’s pharmaceutical regimen consisted of Plavix 75 mg, 2/day, and Boniva 150 mg, 1/mos. At the time of this report, the participant lived alone and performed instrumental activities of daily living and activities of daily living independently. The participant reported no history of falls in the previous 6 months, but one fall in the previous 12 months. Examination The participant’s anthropometric measurements were height ¼ 50 200 (157.5 cm) and weight ¼ 118 lbs (53.5 kg). Prior to this intervention, the participant’s vital signs were recorded while sitting at rest: blood pressure ¼ 150/66 mmHg; pulse rate ¼ 73 beats/min and oxygen saturation ¼ 95%. Valid and reliable outcome measures were used to assess functional mobility, endurance and gait kinematics (gait speed, cadence, joint angles during gait and the symmetry ratio of stride length) for pre–post tests. The Fugl–Meyer assessment (FMA) was used to evaluate motor recovery, which has been identified to have high interrater reliability (Duncan, Propst, and Nelson, 1983), and has also been shown to have good correlation with activities of daily living measures (Sanford et al, 1993). Only the lower extremity portion of the FMA was used in this case report, because of its relevance to the report. The timed up and go (TUG) is a tool that reflects functional mobility and has good test–retest reliability (Ng and Hui-Chan, 2005). The 6-min walk test (6 MWT) was used to evaluate functional mobility and walking endurance. The 6 MWT has good interrater and intrarater reliability (Kosak and Smith, 2005; Pohl et al, 2002). Upon observation using the DartfishÕ Video Analysis Software (Fribourg, Switzerland), the participant presented with postural and gait deficits which included increased kyphosis, forward-head posture, decreased hip and knee flexion during initial swing on the paretic limb, diminished knee extension during heel strike on the paretic limb, and asymmetrical stride length (non-paretic vs paretic: 1.17 m vs 1.12 m). Two-D angle analysis of Dartfish software showed that the participant’s hip flexion angle of the paretic limb (11 ) was limited compared to the non-paretic limb (22 ) during initial swing. The knee flexion angle (44 ) of the paretic limb was significantly constrained compared to the non-paretic limb (67 ) during initial swing. The asymmetrical walking patterns became more prominent during her fast walking. The participant ambulated in a normal speed (0.9 m/s) without the use of an assistive device. The cadence was 82 steps/min prior to the intervention. The participant demonstrated a lateral shifted posture onto the non-paretic limb upon walking 10 m. For the right lateral shift walking pattern, the toe out angle of the paretic limb was limited,
Figure 1. (a) Toe clearance of the non-paretic limb during mid-swing and the toe out angle of the paretic limb. (b) Toe clearance of the paretic limb during mid-swing and the toe out angle of the non-paretic limb. The arrow indicates the direction of the toe out during walking.
whereas the toe out angle of the non-paretic limb was greater than the paretic limb. Thus, the right-shifted line of gravity away from the midline of upright posture might lead the body shift to the non-paretic limb. In addition, it was noted that the participant tripped 1–2 times over the ground on the paretic limb at the midswing phase due to limited hip and knee flexion (Figure 1). Evaluation and diagnosis The participant presented with symptoms that commonly occur with residual effects from a cerebrovascular accident (CVA). The results of the pre-intervention outcome measurement scores were as follows: lower extremity FMA ¼ 19/34; TUG ¼ 20.56 s; 6 MWT ¼ 274.32 m. The participant’s problem list included the following: poor motor recovery; decreased functional mobility; decreased dynamic balance; decreased endurance and impaired posture during gait. After initiating walking, the compensatory muscular action by the non-paretic limb played a primary role to move the body forward because of poor coordination of the paretic limb. For instance, in persons with hemiparesis, the non-paretic stance limb gastrocnemius muscle controls forward momentum in preparation for a swing limb heel strike during gait initiation (GI) (Brunt, Vander Linden, and Behrman, 1995; Nichols, 1997). These findings raise the question of whether increasing gait speed may tend to overuse the non-paretic stance limb, resulting in an increased risk for falling (Forster and Young, 1995; Nichols, 1997). Therefore, with respect to weight shifting on the paretic limb during the proposed stepping training, it was important to facilitate the bilateral coordination between the paretic and non-paretic limbs using a metronome in early stages of the step training (Kautz et al, 2005). The participant’s TUG score placed her into a high risk category for falls (Shumway-Cook, Brauer, and Woollacott, 2000). The participant walked 111 m less than a healthy woman her age, according to an age-specific equation for healthy adults to predict the total distance walked during the 6 MWT (Enright and Sherrill, 1998). This translated into decreased functional mobility and endurance. These outcomes in conjunction with the
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Figure 2. Repeated bilateral step-up and -down training initiating with the paretic limb.
participant’s impaired gait mechanics represented functional limitations for the participant. The participant’s medical diagnosis of CVA and problem list were consistent with the Physical Therapy Practice Pattern 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System-Acquired in Adolescence or Adulthood (American Physical Therapy Association, 2001). Prognosis According to the APTA Guide to Physical Therapy Practice (2001) this patient would require 10–60 visits to achieve anticipated goals and expected outcomes. Previous research investigating body weight support treadmill training (BWSTT) was used as a guide given the absence of research investigating optimal intensity or duration of step training. The duration of BWSTT has varied from as few as 10 to 15 sessions, to as many as 24 or 25 sessions (Barbeau and Visintin, 2003; Visintin, Barbeau, Korner-Bitensky, and Mayo, 1998). When reviewing the literature for 10–15 sessions, mild or moderately impaired patients with stroke responded more quickly than severely impaired patients with BWSTT (Ada et al, 2003; Laufer, Dickstein, Chefez, and Marcovitz, 2001). For this particular case report, the goal for total treatment sessions was directed near the lower end of this spectrum, since the participant was a moderately impaired individual with stroke. The current report included outpatient training for nine sessions (3/week). Intervention Each treatment session required the participant to perform repetitive reciprocal stepping onto a step (Figure 2). The participant led with the paretic limb during ascent and descent of the step, which was derived according to the Kirker, Simpson, Jenner, and Wing (2000) study. A metronome was used to provide cueing for each step. A 1-inch step was used at the beginning of the training to facilitate rhythmic lower extremity movement patterns with a 40 beats/min metronome. Step height was increased according to clinician judgment and participant tolerance. Each session was divided into multiple 1–2-min bouts (3–6 sets) of continuous stepping. The participant received rest breaks between bouts, and the Borg rate of perceived exertion (RPE), which ranges from 6 to 20, was used to determine the participant’s perceived rate of exertion. Each training session ended when the participant reported a 16/20 (feel the heart pounding) on the
Table 1. Progression of a repeated bilateral step-up and -down training.
Sessions 1 2 3 4 5 6 7 8 9
Step heights (in.)
Duration (total mins)
Metronome (beats/min)
Number of steps
1 2 2 3 3 3 4 5 6
7.0 10.0 12.5 13.0 8.25 14.25 11.0 13.25 15.25
40 42 44 42 42 44 40 N/A N/A
280 420 550 546 347 627 440 N/A N/A
Borg RPE scale. During the initial session the participant performed the training protocol with the use of a body weight support system for safety purposes, which was discontinued after the initial session secondary to the participant’s ability to perform the task safely. Outcome measures were recorded during session 1. The participant’s blood pressure, pulse rate and oxygen saturation were recorded at rest prior to the beginning of training and were monitored throughout each session. The participant was provided contact-guard assistance throughout each bout of stepping. No adverse effects were observed with the exception that the participant reported increased fatigue prior to session 5. In addition, the participant reported a fall in the evening a day prior to session 8. The participant did not present with impairments or functional limitations secondary to the fall. The metronome was removed during sessions 8 and 9 secondary to the participant’s complaints of distraction from the attention to the stepping task. Upon observation at this later stage in the stepping intervention, the participant’s step cadence and ability to perform the training successfully was similar with or without the metronome. A summary of the initial and ending step heights, total steps, duration and cadence for each session is summarized in Table 1.
Outcomes The final outcome measurements were recorded after the ninth training session. A total of 10 sessions was the goal of training, however, with scheduling conflicts, a total of 9 were achieved. Table 2 provides the baseline outcome measure results, postintervention scores and percent change for the FMA, TUG and
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Table 2. Outcome measure results.
Fugl-Meyer lower extremity TUG 6-Min Walk Test 6 MWT
Pre-test
Post-test
Percent change
19/34 20.56 s 274.32 m
19/34 14.03 s 281.33 m
0 +31.9 +2.6
6 MWT. The percentage change for the FMA and the 6 MWT are not clinically meaningful, but the 31.9% change in TUG scores does represent a significant attenuation of risk of falls during walking (Shumway-Cook, Brauer, and Woollacott, 2000). With respect to the kinematic components, gait speed, cadence, knee joint angle during gait and the symmetry ratio of stride length were not improved, but hip flexion (the paretic limb) was enhanced from 11 to 18 , which indicates the normal range of motion during the initial swing phase in post-test.
Discussion While the outcome measurements did not reflect a meaningful change in all categories clinically, the results of the training protocol lead to an interesting finding. Functional mobility improved via the TUG scores during only nine sessions of stepping training. The results are not conclusive that this training will have the same effect in all individuals with stroke. However, for post-stroke movement quality, this case report showed the feasibility of the repeated bilateral step-up and -down training as a gait training activity which appeared to effectively challenge the dynamic weight shift onto the paretic limb, to produce symmetrical transition and stepping coordination in this participant with hemiparesis. The task of stepping challenges dynamic balance in a manner similar to the balance required during GI, since initiating gait requires a transition from a relatively large base of support in double stance to a small base of support in single limb stance. Particularly, GI is known as a well-defined motor task often used to assess the effects of sensorimotor deficits as it involves a stereotyped pattern of muscle activity (Brunt et al, 1991, 1999). Ko, Bishop, and Behrman (2011) indicated that the impaired tibialis anterior (TA) muscle on the paretic limb of persons with hemiparesis was activated in a normal sequence of muscle excitation, with greater amplitude, when the paretic limb was loaded to allow the nonparetic limb to initiate the first step. This finding suggests that good weight shifting onto the paretic limb allows the non-paretic limb to execute a good stepping event without any early or delayed response of toe-off. The task of stepping up and down from a step incorporates reciprocal, rhythmic lower extremity movement patterns similar to the mechanics of gait. Mercer, Freburger, Chang, and Purser (2009) indicated that the step test is a valid clinical measure of the paretic limb loading, which may indicate important functional implications in people recovering from stroke. Jaffe et al (2004) studied a training methodology which required participants to step over objects with each foot for a total of 10 steps; the control group stepped over ‘‘real objects’’ and the study group had to step over virtual. Twenty participants having a mean duration of 3.7 years poststroke were included in the study. Gait speed, step length, the ability to step over objects and walking endurance were compared before and after 2 weeks of training and again 2 weeks after cessation of training. Improvements in most outcome measures were noted in both training groups. This study suggests that improvements in walking mechanics are derived from a steppingbased intervention. According to Kirker, Simpson, Jenner, and Wing (2000) a normal pattern of hip muscle activation was
identified in stepping, whereas the response of these muscles to a perturbation while standing remained grossly impaired and was compensated by increased activity of the contralateral muscles. This finding suggests that achieving static balance while standing may not be a prerequisite to start dynamic balance training in persons with hemiparesis. The participant’s post-intervention TUG scores were at the threshold of ‘‘not a high risk for falls’’ category, according to Shumway-Cook, Brauer, and Woollacott (2000) which found a score of 514 s a low risk for falls with 87% sensitivity and specificity. Regarding patient-specific populations, Andersson, Kamwendo, Seiger, and Appelros (2006) found the cut-off for fall risk of older people with stroke to be 514 s likewise. The participant’s post-intervention TUG scores also fell between the normative values for her age, 5–17 s, according to Steffen, Hacker, and Mollinger (2002). This change of TUG score is meaningful and provides confidence to the clinician that this training protocol could be beneficial in improving functional mobility of a participant with stroke (Steffen, Hacker, and Mollinger, 2002). Although TUG scores were improving from her baseline as evidenced by the final session 9 TUG score, the participant had a fall in the late evening at home prior to session 8. According to Rubenstein and Josephson (2006) environmental hazards account for 25–45% of most accidental falls and are considered as the largest fall cause among older adults. The participant was unable to report the reason for falling. Environmental factors, such as poor lighting, time of day and unlevel terrain may have impacted the participant’s fall at home, in which she was uninjured, prior to session 8. The participant did not achieve a minimally clinical important change for the 6 MWT, which is 177 ft (54 m) (Redelmeier, Bayoumi, Goldstein, and Guyatt, 1997). These results could be attributed to various factors. Compensatory motor programs developed by the participant may have allowed her to remain independent at this stage post-CVA (Chen et al, 2003). Faster gait and ability to walk longer distance has likely been the focus for the participant since the CVA. Therefore, abnormal synergies that continue to exist, as evidenced by no improvements or change in the FMA, are overcome via compensatory movement. According to Perry, Garrett, Gronley, and Mulroy (1995) participants that are able to ambulate at speeds 40.8 m/s are classified as unlimited community walkers. In addition, Bohannon (2008) indicated that a comfortable gait speed between 80 and 89 female older adults was 0.78 m/s. Based on the previous studies, the participant’s gait speed was at this threshold prior to training. Accordingly, a ceiling effect of gait speed may have occurred. Significant improvements in gait speed and capacity have been reported after 12 sessions of locomotor training in participants with chronic stroke, but there were no improvements after 12 sessions in acute stroke participants (Plummer et al, 2007). These findings indicate that improving gait speed faster than 0.8 m/s and endurance in this participant with chronic hemiparesis may have required longer bouts of training. The FMA for lower extremity did not change from pre- to post-step training. Possible reasoning for no change in FMA components such as reflex activity, speed, sensation, passive joint motion or pain may be due to the participant being 3 years s/p injury and in the chronic stroke phase. Milovanovic and Popovic (2012) concluded that no significant differences in the FMA were found between people with acute and chronic stroke and that both groups continue to have abnormal synergies. The finding that the participant’s TUG score improved significantly, while the 6 MWT did not, may be due to differences in the components of the two tests. Both the TUG and 6 MWT contain gait components. The kinematic components of gait speed, stride length and knee joint angles during gait, showed no
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significant change from pre- to post-intervention. Only the TUG contains functional mobility components including transitioning from sit to stand and GI. These may be the components that benefited most from the step training. The stepping task intervention allowed for training in the following similar motions as required for sit to stand and GI transitions in the TUG: (1) weight shift for the trunk to move forward to step up in the step training and to stand in the TUG; (2) coactivation of the hip and knee extensors to stand vertically in the step training and in the TUG and (3) stabilization and weight shift in the upright position in preparation for stepping in both step training and in the TUG. Individuals with hemiparesis following stroke frequently have difficulty transferring the appropriate body weight onto the paretic lower limb. Inefficient weight shifting during walking contributes greatly to slower walking and imbalance in persons with hemiparesis. With respect to weight shifting on the paretic limb during bipedal walking, it is important to note that the neural circuitry controlling lower limbs is organized bilaterally to produce coordinated movements (Kautz et al, 2005). Ko, Bishop, and Behrman (2011) indicated that the absent or delayed TA muscle on the paretic limb was activated in a normal sequence of muscle excitation when the paretic limb was loaded to allow the non-paretic limb to initiate the first step in persons with moderate hemiparesis. This case report demonstrates that the proposed step training is feasible, it is capable of repeating weight shifting on the paretic limb, and the results are likely to have important clinical implications for how to repeat a good sensory input with an upright posture and how to facilitate lower limb movements associated with step height. Previous studies did not provide any evidence-based principles of step training regarding the efficacy of bilateral coordination. Thus, the current step training protocol could be adapted by clinicians as a gait training tool to facilitate symmetrical limb loading for persons with hemiparesis. Despite limited outcome measurement changes, the participant did report feeling more balanced and confident while walking within the community. The participant’s perception of balance changes was not objectively measured. The examiners believe recording this information would provide more confidence to the clinician that this training protocol could have an effect on a participant’s perception of improved functional mobility. One of the challenges in the proposed training was to keep consistent, rhythmical movements by the participant. The speed of step training was determined by the metronome, which produces a regulated audible pulse for the performance of stepping up and down. Step height increased according to clinician judgment and participant tolerance. Although metronome pacing and reciprocal stepping may be thought to have an anchoring effect, whereby the participant focuses primarily on the audible cue and steps to it thus stabilizing performance, increasing step height to more than 4 in. increased the intensity and distracted the participant’s attention from performing step up and down with the paretic limb first. Bowen et al (2001) indicated that the simultaneous performance of two tasks can have a dual task decrement on stroke participants’ balance and gait speed. Therefore, it is important to note that the level of dual task may have a considerable impact or interfere with the performance of motor tasks in persons with hemiparesis at a certain point of physical difficulty or intensity of the task. In addition, 6 MWT or TUG has been the most frequently mentioned to quantify gait function in a clinic or laboratory setting, but may not fully represent the functional improvement of walking performance outside the clinic (Bowden and Behrman, 2007). The step activity monitor (SAM) (Cyma Corporation, Seattle, WA) has been known as an effective clinical tool to assess
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not only the overall physical activity measured by the total number of steps but also the intensity of step activity measured by step numbers per minute (Bowden and Behrman, 2007; Brandes and Rosenbaum, 2004; McDonald et al, 2005). The SAM may be better suited to identify the effectiveness of the proposed training as an outcome measure in the home and community. Plautz, Milliken, and Nudo (2000) indicated that the functional reorganization of motor cortex is altered by motor skill acquisition, but not by repetitive use alone. For future research, the repetitive step-up and -down training may need to consider how to enhance the accuracy of a stepping movement (e.g. foot position, speed, trajectory of movement and body alignment) as a prerequisite factor for functional improvement of walking performance in people with hemiparesis.
Conclusion The TUG functional mobility scale showed a meaningful change after step training in a participant with chronic stroke of 3 years. Neither the 6 MWT nor the FMA showed changes from pre- to post-step training. Kinematic components of gait, such as gait speed, stride length and knee joint angle during gait, failed to show a significant change from pre- to post-intervention. However, hip flexion on the paretic limb was improved to the normal range of motion during the initial swing phase in post-test. The TUG may have unique components, that include dynamic weight shifting, which are improved with step training. The proposed step training is feasible for clinicians to provide an intervention for patients that maintain an upright posture and reciprocal stepping while encouraging dynamic weight shifting onto the paretic limb in a restricted physical space.
Declaration of interest The authors report no declarations of interest.
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