Effects of task-oriented treadmill-walking training on walking ability of stoke patients Oh-hyuk Kwon1, Youngkeun Woo2, Ju-sang Lee3, Kyung-hoon Kim1 1
Department of Physical Therapy, Bundang Jesaeng Hospital, Seongnam, Republic of Korea, 2Department of Physical Therapy, College of Medical Sciences, Jeonju University, Republic of Korea, 3Department of Physical Therapy, Hallym College, Chuncheon, Republic of Korea Background: Generally, treadmill-walking training focuses on weight bearing and the speed of walking. However, changes in direction, speed, and slope while walking require adaptation. Objective: The effects of task-oriented treadmill-walking training (TOTWT) on the walking ability of stroke patients were evaluated. Methods: Subjects were randomly divided into two groups: the task-oriented treadmill-walking training (TOTWT) group and the conventional treadmill-walking training (CTWT) group. Evaluation was performed before the commencement of the training and again 4 and 8 wk after training was initiated. The OptoGait system measured gait parameters. The Timed Up and Go test and 6-min walk test were also performed. Results: Within each group, both the TOTWT and the CTWT groups significantly differed before and after the intervention in all tests (P v 0.05); the CTWT group showed greater improvement in all tests following TOTWT (P v 0.05). Conclusion: TOTWT improves gait and rehabilitation in the stroke-affected limb, and also improves general gait characteristics.
Keywords: Task-oriented, Treadmill, Gait, Stroke
Introduction Walking is the most basic of human activities, moving the body from one location to another.1 The walking ability of stroke patients greatly affects their quality of everyday life.2 Although the walking ability of some stroke patients improves with time, it remains limited in others, affecting their independence and endurance in activities inside and outside the home.3 Therefore, the improvement of walking ability of stroke patients is an important goal in rehabilitation, to aid their recovery and independence.4 Treatment methods to improve stroke patients’ walking ability include proprioceptive neuromuscular facilitation,5 Bobath neurodevelopmental treatment,6 training in functional tasks similar to activities of daily living,7,8 and treadmill gait training.9 The task-oriented training proposed by Carr and Shepherd involves functional tasks and movements that patients need to perform in their daily environments.10 According to some studies, task-oriented training is better than other methods in improving stroke
Correspondence to: Youngkeun Woo, Department of Physical Therapy, College of Medical Sciences, Jeonju University, 303, Cheonjam-ro, Wansan-gu, Jeonju 560-759, Republic of Korea. Email: [email protected]
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patients’ walking ability.2,11 In the clinical setting, treadmill walking has been evaluated through the monitoring of walking strides. This can be easily performed as treadmill walking allows for repetitive strides, which are not always possible with walking over ground. Moreover, repetitive treadmill walking stimulates functional weight support and balance of the basic components of walking.2,12–15 Treadmill training usually focuses on the improvement of walking speed of stroke patients through speed-dependent methods.16–18 Furthermore, treadmill training with partial weight support focuses on strengthening and retraining motor control of gait, which also assists in standing.19 Thomas and Fast20 and Threlkeld et al. (1989)21 noted improved balance and walking ability after backward walking training in conjunction with improved lower limb strength after intervention.21 Thus, treadmill-walking training achieves better outcomes than ground-walking training.22 DePaul et al.23 noted improved endurance, balance, and quality of life after weight-bearing treadmill training compared with the variability of over-ground-walking training in 70 stroke patients. Treadmill treatment techniques aimed at improving postural symmetry focus on the stroke patient taking repetitive steps while extending the time of weight bearing on the affected side.24 An additional aim of Topics in Stroke Rehabilitation
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such techniques is to improve the patient’s gait by providing sensory inputs to encourage normal walking25 through repetitive walking patterns.26 Several studies questioned the functional effects of conventional treadmill gait training (i.e. repeating simple motions of the lower extremities under clinically adjusted conditions) and emphasized the advantages of ground gait training in more realistic environments.27,28 Current research on treadmill gait training utilized indoor environments; outdoor factors, such as slope, direction, and speed, were not considered, despite the focus on improving gait in stroke patients.29 Shumway-Cook et al.30 suggested that a prerequisite for community walking is the ability to perform tasks on irregular ground surfaces, slopes, and stairways. People in community settings generally have to perform diverse tasks at different elevations and clearances, and programs designed to reflect these complex tasks are needed for stroke patients who lack mobility.31,32 Therefore, this study examined the effects of diversified task-oriented treadmill gait training on stroke patients’ walking ability. The tasks included changes in speed, gradient, weight bearing, and direction on a treadmill.
Methods Participants The study included 40 stroke patients admitted to B Hospital in Bundang, Korea, between June and August 2013 and who received physical therapy. The goals of the study were explained, and all agreed to participate. The study was approved by the Bronco Memorial Hospital Institutional Review Board (IRB) (RTC2013-AB-003). The selection criteria were as follows: (1) post-stroke duration of at least 3 but not more than 24 months, (2) no serious visual disorder, field defect, or hearing impairment, as determined by the doctor in charge, (3) score on the Mini-Mental State Examination not lower than 24, (4) ability to walk independently without any walking aid, (5) functional ambulation category 4 or 5, (6) understanding of the procedure and purpose of the study, and voluntary participation (Table 1). Subjects were randomly assigned to two groups to minimize bias. Each selected a card with a number between 1 and 44. The cards were placed in a box to confirm equal opportunity for card selection. Odd numbers were assigned to the task-oriented treadmill-walking training (TOTWT) group, and even numbers to the conventional treadmill-walking training (CTWT) group. Each group of 22 subjects was evaluated before training was initiated, and again 4 and 8 weeks after training began. Two patients in 448 2
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Table 1 General characteristics of the subjects (N540) Group Variables
TOTWT (n520) CTWT (n520) T
P
Height (cm) Weight (kg) Age (year) MMSE-K (score) Onset (months)
167.65+ 7.56 62.70+ 8.75 50.70+ 15.16 27.60+ 1.79 14.25+ 6.27
ns ns ns ns ns P
MAS G0 G1 G1z Gender Male Female Diagnosis Infarction Hemorrhage Side of brain lesion Right Left FAC 4 5
164.95+ 8.06 62.20+ 12.07 47.15+ 18.65 27.75+ 1.80 15.25+ 6.54
0.281 0.882 0.513 0.793 0.624 Chi2
9 (45.0%) 6 (30.0%) 5 (25.0%)
11 (55.0%) 4 (20.0%) 5 (25.0%)
0.741 ns
14 (70.0%) 6 (30.0%)
12 (60.0%) 8 (40.0%)
0.507 ns
11 (55.0%) 9 (45.0%)
12 (60.0%) 8 (40.0%)
0.749 ns
10 (50.0%) 10 (50.0%)
9 (45.0%) 11 (55.0%)
0.752 ns
15 (75%) 5 (25%)
13 (65%) 7 (35%)
0.490 ns
Values are N (%) or mean+ standard deviation; ns: not significant; TOTWT: task-oriented treadmill-walking training, CTWT: conventional treadmill-walking training, MMSE-K: Mini-Mental State Examination-Korean version, MAS: modified ashworth scale, G0: Grade 0, G1: Grade 1, G1z: Grade 1z, FAC: functional ambulatory category. General characteristics and dependent variables are calculated by independent t-test and chi-squared test.
the TOTWT group dropped out of training and two in the CTWT group were transferred to other hospitals. The remaining 40 patients completed the study.
Intervention Both groups received conservative physical therapy, including joint motion exercises, stretching, and muscle strengthening exercises for 30 minutes in the adult exercise therapy room. This was followed by TOTWT for 30 minutes, five times per week, for 8 weeks. The subjects randomly selected a program during the 1-minute rest period between treadmill training sessions, with a varying slope, speed, direction, and amount of weight support. Walking speed on the treadmill was based on and set at three times the comfortable ground-walking speed. The average speed was measured over a distance of 7 m, v2 m each at the beginning and end of the walkway, to account for the acceleration and deceleration phase of walking. The reliability for this test was reported as 0.87,33 and the validity was 0.78.34 Training was stopped if the subject was unable to continue for 30 minutes. Five minutes rest was permitted for a complaint of pain, or for abnormal breathing or changes in complexion (Table 2).35 Topics in Stroke Rehabilitation
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Table 2 Program of task-oriented treadmill gait training
Speed (1) Direction (2) Gradient (3) Weight support (4)
Default set
Change 1
Change 2
Change 3
1.2 km/hour Forward 0uu 40%
1.3 km/hour Backward 2.5uu 30%
1.4 km/hour Forward 5uu 20%
1.5 km/hour Backward 10uu 10%
Task-oriented treadmill-walking training This study used TOTWT, with changes in any two of the following four independent variables: (1) speed, (2) direction, (3) slope gradient, and (4) weight bearing. Each patient selected six pieces of paper with the letters A–F in random order to perform the exercises on the treadmill. Any piece of paper selected once was not selected again. The subjects exercised for 30 minutes, performing six tasks, each one for 4 minutes, followed by rest for 1 minute. The patient prepared for the next task during the 1 minute rest. The six tasks in the program were A: 1, 2 (changes in speed and direction); B: 1, 3 (changes in speed and gradient); C: 1, 4 (changes in speed and weight bearing); D: 2, 3 (changes in direction and gradient); E: 2, 4 (changes in direction and weight bearing); and F: 3, 4 (changes in gradient and weight bearing). A patient who selected tasks in the order of A through F performed these as follows: (1) Task A – backward training for 4 minutes at a speed of 1.3 km/hour, a gradient of 0uu, and 40% weight bearing, followed by rest for 1 minute; (2) Task B – forward training for 4 minutes at a speed of 1.4 km/ hour, a gradient of 2.5uu, and 40% weight bearing, followed by rest for 1 minute; (3) Task C – forward training for 4 minutes at a speed of 1.5 km/hour, a gradient of 0uu, and 30% weight bearing, followed by rest for 1 minute; (4) Task D – backward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 2.5uu, and 40% weight bearing, followed by rest for 1 minute; (5) Task E – forward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 0uu, and 30% weight bearing, followed by rest for 1 minute; (6) Task F – forward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 2.5uu, and 20% weight bearing, followed by rest for 1 minute. Subjects selfselected and applied different speeds, directions, slope gradients, and weight bearing during treadmill gait training. Ground-walking was analyzed for the middle 7 of 11 m, excluding acceleration and deceleration phases. Subjects were verbally instructed to ‘walk at your comfortable speed’.36 The speed was increased by 0.1 km/hour each time a change was made.37 Each subject was instructed to walk steadily for 20 seconds on the treadmill. The direction of 446
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walking was changed between forward and backward,38 the gradient of the treadmill was increased from 0uu to 2.5uu, 5uu, and 10uu,39 and the degree of weight bearing by the subject was gradually reduced from 40% to 30%, 20%, and 10%.40,41 Three physical therapists implemented the TOTWT for each subject. One stood right behind the subject to help with weight bearing on either the unaffected or affected lower extremity and with shifting weight between the two lower extremities. The other two therapists stood at either side of the subject to assist with stepping and motor control during the swing and stance phases while manually correcting walking patterns. The subject was verbally instructed to adopt appropriate walking patterns (Fig. 1).
Figure 1 Task-oriented treadmill-walking training (TOTWT).
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Conventional treadmill-walking training Variable speed, direction, slope gradient, and weight bearing were not applied during CTWT. Comfortable walking speed was set in the same manner as in TOTWT by verbal instruction, and was again three times faster. Three physical therapists assisted: one stood behind the subject to help with contralateral and ipsilateral weight bearing by supporting the trunk; two were positioned outside of both legs during the stance and swing phases and provided a secondary control exercise by correcting the gait pattern. We promote proper gait patterns in subjects with voice prompts by researchers in training.
Outcome Measures Clinical assessments Timed Up and Go (TUG) test The TUG test measured the time taken for a patient sitting on a 46 cm high chair to stand up at a verbal command, walk 3 m, pass a halfway point, turn around toward the unaffected side, then return to the chair and adopt the original posture. Each patient completed the TUG test three times for an average value.42 The test-retest reliability for the stroke patients was high (r50.95).43 6-minute walk test The 6-minute walk test was conducted in the hospital corridor. Each subject walked unaided back and forth along a 25-m walkway for 6 minutes, with markers placed on the floor at intervals of 1 m. The total distance walked was measured using the markers.44 The patients were allowed to self-adjust walking speeds and rest times. The intra-rater reliability for the stroke patients was r50.99.18
Gait analysis OptoGait OptoGait (Microgate Srl, Bolzano, Italy) was used to collect data on walking patterns for quantitative analysis. Each subject was instructed to walk 7 m at a comfortable speed. Sensors on the feet collected information on walking variables while the subject walked for 3 m on a 7-m platform, excluding the initial 2 m in the accelerating phase and the last 2 m in the decelerating phase. Stride length, stride time, cadence, and average walking speeds were analyzed. The affected lower extremity was assessed for step length, single support, step time, and average walking speed. To correct for inter-tester differences, one skilled physical therapist took all the measurements. The patients used no walking aids, such as body weight supports or suspension systems. The intra-rater reliability was r50.99, and the test-retest reliability was r50.98–0.99.45 450
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Statistical analysis All statistical analyses in this study were conducted using PASW (Predictive Analytics Software) 18.0 for Windows. Chi-squared testing analyzed the two groups for spasticity, gender, diagnoses, and the side of brain lesions. Heights, weights, Korean MiniMental State Examination scores, and time since the onset of the disease were analyzed through independent sample t-tests. Normality was tested using Kolmorogov–Smirnov tests. Repeated analysis of variance (ANOVA) examined differences within the two groups at 0, 4, and 8 weeks of training, as well as differences between the two groups attributable to therapeutic exercise methods at the same time points. The statistical significance level of all data was set to alpha50.05.
Results Comparison of changes in the general characteristics of walking before the experiment, and 4 and 8 weeks after the experiment Stride lengths of the TOTWT group increased significantly, from 67.51+ 20.16 cm before the experiment, to 87.64+ 19.94 cm 4 weeks after the experiment, and to 106.85+ 23.53 cm 8 weeks after the experiment (P50.000). Stride lengths of the CTWT group also increased significantly, from 66.74+ 23.13 cm before the experiment, to 78.61+ 22.00 cm 4 weeks later, and 89.89+ 22.30 cm 8 weeks later (P50.000). The changes in the stride lengths at the 4- (P50.004) and 8-week (P50.008) periods were statistically significantly different between the two groups. The gait cycle of the TOTWT group decreased significantly, from 2.50+ 0.92 seconds before the experiment, to 1.72+ 0.47 seconds 4 weeks after the experiment, and to 1.44+ 0.45 seconds 8 weeks after the experiment (P50.000). The gait cycle of the CTWT group also decreased significantly, from 2.51+ 0.96 seconds before the experiment, to 2.14+ 0.81 seconds 4 weeks later, and to 1.66+ 0.58 seconds 8 weeks later (P50.000). The changes in the gait cycle at the 4(P50.015) and 8-week (P50.008) periods were statistically significantly different between the two groups. Cadence of the TOTWT group increased significantly, from 0.51+ 0.09 step/second before the experiment, to 0.68+ 0.13 step/seconds 4 weeks after the experiment, and to 0.78+ 0.09 step/second 8 weeks after the experiment (P50.000). The cadence of the CTWT group also increased significantly, from 0.51+ 0.09 steps/ second before the experiment, to 0.60+ 0.11 step/ second 4 weeks later, and 0.65+ 0.08 step/second 8 weeks later (P50.000). The changes in the cadence at the 4- (P50.018) and 8-week (P50.033) periods were Topics in Stroke Rehabilitation
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statistically significantly different between the two groups. Average speed of the TOTWT group increased significantly, from 0.60+ 0.22 m/second before the experiment, to 0.78+ 0.25 m/second 4 weeks after the experiment, and to 1.00+ 0.27 m/second 8 weeks after the experiment (P50.000). Average speed of the CTWT group also increased significantly, from 0.60+ 0.15 m/second before the experiment, to 0.69+ 0.18 m/second 4 weeks later, and 0.83+ 0.19 m/ second 8 weeks later (P50.000). The changes in the average speed at the 4- (P50.008) and 8-week (P50.007) periods were statistically significantly different between the two groups (Table 3).
Comparison of changes in walking characteristics of the affected side before the experiment, and 4 and 8 weeks after the experiment Affected step length of the TOTWT group increased significantly, from 33.58+ 11.11 cm before the experiment, to 43.32+ 10.87 cm 4 weeks after the experiment, and to 53.91+ 12.94 cm 8 weeks after the experiment (P50.000). Affected step length of the CTWT group also increased significantly, from 33.30+ 11.49 cm before the experiment, to 39.18+ 11.04 cm 4 weeks later, and 44.85+ 13.18 cm 8 weeks later (P50.000). Changes in the affected step length at the 4- (P50.037) and 8-week (P50.022) periods were statistically significantly different between the two groups. Affected single support of the TOTWT group increased significantly, from 26.23+ 8.69% before the experiment, to
37.60+ 6.05% 4 weeks after the experiment, and to 40.25 + 6.30% 8 weeks after the experiment (P50.000). Affected single support of the CTWT group also increased significantly, from 29.62+ 5.96% before the experiment, to 36.94+ 5.36% 4 weeks later, and 37.09+ 6.12% 8 weeks later (P50.000). Changes in the affected single support at the 4- (P50.039) and 8-week (P50.031) periods were statistically significantly different between the two groups. Affected step of the TOTWT group decreased significantly, from 1.23+ 0.46 seconds before the experiment, to 0.87+ 0.31 seconds 4 weeks after the experiment, and to 0.75+ 0.27 seconds 8 weeks after the experiment (P50.000). Affected step of the CTWT group also decreased significantly, from 1.24+ 0.49 seconds before the experiment, to 1.05+ 0.39 seconds 4 weeks later, and 0.84+ 0.26 seconds 8 weeks later (P50.000). Changes in the affected step at the 4- (P50.025) and 8-week (P50.048) periods were statistically significantly different between the two groups. Affected speed of the TOTWT group increased significantly, from 0.59+ 0.34 m/second before the experiment, to 0.77+ 0.37 m/second 4 weeks after the experiment, and to 0.95+ 0.36 m/second 8 weeks after the experiment (P50.000). Affected speed of the CTWT group also increased significantly, from 0.60+ 0.17 m/second before the experiment, to 0.67+ 0.19 m/second 4 weeks later, and 0.79+ 0.21 m/ second 8 weeks later (P50.000). Changes in the affected speed at the 4- (P50.036) and 8-week (P50.029) periods were statistically significantly different between the two groups (Table 4).
Table 3 Comparison of general characteristics of gait between two groups (N540) Variable SL (cm)
GC (seconds)
Cadence (step/second)
AS (m/second)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
67.51+ 20.16 87.64+ 19.94{ 106.85+ 23.53z 0.000* 2.50+ 0.92 1.72+ 0.47{ 1.44+ 0.45z 0.000* 0.51+ 0.09 0.68+ 0.13{ 0.78+ 0.09z 0.000* 0.60+ 0.22 0.78+ 0.25{ 1.00+ 0.27z 0.000*
66.74+ 23.13 78.61+ 22.00{ 89.89+ 22.30z 0.000* 2.51+ 0.96 2.14+ 0.81{ 1.66+ 0.58z 0.000* 0.51+ 0.09 0.60+ 0.11{ 0.65+ 0.08z 0.000* 0.60+ 0.15 0.69+ 0.18{ 0.83+ 0.19z 0.000*
F
P
9.386 7.722
0.0041 0.008||
6.451 7.926
0.0151 0.008||
6.092 4.893
0.0181 0.033||
7.710 8.125
0.0081 0.007||
* Pv0.05, Values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. SL: stride length; GC: gait cycle; AS: average speed; TOTWT: task-oriented treadmill-walking training; CTWT: conventional treadmillwalking training; ANOVA: analysis of variance
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Table 4 Comparison of affected side characteristics of gait between two groups (N540) Variable ASL (cm)
ASS (%)
AST (seconds)
ASp (m/second)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
33.58+ 11.11 43.32+ 10.87{ 53.91+ 12.94z 0.000* 26.23+ 8.69 37.60+ 6.05{ 40.25+ 6.30z 0.000* 1.23+ 0.46 0.87+ 0.31{ 0.75+ 0.27z 0.000* 0.59+ 0.34 0.77+ 0.37{ 0.95+ 0.36z 0.000*
33.30+ 11.49 39.18+ 11.04{ 44.85+ 13.18z 0.000* 29.62+ 5.96 36.94+ 5.36{ 37.09+ 6.12z 0.000* 1.24+ 0.49 1.05+ 0.39{ 0.84+ 0.26z 0.000* 0.60+ 0.17 0.67+ 0.19{ 0.79+ 0.21z 0.000*
F
P
4.677 5.722
0.0371 0.022||
4.577 5.033
0.0391 0.031||
5.476 4.162
0.0251 0.048||
4.738 5.125
0.0361 0.029||
* Pv0.05, values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. ASL: affected step length; ASS: affected single support; AST: affected step, ASp: affected speed, TOTWT: task-oriented treadmillwalking training, CTWT: conventional treadmill-walking training; ANOVA: analysis of variance.
Comparison of changes in the clinical gait index before the experiment, and 4 and 8 weeks after the experiment The TUG test of the TOTWT group decreased significantly, from 26.94+ 4.90 seconds before the experiment, to 23.84+ 4.79 seconds 4 weeks after the experiment, and to 19.95+ 4.89 seconds 8weeks after the experiment (P50.000). The TUG test of the CTWT group also decreased significantly, from 23.85+ 5.05 seconds before the experiment, to 22.18+ 5.65 seconds 4 weeks later and 20.03+ 5.79 seconds 8 weeks later (P50.000). Changes in the TUG test at the 4(P50.000) and 8-week (P50.000) periods were statistically significantly different between the two groups. The 6-minute walk test of the TOTWT group increased significantly, from 239.50+ 21.18 m before the experiment, to 252.95+ 22.26 minutes 4 weeks after the experiment, and to 272.30+ 21.19 m 8 weeks after the experiment (P50.000). The 6-minute walk test of the CTWT group also increased significantly, from 239.60+ 21.65 m before the experiment, to 243.45+ 19.77 m 4 weeks later, and 255.35+ 20.14 m 8 weeks later (P50.000). Changes in the 6-minute walk test at the 4- (P50.003) and 8-week (P50.000) periods were statistically significantly different between the two groups (Table 5).
Discussion This study was designed to verify the effectiveness of TOTWT of stroke patients in clinical settings compared to the widely used CTWT. Variations in speed, direction, gradient, and weight bearing in the TOTWT were shown to be effective in previous studies. 452 6
OptoGait was used to examine walking variables and showed statistically significant improvements. This is consistent with a study by Patterson et al.,46 in which stroke patients showed significant differences in step length on the affected side following treadmill training. The increases in stride and step lengths on the affected side in this study are attributed to performing diverse tasks on the treadmill. These increase the range of motion of the affected lower extremity and improve step lengths on the affected side. They also improve step length on the unaffected side and eventually increase stride length. Affected side single-support phase analysis showed significant differences in length. Cadence analysis showed significant differences. The results are consistent with those of Yang et al.,8 in which the average walking speed, cadence, and stride length of an experimental group that underwent task-oriented training significantly improved. Diverse treadmill tasks increased the weight-bearing time on the affected side and shortened the support time for both extremities. This probably limited the reduction in cadence in stroke patients, which is attributable to the shortening of the weight bearing time on the affected side and the increase in the support time for both extremities. Ribeiro et al.47 studied the effects of weight-bearing treadmill gait training and proprioceptive neuromuscular facilitation in hemiplegia patients; the symmetry of patient gaits significantly improved, consistent with the results of this study. The authors attributed the improvement in gait symmetry to the task-oriented gait training, which helps to improve Topics in Stroke Rehabilitation
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Table 5 Comparison of change of clinical gait index between two groups (N540) Variable TUG (seconds)
6 minutes WT (m)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
26.94+ 4.90 23.84+ 4.79{ 19.95+ 4.89z 0.000* 239.50+ 21.18 252.95+ 22.26{ 272.30+ 21.19z 0.000*
23.85+ 5.05 22.18+ 5.65{ 20.03+ 5.79z 0.000* 239.60+ 21.65 243.45+ 19.77{ 255.35+ 20.14z 0.000*
F
P
25.259 148.678
0.0001 0.000||
10.065 17.170
0.0031 0.000||
* Pv0.05, values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. TUG: Timed Up and Go test; 6-minute WT: 6-minute walk test; TOTWT: task-oriented treadmill-walking training; CTWT: conventional treadmill-walking training; ANOVA: analysis of variance.
muscular strength in single-support phases. The step and stride times of the affected side significantly differed in our study, consistent with findings by Chen et al.48 These authors evaluated gait cycles, hip joint angles, and knee joint angles of eight stroke patients with different degrees of spasticity. These were measured at different average walking speeds, with and without weight bearing, and with and without handrails. As weight bearing on the affected side increased, the swing-phase time decreased, and the asymmetry of the gait decreased. When weight bearing and handrails were used in combination, gait components, such as single support, average walking speeds, and gait cycles, improved. They attributed their findings to increased trunk stability due to TOTWT, with increased swing-phase time due to weight bearing. This reduced gait asymmetry. In this study, the walking speeds of the affected side and the average walking speeds differed significantly. This is consistent with a study by Yang et al.,8 in which muscle strength increased by 61.5% and average walking speed increased after taskoriented training for 4 weeks. The authors attributed their results to increased muscle strength due to TOTWT. This enhanced and smoothed the swing and stance phases of the affected and unaffected lower extremities, with resulting increases in stride lengths and cadences. There were significant differences in the clinical walking evaluation indexes obtained through the TUG tests. These results are consistent with a study by Leroux et al.49 of 44 stroke patients, who were divided into experimental and control groups. The experimental group took part in a task-oriented exercise program; the control group did not take part in any exercise program. Both the balance and the mobility of the experimental group significantly increased, and there were high correlations between postural stability and the results of the TUG test. 450
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These results suggest that task-oriented training on a treadmill likely reduces weight bearing during the stance phases; this stabilizes the trunk, thereby improving the ability to control lower extremity movements. As a result, average walking speeds increase. The results of the 6-minute walk tests also revealed significant differences. This is consistent with a study by Outermans et al.,50 in which the walking ability of a group that underwent task-oriented training improved, and also a study by Polese et al.,51 in which the walking speed and step lengths of stroke patients increased after they used a treadmill. These results suggest that taskoriented treadmill gait training can improve trunk control, reduce muscle tone, improve lower extremity movement control, and increase muscle strength, thereby enabling patients to walk longer distances. A limitation of the current study is that the daily activities/tasks of the experimental group could not be completely controlled. In addition, the results cannot be generalized because the number of patients included in the study was small, and the study comprised only those stroke patients who could walk. Future follow-up studies should be conducted after task-oriented treadmill gait training to determine whether the training is transferred to learning. Task-oriented treadmill-walking training in this study is one of the various methods that can be used to improve the walking ability of stroke patients. More studies of TOTWT are needed, to include patients with brain lesions and potentially higher levels of ability.
Conclusions This study examined whether weight-bearing TOTWT, based on varying speed, direction, slope gradient, and weight bearing, improved walking ability of stroke patients. The walking ability of the TOTWT group increased. The TOTWT is effective as a rehabilitation training program to improve general characteristics of stroke patients’ gaits, 4537
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characteristics of their affected lower extremity during walking, and their clinical walking evaluation indexes.
Disclaimer Statements Contributors OH Kwon performed the experiments, data analysis, and manuscript preparation. YK Woo developed the idea for the study, directed experiments, and drafted the manuscript. JS Lee directed experiments, and guided data analysis. KH Kim performed the experiments and data analysis. All authors read and approved the final manuscript. Funding None. Conflicts of interest None. Ethics approval This study was approved by the Bronco Memorial Hospital Institutional Review Board (IRB) (RTC2013-AB-003).
References 1 Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St. Louis: Mosby; 2012. 2 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(6):612–620. 3 Chen G, Patten C. Treadmill training with harness support: selection of parameters for individuals with poststroke hemiparesis. J Rehabil Res Dev. 2006;43(4):485–498. 4 Werner C, Von Frankenberg S, Treig T, Konrad M, Hesse S. Treadmill training with partial body weight support and an electro-mechanical gait trainer for restoration of gait in subacute stroke patients: a randomized cross over study. Stroke. 2002;33(12):2895–2901. 5 Voss DE, Knott M. Patterns of motion for proprioceptive neuromuscular facilitation. Br J Phys Med. 1954;17(9):191–198. 6 Bobath B. Adult Hemiplegia: Evaluation and Treatment. 3rd edn. London: Butterworth-Heinemann Medical Books; 1990. 7 Dean CM, Shepherd RB. Task-related training improves performance of seated reaching tasks after stroke. a randomized controlled trial. Stroke. 1997;28(4):722–728. 8 Yang YR, Wang RY, Lin KH, Chu MY, Chan RC. Taskoriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil. 2006;20(10):860–870. 9 Franceschini M, Carda S, Agosti M, Antenucci R, Malgrati D, Cisari C. Walking after stroke: what does treadmill training with body weight support add to overground gait training in patients early after stroke: a single- blind, randomized, controlled trial. Stroke. 2009;40(9):3079–3085. 10 George D. Locomotor Training with Body Weight Support after Stroke: the Effect of different Training Paremeters. J Neurological Phys Ther. 2004;28(1):20–28. 11 Dean CM, Carol LR, Fransine M. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81(4):409–417. 12 Mandel AR, Nymark JR, Balmer SJ, Grinnell DM, O’Riain MD. Electromyographic versus rhythmic positional biofeedback in computerized gait retraining with stroke patients. Arch Phys Med Rehabil. 1990;71(9):649–654. 13 Schauer M, Mauritz KH. Musical motor feedback (MMF) in walking hemiparetic stroke patients: randomized trials of gait improvement. Clin Rehabil. 2003;17(7):713–722.
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14 Thaut MH, McIntosh GC, Rice RR. Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation. J Neurol Sci. 1997;151(2):207–212. 15 Winter DA. Biomechaics of normal and pathological gait: implication for understanding human locomotor control. J Mot Behav. 1989;21(4):337–355. 16 Ada L, Dean CM, Hall JM, Bampton J, Crompton S. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebocontrolled, randomized trial. Arch Phys Med Rehabil. 2003; 84(10):1486–1491. 17 Moseley AM, Stark A, Cameron ID, Pollock A. Treadmill training and body weight support for walking after stroke. Stroke. 2003;34(12):3006. 18 Pohl M, Mehrholz J, Ritschel C, Ru¨ckriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: a randomized controlled trial. Stroke. 2002;33(2):553–558. 19 Dobkin BH. Strategies for stroke rehabilitation. Lancet Neurol. 2004;3(9):528–536. 20 Thomas MA, Fast A. One step forward and two step back: the dangers of walking backwards in therapy. Am J Phys Med Rehabil. 2000;79(5):459–461. 21 Threlkeld AJ, Horn TS, Wojtowicz GM, Rooney JG, Shapiro R. Kinematics, ground reaction force, and muscle balance produced by backward running. J Orthop Sports Phys Ther. 1989;11:56–63. 22 Laufer Y, Dickstein R, Chefez Y, Marcovitz E. The effects 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. 23 DePaul VG, Wishart LR, Richardson J, Lee TD, Thabane L. Varied overground walking-task practice versus body-weightsupported treadmill training in ambulatory adults within one year of stroke: a randomized controlled trial protocol. BMC Neurol. 2011;11:129. 24 Hesse S, Konrad M, Uhlenbrock D. Treadmill walking with partial body weight support versus floor walking in hemiparetic subjects. Arch Phys Med Rehabil. 1999;80(4):421–427. 25 Malouin F, Potvin M, Prevost J, Richards CL, Wood-Dauphinee S. Use of an intensive task-oriented gait training program in a series of patients with acute cerebrovascular accidents. Phys Therap. 1992;72(11):781–789, [discussion 789-793]. 26 Chen CL, Chen HC, Tang SF, Wu CY, Cheng PT, Hong WH. Gait performance with compensatory adaptations in stroke patients with different degrees of motor recovery. Am J Phys Med Rehabil. 2003;82(12):925–935. 27 Jones AM, Doust JH. A 1% treadmill grade most accurately reflects the energetic cost of outdoor running. J Sports Sci. 1996;14(4):321–327. 28 Park HS, Yoon JW, Kim J, Iseki K, Hallett M. Development of a VR-based treadmill control interface for gait assessment of patients with Parkinson’s disease. In: IEEE Int Conf Rehabil Robot, Kyoto, 2011. 29 Hwang EO, Oh DW, Kim SY. Community ambulation in patients with chronic post-stroke hemiparesis: comparison of walking variables in five different community situations. Korean Acad Phys Ther Sci. 2009;16(1):31–39. 30 Shumway-Cook A, Patla AE, Stewart A, Ferrucci L, Ciol MA, Guralnik JM. Environmental demands associated with community mobility in older adults with and without mobility disabilities. Phys Ther. 2002;82(7):670–681. 31 Lam YS, Man DW, Tam SF, Weiss PL. Virtual reality training for stroke rehabilitaion. Neur Rehabil. 2006;21(3):245–253. 32 Yang YR, Tsai MP, Chuang WY, Sung WH, Wang YY. Virtual reality-based training improves community ambulation in individuals with stroke: a randomized controlled trial. Gait Posture. 2008;28(2):201–206. 33 Green J, Forster A, Young J. Relaibility of gait speed measured by a timed walking test in patients one year after stroke. Clin Rehabil. 2002;16(3):306–314. 34 Maeda A, Yuasa T, Nakamura K, Higuchi S, Motohashi Y. Physical performace tests after stroke: reliability and validity. Am J Phys Med Rehabil. 2000;79(6):519–525. 35 Kesar TM, Reisman DS, Perumal R, Jancosko AM, Higginson JS, Rudolph KS, et al. Combined effects of fast treadmill walking and functional electrical stimulation on post-stroke gait. Gait Posture. 2011;33(2):309–313.
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36 Aaslund MK, Helbostad JL, Moe-Nilssen R. Familiarisation to body weight supported treadmill training for patients poststroke. Gait Posture. 2011;34(4):467–472. 37 Ditor DS, Macdonald MJ, Kamath MV, Buqaresti J, Adams M, McCartney N, et al. The effects of body-weight support ed treadmill training on cardiova scular regulation in individuals with motor-complete SCI. Spinal Cord. 2005;43(11):664–673. 38 Yang YR, Yen JG, Wanq RY, Yen LL, Lieu FK. Gait outcomes after additional backward walking training in patients with stoke: a randomized controlled trial. Clin Rehabil. 2005;19(3):264–273. 39 Phadke CP. Immediate effects of a single inclined treadmill walking session on level ground walking in individuals after stroke. Am J Phys Med Rehabil. 2012;91(3):337–345. 40 Sousa CO, Barela JA, Prado-Medeiros CL, Salvini TF, Barela AM. Gait training with partial body weight support during over ground walking for individuals with chronic stroke: a pilot study. J Neuro eng Rehabil. 2011;24(8):48. 41 Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke. 1998;29(6):1122–1128. 42 Glatthorn JF, Gouge S, Nussbaumer S, Stauffacher S, Impellizzeri FM, Maffiuletti NA. Validity and reliability of Optojump photoelectric cells for estimating vertical jump height. J Strength Cond Res. 2011;25(2):556–560. 43 De Wit DC, Buurke JH, Nijlant JM, Ijzerman MJ, Hermens HJ. The effect of an ankle-foot orthosis on walking ability in chronic stroke patients: a randomized controlled trial. Clin Rehabil. 2004;18(5):550–557. 44 Ng SS, Hui-Chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor
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capacities in people with chronic stroke. Arch Phys Med Rehabil. 2005;86(8):1641–1647. Flansbjer UB, Holmba¨ck 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. Patterson SL, Rodgers MM, Macko RF, Forrester LW. Effect of treadmill exercise training on spatial and temporal gait parameters in subjects with chronic stroke: a preliminary report. J Rehabil Res Dev. 2008;45(2):221–228. Ribeiro T, Britto H, Oliveira D, Silva E, Galva˜o E, Lindquist A. Effects of treadmill training with partial body weight support and the proprioceptive neuromuscular facilitation method on hemiparetic gait: a randomized controlled study. Eur J Phys Rehabil Med. 2013;49(4):451–461. Chen G, Patten C, Kothari DH, Zajac FE. Gait deviations associated with post-stroke hemiparesis: improvement during treadmill walking using weight support, speed, support stiffness, and handrail hold. Gait Posture. 2005;22(1): 57–62. Leroux A, Pinet H, Nadeau S. Task-oriented intervention in chronic stroke: changes in clinical and laboratory measures of balance and mobility. Am J Phys Med Rehabil. 2006;85(10): 820–830. Outermans JC, van Peppen RP, Wittink H, Takken T, Kwakkel G. Effects of a high-intensity task-oriented training on gait performance early after stroke: a pilot study. Clin Rehabil. 2010;24(11):979–987. Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF. Treadmill training is effective for ambulatory adults with stroke: a systematic review. J Physiother. 2013;59(2):73–80.
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Department of Physical Therapy, Bundang Jesaeng Hospital, Seongnam, Republic of Korea, 2Department of Physical Therapy, College of Medical Sciences, Jeonju University, Republic of Korea, 3Department of Physical Therapy, Hallym College, Chuncheon, Republic of Korea Background: Generally, treadmill-walking training focuses on weight bearing and the speed of walking. However, changes in direction, speed, and slope while walking require adaptation. Objective: The effects of task-oriented treadmill-walking training (TOTWT) on the walking ability of stroke patients were evaluated. Methods: Subjects were randomly divided into two groups: the task-oriented treadmill-walking training (TOTWT) group and the conventional treadmill-walking training (CTWT) group. Evaluation was performed before the commencement of the training and again 4 and 8 wk after training was initiated. The OptoGait system measured gait parameters. The Timed Up and Go test and 6-min walk test were also performed. Results: Within each group, both the TOTWT and the CTWT groups significantly differed before and after the intervention in all tests (P v 0.05); the CTWT group showed greater improvement in all tests following TOTWT (P v 0.05). Conclusion: TOTWT improves gait and rehabilitation in the stroke-affected limb, and also improves general gait characteristics.
Keywords: Task-oriented, Treadmill, Gait, Stroke
Introduction Walking is the most basic of human activities, moving the body from one location to another.1 The walking ability of stroke patients greatly affects their quality of everyday life.2 Although the walking ability of some stroke patients improves with time, it remains limited in others, affecting their independence and endurance in activities inside and outside the home.3 Therefore, the improvement of walking ability of stroke patients is an important goal in rehabilitation, to aid their recovery and independence.4 Treatment methods to improve stroke patients’ walking ability include proprioceptive neuromuscular facilitation,5 Bobath neurodevelopmental treatment,6 training in functional tasks similar to activities of daily living,7,8 and treadmill gait training.9 The task-oriented training proposed by Carr and Shepherd involves functional tasks and movements that patients need to perform in their daily environments.10 According to some studies, task-oriented training is better than other methods in improving stroke
Correspondence to: Youngkeun Woo, Department of Physical Therapy, College of Medical Sciences, Jeonju University, 303, Cheonjam-ro, Wansan-gu, Jeonju 560-759, Republic of Korea. Email: [email protected]
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patients’ walking ability.2,11 In the clinical setting, treadmill walking has been evaluated through the monitoring of walking strides. This can be easily performed as treadmill walking allows for repetitive strides, which are not always possible with walking over ground. Moreover, repetitive treadmill walking stimulates functional weight support and balance of the basic components of walking.2,12–15 Treadmill training usually focuses on the improvement of walking speed of stroke patients through speed-dependent methods.16–18 Furthermore, treadmill training with partial weight support focuses on strengthening and retraining motor control of gait, which also assists in standing.19 Thomas and Fast20 and Threlkeld et al. (1989)21 noted improved balance and walking ability after backward walking training in conjunction with improved lower limb strength after intervention.21 Thus, treadmill-walking training achieves better outcomes than ground-walking training.22 DePaul et al.23 noted improved endurance, balance, and quality of life after weight-bearing treadmill training compared with the variability of over-ground-walking training in 70 stroke patients. Treadmill treatment techniques aimed at improving postural symmetry focus on the stroke patient taking repetitive steps while extending the time of weight bearing on the affected side.24 An additional aim of Topics in Stroke Rehabilitation
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such techniques is to improve the patient’s gait by providing sensory inputs to encourage normal walking25 through repetitive walking patterns.26 Several studies questioned the functional effects of conventional treadmill gait training (i.e. repeating simple motions of the lower extremities under clinically adjusted conditions) and emphasized the advantages of ground gait training in more realistic environments.27,28 Current research on treadmill gait training utilized indoor environments; outdoor factors, such as slope, direction, and speed, were not considered, despite the focus on improving gait in stroke patients.29 Shumway-Cook et al.30 suggested that a prerequisite for community walking is the ability to perform tasks on irregular ground surfaces, slopes, and stairways. People in community settings generally have to perform diverse tasks at different elevations and clearances, and programs designed to reflect these complex tasks are needed for stroke patients who lack mobility.31,32 Therefore, this study examined the effects of diversified task-oriented treadmill gait training on stroke patients’ walking ability. The tasks included changes in speed, gradient, weight bearing, and direction on a treadmill.
Methods Participants The study included 40 stroke patients admitted to B Hospital in Bundang, Korea, between June and August 2013 and who received physical therapy. The goals of the study were explained, and all agreed to participate. The study was approved by the Bronco Memorial Hospital Institutional Review Board (IRB) (RTC2013-AB-003). The selection criteria were as follows: (1) post-stroke duration of at least 3 but not more than 24 months, (2) no serious visual disorder, field defect, or hearing impairment, as determined by the doctor in charge, (3) score on the Mini-Mental State Examination not lower than 24, (4) ability to walk independently without any walking aid, (5) functional ambulation category 4 or 5, (6) understanding of the procedure and purpose of the study, and voluntary participation (Table 1). Subjects were randomly assigned to two groups to minimize bias. Each selected a card with a number between 1 and 44. The cards were placed in a box to confirm equal opportunity for card selection. Odd numbers were assigned to the task-oriented treadmill-walking training (TOTWT) group, and even numbers to the conventional treadmill-walking training (CTWT) group. Each group of 22 subjects was evaluated before training was initiated, and again 4 and 8 weeks after training began. Two patients in 448 2
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Table 1 General characteristics of the subjects (N540) Group Variables
TOTWT (n520) CTWT (n520) T
P
Height (cm) Weight (kg) Age (year) MMSE-K (score) Onset (months)
167.65+ 7.56 62.70+ 8.75 50.70+ 15.16 27.60+ 1.79 14.25+ 6.27
ns ns ns ns ns P
MAS G0 G1 G1z Gender Male Female Diagnosis Infarction Hemorrhage Side of brain lesion Right Left FAC 4 5
164.95+ 8.06 62.20+ 12.07 47.15+ 18.65 27.75+ 1.80 15.25+ 6.54
0.281 0.882 0.513 0.793 0.624 Chi2
9 (45.0%) 6 (30.0%) 5 (25.0%)
11 (55.0%) 4 (20.0%) 5 (25.0%)
0.741 ns
14 (70.0%) 6 (30.0%)
12 (60.0%) 8 (40.0%)
0.507 ns
11 (55.0%) 9 (45.0%)
12 (60.0%) 8 (40.0%)
0.749 ns
10 (50.0%) 10 (50.0%)
9 (45.0%) 11 (55.0%)
0.752 ns
15 (75%) 5 (25%)
13 (65%) 7 (35%)
0.490 ns
Values are N (%) or mean+ standard deviation; ns: not significant; TOTWT: task-oriented treadmill-walking training, CTWT: conventional treadmill-walking training, MMSE-K: Mini-Mental State Examination-Korean version, MAS: modified ashworth scale, G0: Grade 0, G1: Grade 1, G1z: Grade 1z, FAC: functional ambulatory category. General characteristics and dependent variables are calculated by independent t-test and chi-squared test.
the TOTWT group dropped out of training and two in the CTWT group were transferred to other hospitals. The remaining 40 patients completed the study.
Intervention Both groups received conservative physical therapy, including joint motion exercises, stretching, and muscle strengthening exercises for 30 minutes in the adult exercise therapy room. This was followed by TOTWT for 30 minutes, five times per week, for 8 weeks. The subjects randomly selected a program during the 1-minute rest period between treadmill training sessions, with a varying slope, speed, direction, and amount of weight support. Walking speed on the treadmill was based on and set at three times the comfortable ground-walking speed. The average speed was measured over a distance of 7 m, v2 m each at the beginning and end of the walkway, to account for the acceleration and deceleration phase of walking. The reliability for this test was reported as 0.87,33 and the validity was 0.78.34 Training was stopped if the subject was unable to continue for 30 minutes. Five minutes rest was permitted for a complaint of pain, or for abnormal breathing or changes in complexion (Table 2).35 Topics in Stroke Rehabilitation
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Table 2 Program of task-oriented treadmill gait training
Speed (1) Direction (2) Gradient (3) Weight support (4)
Default set
Change 1
Change 2
Change 3
1.2 km/hour Forward 0uu 40%
1.3 km/hour Backward 2.5uu 30%
1.4 km/hour Forward 5uu 20%
1.5 km/hour Backward 10uu 10%
Task-oriented treadmill-walking training This study used TOTWT, with changes in any two of the following four independent variables: (1) speed, (2) direction, (3) slope gradient, and (4) weight bearing. Each patient selected six pieces of paper with the letters A–F in random order to perform the exercises on the treadmill. Any piece of paper selected once was not selected again. The subjects exercised for 30 minutes, performing six tasks, each one for 4 minutes, followed by rest for 1 minute. The patient prepared for the next task during the 1 minute rest. The six tasks in the program were A: 1, 2 (changes in speed and direction); B: 1, 3 (changes in speed and gradient); C: 1, 4 (changes in speed and weight bearing); D: 2, 3 (changes in direction and gradient); E: 2, 4 (changes in direction and weight bearing); and F: 3, 4 (changes in gradient and weight bearing). A patient who selected tasks in the order of A through F performed these as follows: (1) Task A – backward training for 4 minutes at a speed of 1.3 km/hour, a gradient of 0uu, and 40% weight bearing, followed by rest for 1 minute; (2) Task B – forward training for 4 minutes at a speed of 1.4 km/ hour, a gradient of 2.5uu, and 40% weight bearing, followed by rest for 1 minute; (3) Task C – forward training for 4 minutes at a speed of 1.5 km/hour, a gradient of 0uu, and 30% weight bearing, followed by rest for 1 minute; (4) Task D – backward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 2.5uu, and 40% weight bearing, followed by rest for 1 minute; (5) Task E – forward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 0uu, and 30% weight bearing, followed by rest for 1 minute; (6) Task F – forward training for 4 minutes at a speed of 1.2 km/hour, a gradient of 2.5uu, and 20% weight bearing, followed by rest for 1 minute. Subjects selfselected and applied different speeds, directions, slope gradients, and weight bearing during treadmill gait training. Ground-walking was analyzed for the middle 7 of 11 m, excluding acceleration and deceleration phases. Subjects were verbally instructed to ‘walk at your comfortable speed’.36 The speed was increased by 0.1 km/hour each time a change was made.37 Each subject was instructed to walk steadily for 20 seconds on the treadmill. The direction of 446
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walking was changed between forward and backward,38 the gradient of the treadmill was increased from 0uu to 2.5uu, 5uu, and 10uu,39 and the degree of weight bearing by the subject was gradually reduced from 40% to 30%, 20%, and 10%.40,41 Three physical therapists implemented the TOTWT for each subject. One stood right behind the subject to help with weight bearing on either the unaffected or affected lower extremity and with shifting weight between the two lower extremities. The other two therapists stood at either side of the subject to assist with stepping and motor control during the swing and stance phases while manually correcting walking patterns. The subject was verbally instructed to adopt appropriate walking patterns (Fig. 1).
Figure 1 Task-oriented treadmill-walking training (TOTWT).
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Conventional treadmill-walking training Variable speed, direction, slope gradient, and weight bearing were not applied during CTWT. Comfortable walking speed was set in the same manner as in TOTWT by verbal instruction, and was again three times faster. Three physical therapists assisted: one stood behind the subject to help with contralateral and ipsilateral weight bearing by supporting the trunk; two were positioned outside of both legs during the stance and swing phases and provided a secondary control exercise by correcting the gait pattern. We promote proper gait patterns in subjects with voice prompts by researchers in training.
Outcome Measures Clinical assessments Timed Up and Go (TUG) test The TUG test measured the time taken for a patient sitting on a 46 cm high chair to stand up at a verbal command, walk 3 m, pass a halfway point, turn around toward the unaffected side, then return to the chair and adopt the original posture. Each patient completed the TUG test three times for an average value.42 The test-retest reliability for the stroke patients was high (r50.95).43 6-minute walk test The 6-minute walk test was conducted in the hospital corridor. Each subject walked unaided back and forth along a 25-m walkway for 6 minutes, with markers placed on the floor at intervals of 1 m. The total distance walked was measured using the markers.44 The patients were allowed to self-adjust walking speeds and rest times. The intra-rater reliability for the stroke patients was r50.99.18
Gait analysis OptoGait OptoGait (Microgate Srl, Bolzano, Italy) was used to collect data on walking patterns for quantitative analysis. Each subject was instructed to walk 7 m at a comfortable speed. Sensors on the feet collected information on walking variables while the subject walked for 3 m on a 7-m platform, excluding the initial 2 m in the accelerating phase and the last 2 m in the decelerating phase. Stride length, stride time, cadence, and average walking speeds were analyzed. The affected lower extremity was assessed for step length, single support, step time, and average walking speed. To correct for inter-tester differences, one skilled physical therapist took all the measurements. The patients used no walking aids, such as body weight supports or suspension systems. The intra-rater reliability was r50.99, and the test-retest reliability was r50.98–0.99.45 450
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Statistical analysis All statistical analyses in this study were conducted using PASW (Predictive Analytics Software) 18.0 for Windows. Chi-squared testing analyzed the two groups for spasticity, gender, diagnoses, and the side of brain lesions. Heights, weights, Korean MiniMental State Examination scores, and time since the onset of the disease were analyzed through independent sample t-tests. Normality was tested using Kolmorogov–Smirnov tests. Repeated analysis of variance (ANOVA) examined differences within the two groups at 0, 4, and 8 weeks of training, as well as differences between the two groups attributable to therapeutic exercise methods at the same time points. The statistical significance level of all data was set to alpha50.05.
Results Comparison of changes in the general characteristics of walking before the experiment, and 4 and 8 weeks after the experiment Stride lengths of the TOTWT group increased significantly, from 67.51+ 20.16 cm before the experiment, to 87.64+ 19.94 cm 4 weeks after the experiment, and to 106.85+ 23.53 cm 8 weeks after the experiment (P50.000). Stride lengths of the CTWT group also increased significantly, from 66.74+ 23.13 cm before the experiment, to 78.61+ 22.00 cm 4 weeks later, and 89.89+ 22.30 cm 8 weeks later (P50.000). The changes in the stride lengths at the 4- (P50.004) and 8-week (P50.008) periods were statistically significantly different between the two groups. The gait cycle of the TOTWT group decreased significantly, from 2.50+ 0.92 seconds before the experiment, to 1.72+ 0.47 seconds 4 weeks after the experiment, and to 1.44+ 0.45 seconds 8 weeks after the experiment (P50.000). The gait cycle of the CTWT group also decreased significantly, from 2.51+ 0.96 seconds before the experiment, to 2.14+ 0.81 seconds 4 weeks later, and to 1.66+ 0.58 seconds 8 weeks later (P50.000). The changes in the gait cycle at the 4(P50.015) and 8-week (P50.008) periods were statistically significantly different between the two groups. Cadence of the TOTWT group increased significantly, from 0.51+ 0.09 step/second before the experiment, to 0.68+ 0.13 step/seconds 4 weeks after the experiment, and to 0.78+ 0.09 step/second 8 weeks after the experiment (P50.000). The cadence of the CTWT group also increased significantly, from 0.51+ 0.09 steps/ second before the experiment, to 0.60+ 0.11 step/ second 4 weeks later, and 0.65+ 0.08 step/second 8 weeks later (P50.000). The changes in the cadence at the 4- (P50.018) and 8-week (P50.033) periods were Topics in Stroke Rehabilitation
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statistically significantly different between the two groups. Average speed of the TOTWT group increased significantly, from 0.60+ 0.22 m/second before the experiment, to 0.78+ 0.25 m/second 4 weeks after the experiment, and to 1.00+ 0.27 m/second 8 weeks after the experiment (P50.000). Average speed of the CTWT group also increased significantly, from 0.60+ 0.15 m/second before the experiment, to 0.69+ 0.18 m/second 4 weeks later, and 0.83+ 0.19 m/ second 8 weeks later (P50.000). The changes in the average speed at the 4- (P50.008) and 8-week (P50.007) periods were statistically significantly different between the two groups (Table 3).
Comparison of changes in walking characteristics of the affected side before the experiment, and 4 and 8 weeks after the experiment Affected step length of the TOTWT group increased significantly, from 33.58+ 11.11 cm before the experiment, to 43.32+ 10.87 cm 4 weeks after the experiment, and to 53.91+ 12.94 cm 8 weeks after the experiment (P50.000). Affected step length of the CTWT group also increased significantly, from 33.30+ 11.49 cm before the experiment, to 39.18+ 11.04 cm 4 weeks later, and 44.85+ 13.18 cm 8 weeks later (P50.000). Changes in the affected step length at the 4- (P50.037) and 8-week (P50.022) periods were statistically significantly different between the two groups. Affected single support of the TOTWT group increased significantly, from 26.23+ 8.69% before the experiment, to
37.60+ 6.05% 4 weeks after the experiment, and to 40.25 + 6.30% 8 weeks after the experiment (P50.000). Affected single support of the CTWT group also increased significantly, from 29.62+ 5.96% before the experiment, to 36.94+ 5.36% 4 weeks later, and 37.09+ 6.12% 8 weeks later (P50.000). Changes in the affected single support at the 4- (P50.039) and 8-week (P50.031) periods were statistically significantly different between the two groups. Affected step of the TOTWT group decreased significantly, from 1.23+ 0.46 seconds before the experiment, to 0.87+ 0.31 seconds 4 weeks after the experiment, and to 0.75+ 0.27 seconds 8 weeks after the experiment (P50.000). Affected step of the CTWT group also decreased significantly, from 1.24+ 0.49 seconds before the experiment, to 1.05+ 0.39 seconds 4 weeks later, and 0.84+ 0.26 seconds 8 weeks later (P50.000). Changes in the affected step at the 4- (P50.025) and 8-week (P50.048) periods were statistically significantly different between the two groups. Affected speed of the TOTWT group increased significantly, from 0.59+ 0.34 m/second before the experiment, to 0.77+ 0.37 m/second 4 weeks after the experiment, and to 0.95+ 0.36 m/second 8 weeks after the experiment (P50.000). Affected speed of the CTWT group also increased significantly, from 0.60+ 0.17 m/second before the experiment, to 0.67+ 0.19 m/second 4 weeks later, and 0.79+ 0.21 m/ second 8 weeks later (P50.000). Changes in the affected speed at the 4- (P50.036) and 8-week (P50.029) periods were statistically significantly different between the two groups (Table 4).
Table 3 Comparison of general characteristics of gait between two groups (N540) Variable SL (cm)
GC (seconds)
Cadence (step/second)
AS (m/second)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
67.51+ 20.16 87.64+ 19.94{ 106.85+ 23.53z 0.000* 2.50+ 0.92 1.72+ 0.47{ 1.44+ 0.45z 0.000* 0.51+ 0.09 0.68+ 0.13{ 0.78+ 0.09z 0.000* 0.60+ 0.22 0.78+ 0.25{ 1.00+ 0.27z 0.000*
66.74+ 23.13 78.61+ 22.00{ 89.89+ 22.30z 0.000* 2.51+ 0.96 2.14+ 0.81{ 1.66+ 0.58z 0.000* 0.51+ 0.09 0.60+ 0.11{ 0.65+ 0.08z 0.000* 0.60+ 0.15 0.69+ 0.18{ 0.83+ 0.19z 0.000*
F
P
9.386 7.722
0.0041 0.008||
6.451 7.926
0.0151 0.008||
6.092 4.893
0.0181 0.033||
7.710 8.125
0.0081 0.007||
* Pv0.05, Values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. SL: stride length; GC: gait cycle; AS: average speed; TOTWT: task-oriented treadmill-walking training; CTWT: conventional treadmillwalking training; ANOVA: analysis of variance
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Table 4 Comparison of affected side characteristics of gait between two groups (N540) Variable ASL (cm)
ASS (%)
AST (seconds)
ASp (m/second)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
33.58+ 11.11 43.32+ 10.87{ 53.91+ 12.94z 0.000* 26.23+ 8.69 37.60+ 6.05{ 40.25+ 6.30z 0.000* 1.23+ 0.46 0.87+ 0.31{ 0.75+ 0.27z 0.000* 0.59+ 0.34 0.77+ 0.37{ 0.95+ 0.36z 0.000*
33.30+ 11.49 39.18+ 11.04{ 44.85+ 13.18z 0.000* 29.62+ 5.96 36.94+ 5.36{ 37.09+ 6.12z 0.000* 1.24+ 0.49 1.05+ 0.39{ 0.84+ 0.26z 0.000* 0.60+ 0.17 0.67+ 0.19{ 0.79+ 0.21z 0.000*
F
P
4.677 5.722
0.0371 0.022||
4.577 5.033
0.0391 0.031||
5.476 4.162
0.0251 0.048||
4.738 5.125
0.0361 0.029||
* Pv0.05, values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. ASL: affected step length; ASS: affected single support; AST: affected step, ASp: affected speed, TOTWT: task-oriented treadmillwalking training, CTWT: conventional treadmill-walking training; ANOVA: analysis of variance.
Comparison of changes in the clinical gait index before the experiment, and 4 and 8 weeks after the experiment The TUG test of the TOTWT group decreased significantly, from 26.94+ 4.90 seconds before the experiment, to 23.84+ 4.79 seconds 4 weeks after the experiment, and to 19.95+ 4.89 seconds 8weeks after the experiment (P50.000). The TUG test of the CTWT group also decreased significantly, from 23.85+ 5.05 seconds before the experiment, to 22.18+ 5.65 seconds 4 weeks later and 20.03+ 5.79 seconds 8 weeks later (P50.000). Changes in the TUG test at the 4(P50.000) and 8-week (P50.000) periods were statistically significantly different between the two groups. The 6-minute walk test of the TOTWT group increased significantly, from 239.50+ 21.18 m before the experiment, to 252.95+ 22.26 minutes 4 weeks after the experiment, and to 272.30+ 21.19 m 8 weeks after the experiment (P50.000). The 6-minute walk test of the CTWT group also increased significantly, from 239.60+ 21.65 m before the experiment, to 243.45+ 19.77 m 4 weeks later, and 255.35+ 20.14 m 8 weeks later (P50.000). Changes in the 6-minute walk test at the 4- (P50.003) and 8-week (P50.000) periods were statistically significantly different between the two groups (Table 5).
Discussion This study was designed to verify the effectiveness of TOTWT of stroke patients in clinical settings compared to the widely used CTWT. Variations in speed, direction, gradient, and weight bearing in the TOTWT were shown to be effective in previous studies. 452 6
OptoGait was used to examine walking variables and showed statistically significant improvements. This is consistent with a study by Patterson et al.,46 in which stroke patients showed significant differences in step length on the affected side following treadmill training. The increases in stride and step lengths on the affected side in this study are attributed to performing diverse tasks on the treadmill. These increase the range of motion of the affected lower extremity and improve step lengths on the affected side. They also improve step length on the unaffected side and eventually increase stride length. Affected side single-support phase analysis showed significant differences in length. Cadence analysis showed significant differences. The results are consistent with those of Yang et al.,8 in which the average walking speed, cadence, and stride length of an experimental group that underwent task-oriented training significantly improved. Diverse treadmill tasks increased the weight-bearing time on the affected side and shortened the support time for both extremities. This probably limited the reduction in cadence in stroke patients, which is attributable to the shortening of the weight bearing time on the affected side and the increase in the support time for both extremities. Ribeiro et al.47 studied the effects of weight-bearing treadmill gait training and proprioceptive neuromuscular facilitation in hemiplegia patients; the symmetry of patient gaits significantly improved, consistent with the results of this study. The authors attributed the improvement in gait symmetry to the task-oriented gait training, which helps to improve Topics in Stroke Rehabilitation
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Table 5 Comparison of change of clinical gait index between two groups (N540) Variable TUG (seconds)
6 minutes WT (m)
0 week 4 weeks 8 weeks P 0 week 4 weeks 8 weeks P
TOTWT (n520)
CTWT (n520)
26.94+ 4.90 23.84+ 4.79{ 19.95+ 4.89z 0.000* 239.50+ 21.18 252.95+ 22.26{ 272.30+ 21.19z 0.000*
23.85+ 5.05 22.18+ 5.65{ 20.03+ 5.79z 0.000* 239.60+ 21.65 243.45+ 19.77{ 255.35+ 20.14z 0.000*
F
P
25.259 148.678
0.0001 0.000||
10.065 17.170
0.0031 0.000||
* Pv0.05, values are mean+ standard deviation. { significantly different compared with 0–4 weeks. z significantly different compared with 4–8 weeks. 1 significantly different compared with 0–4 weeks between two groups. | significantly different compared with 4–8 weeks between two groups by repeated ANOVA. TUG: Timed Up and Go test; 6-minute WT: 6-minute walk test; TOTWT: task-oriented treadmill-walking training; CTWT: conventional treadmill-walking training; ANOVA: analysis of variance.
muscular strength in single-support phases. The step and stride times of the affected side significantly differed in our study, consistent with findings by Chen et al.48 These authors evaluated gait cycles, hip joint angles, and knee joint angles of eight stroke patients with different degrees of spasticity. These were measured at different average walking speeds, with and without weight bearing, and with and without handrails. As weight bearing on the affected side increased, the swing-phase time decreased, and the asymmetry of the gait decreased. When weight bearing and handrails were used in combination, gait components, such as single support, average walking speeds, and gait cycles, improved. They attributed their findings to increased trunk stability due to TOTWT, with increased swing-phase time due to weight bearing. This reduced gait asymmetry. In this study, the walking speeds of the affected side and the average walking speeds differed significantly. This is consistent with a study by Yang et al.,8 in which muscle strength increased by 61.5% and average walking speed increased after taskoriented training for 4 weeks. The authors attributed their results to increased muscle strength due to TOTWT. This enhanced and smoothed the swing and stance phases of the affected and unaffected lower extremities, with resulting increases in stride lengths and cadences. There were significant differences in the clinical walking evaluation indexes obtained through the TUG tests. These results are consistent with a study by Leroux et al.49 of 44 stroke patients, who were divided into experimental and control groups. The experimental group took part in a task-oriented exercise program; the control group did not take part in any exercise program. Both the balance and the mobility of the experimental group significantly increased, and there were high correlations between postural stability and the results of the TUG test. 450
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These results suggest that task-oriented training on a treadmill likely reduces weight bearing during the stance phases; this stabilizes the trunk, thereby improving the ability to control lower extremity movements. As a result, average walking speeds increase. The results of the 6-minute walk tests also revealed significant differences. This is consistent with a study by Outermans et al.,50 in which the walking ability of a group that underwent task-oriented training improved, and also a study by Polese et al.,51 in which the walking speed and step lengths of stroke patients increased after they used a treadmill. These results suggest that taskoriented treadmill gait training can improve trunk control, reduce muscle tone, improve lower extremity movement control, and increase muscle strength, thereby enabling patients to walk longer distances. A limitation of the current study is that the daily activities/tasks of the experimental group could not be completely controlled. In addition, the results cannot be generalized because the number of patients included in the study was small, and the study comprised only those stroke patients who could walk. Future follow-up studies should be conducted after task-oriented treadmill gait training to determine whether the training is transferred to learning. Task-oriented treadmill-walking training in this study is one of the various methods that can be used to improve the walking ability of stroke patients. More studies of TOTWT are needed, to include patients with brain lesions and potentially higher levels of ability.
Conclusions This study examined whether weight-bearing TOTWT, based on varying speed, direction, slope gradient, and weight bearing, improved walking ability of stroke patients. The walking ability of the TOTWT group increased. The TOTWT is effective as a rehabilitation training program to improve general characteristics of stroke patients’ gaits, 4537
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characteristics of their affected lower extremity during walking, and their clinical walking evaluation indexes.
Disclaimer Statements Contributors OH Kwon performed the experiments, data analysis, and manuscript preparation. YK Woo developed the idea for the study, directed experiments, and drafted the manuscript. JS Lee directed experiments, and guided data analysis. KH Kim performed the experiments and data analysis. All authors read and approved the final manuscript. Funding None. Conflicts of interest None. Ethics approval This study was approved by the Bronco Memorial Hospital Institutional Review Board (IRB) (RTC2013-AB-003).
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