| | Locomotor Treadmill Training With Partial Body-Weight Support Before Overground Gait in Adults With Acute Stroke: A Pilot StudyAbstract McCain KJ, Pollo FE, Baum BS, Coleman SC, Baker S, Smith PS. Locomotor treadmill training with partial body-weight support before overground gait in adults with acute stroke: a pilot study. ObjectiveTo investigate the impact of locomotor treadmill training with partial body-weight support (BWS) before the initiation of overground gait for adults less than 6 weeks poststroke. DesignParallel group, posttest only. SettingInpatient rehabilitation center. ParticipantsAdults after first stroke admitted to an inpatient rehabilitation unit: treadmill group (n=7) and comparison group (n=7). InterventionsLocomotor treadmill training with partial BWS or traditional gait training methods. Main Outcome MeasuresGait kinematics, symmetry, velocity, and endurance at least 6 months postinsult. ResultsData from 3-dimensional gait analysis and 6-minute walk test (6MWT) supported improved gait for adults postacute stroke who practiced gait on a treadmill before walking over ground. Gait analysis showed increased knee flexion during swing and absence of knee hyperextension in stance for the treadmill group. In addition, more normal ankle kinematics at initial contact and terminal stance were observed in the treadmill group. Improved gait symmetry in the treadmill group was confirmed by measures of single support time, hip flexion at initial contact, maximum knee flexion, and maximum knee extension during stance. The treadmill group also walked further and faster in the 6MWT than the comparison group. ConclusionsApplication of locomotor treadmill training with partial BWS before overground gait training may be more effective in establishing symmetric and efficient gait in adults postacute stroke than traditional gait training methods in acute rehabilitation. EACH YEAR ABOUT 700,000 people suffer a new or recurrent stroke in the United States.1 Approximately 5.5 million U.S. stroke survivors are alive today, and most have some permanent stroke-related disability.2 Gait impairment is common after cerebrovascular accident (CVA), with many stroke survivors living with residual gait problems, despite extensive rehabilitation.3 Gait after stroke is perhaps best distinguished by asymmetry.4, 5, 6, 7, 8, 9, 10 Characteristics of gait after stroke that have been identified include reduced stride and step length, wide base of support, increased stance periods, and altered swing phase periods.11, 12, 13 Knee hyperextension during stance phase on the affected limb is common,4, 7 as is impaired ankle dorsiflexion control.4, 14 Reports of gait velocity after stroke vary greatly, depending on factors such as time postonset and distance measured. Velocity for a group of persons in the acute phase of recovery was reported at .29±.27m/s,15 whereas velocity of .58±.38m/s was reported for a diverse group of subjects with hemiplegia in the chronic stage of recovery.9 In contrast, velocity for healthy adults has been reported at approximately 1.49m/s.16 It has also been shown that the metabolic costs of walking are considerably higher for persons with hemiplegia, with gait requiring between 50% to 67% more metabolic energy expenditure than for persons without hemiplegia walking at the same velocity.12 The characteristic slow, asymmetric, and inefficient pattern of walking for a person after stroke often limits his/her ability to resume previous roles within the home and the community.17 There is no consensus regarding the optimal treatment to reestablish normative gait after stroke. A variety of techniques are applied in clinics, from traditional techniques to newer technologies.18 Many clinicians throughout the world use the Bobath concept, also known as neurodevelopmental treatment.19 Unfortunately, few treatments have strong evidence to support or refute their use in gait rehabilitation after stroke.19, 20 There is a growing body of evidence that locomotor treadmill training with partial body-weight support (BWS) may be an effective method of improving gait quality, velocity, and trunk stability after stroke.21, 22, 23 The application of locomotor training involving BWS in subjects with neurologic impairment was first proposed in 1985,24 with early clinical applications in stroke and spinal cord injury.24, 25 Since those initial studies, small clinical trials have been performed to establish the feasibility and safety of the intervention.26, 27, 28, 29, 30 There is also increasing evidence that treadmill walking with BWS is superior to conventional training approaches for locomotor training after stroke.21, 27 Several advantages of gait training on the treadmill with BWS have been highlighted in these early studies. The intervention allows the manipulation of postural instability and balance through a weight-bearing progression while facilitating stepping.31 It also makes gait training possible with people who cannot safely be guarded during overground gait training,32 and the intervention can be initiated earlier than conventional methods.33 Locomotor treadmill training with partial BWS has been shown to reduce the cardiovascular demands on persons after stroke34, 35 and also has the advantage of eliminating the fear of falling that is common.35, 36 It has been shown that earlier gait recovery after stroke is associated with future gait independence37 and that task-specific interventions that are applied early and intensively may be the most effective.38 Studies have reported initiation of locomotor treadmill training with BWS early after stroke onset,23, 28, 30, 39 but the definition of early varied greatly (from weeks to a year), and the timing and training of the overground component of gait were not well addressed. There appears to be a general consensus that early intervention is optimal to encourage motor recovery after stroke,40, 41, 42, 43 yet few studies have attempted to begin locomotor training on the treadmill during the acute period of recovery after stroke. To our knowledge, this study is the first to report treadmill training before overground gait has been attempted. Therefore, the purpose of this study was to investigate the impact of locomotor treadmill training with partial BWS on participants in the acute stage of recovery from stroke who began gait training on the treadmill with BWS before therapeutic training for walking overground. The research hypothesis was that participants poststroke who are gait trained in the acute phase of recovery using locomotor treadmill training with partial BWS, before the initiation of overground walking, will have improved gait kinematics, gait symmetry, gait velocity, and gait endurance 6 months or greater after stroke onset compared with a group of participants who received traditional gait training in the acute phase of rehabilitation. Methods  Study Design The institutional review board of Baylor Institute for Rehabilitation approved this study. People were entered without regard to race or sex and were not excluded based on funding status. Each person, or his/her designated representative, signed a consent form before the initiation of the study. The study was a parallel group, posttest design to investigate the benefits of locomotor training with partial BWS, before the initiation of overground walking, in a population of adults poststroke. Study Sample Persons were recruited for the treadmill group from a convenience sample among persons recovering from stroke admitted to a satellite unit of Baylor Institute for Rehabilitation. (The equipment necessary to implement the locomotor treadmill training with partial BWS was located on this satellite unit.) All people who met the inclusion criteria on this unit between October 2005 and April 2006 were approached concerning participation in the study. A total of 11 persons were approached, 4 of whom were ultimately disqualified (1 for cerebellar lesion, 1 for bilateral lesions, 1 for size issues, 1 for uncontrolled blood pressure). Seven people were enrolled and completed the study protocol. Participants for the comparison group were also recruited from a convenience sample from adults poststroke who received traditional inpatient therapy services on the main campus at Baylor Institute for Rehabilitation. (The main campus location did not have access to the locomotor treadmill training unit.) Persons in the comparison group received inpatient services between September 2005 and June 2006. A total of 9 people were recruited and assessed. Two were disqualified, one for date of stroke and one for site of stroke. The inclusion and exclusion criteria for this pilot study are outlined in table 1. Table 2 includes the descriptive details of the participants, including age, length of stay on the rehabilitation unit, and FIM instrument scores. The FIM has been used extensively with subjects with stroke on rehabilitation units44, 45 and was used to validate the similarities between the groups. Table 3 describes the type of stroke and the side and location of the lesion, along with medical comorbidities of the participants. | | |  | Inclusion Criteria | Exclusion Criteria | |
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| •Men or women 18–85y of age •<6wk after first time ischemic or hemorrhagic stroke •Able to sit independently at least 3min •Able to stand with or without assistance •Able to give consent or have available authorized surrogate for consent •No significant therapeutic gait practice before start of study (>2 on locomotion section of FIM) •2–8wk of inpatient rehabilitation LOS at Baylor Institute for Rehabilitation | •Cerebellar or bilateral stroke •Nonambulatory before stroke •Significant cognitive impairment (<2 on comm/soc cog section of FIM) •Severe cardiac problems (ie, CHF, uncontrolled hypertension) •Weight greater >120kg (265lb) •Presence of comorbidities or health conditions that would affect gait training •Recent myocardial infarct (4wk) •Able to complete 5 or more full heel raises with affected ankle in standing with knee extended with no more than 1–2 fingers on support surface at time of enrollment in treadmill group (to exclude participants who would likely not require lower-extremity bracing) | | | | |
| | | | Characteristics | Treadmill (n=7) | Comparison (n=7) | P | |
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| Mean ± SD | Min–Max | Mean ± SD | Min–Max | |
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| Age (y) | 57.0±17.6 | 28–74 | 61.6±8.2 | 50–72 | .949 | | | Rehabilitation LOS (d) | 28.0±1.3 | 26–30 | 39.0±15.6 | 22–63 | .401 | | | Initial transfer FIM⁎ | 5.1±2.9 | 2–9 | 7.3±2.4 | 3–10 | .192 | | | Initial comm/soc cog FIM† | 19.3±5.6 | 12–28 | 17.1±6.6 | 9–25 | .608 | | | Initial gait FIM‡ | 0.71±0.49 | 0–1 | 1.00±0.58 | 0–2 | .375 | | | Discharge gait FIM | 5.29±1.11 | 4–7 | 4.00±1.29 | 2–6 | .086 | | | Total gait training (min)§ | 437±102 | 270–540 | 677±372 | 300–1290 | .306 | | | Days postinjury∥ | 216.0±41.8 | 184–305 | 246.0±60.7 | 186–335 | .443 | | | | |
| ⁎ For transfer section (bed, chair, wheelchair, toilet, tub and shower transfers), maximum possible points is 21. †For communication and social cognition sections (comprehension, expression, social interaction, problem solving, memory), maximum possible points is 35. ‡For gait item only (no stairs), maximum possible points is 7. §Total number of minutes spent on gait training during inpatient rehabilitation stay. ∥Number of days poststroke when testing was completed. |
| | | | Subject | Group | Etiology | Stroke Location | Comorbidity | |
|---|
| 101 | T | H | R intraparenchymal fronto-temporal | Migraines | | | 102 | T | I | L temporal lobe | HTN, DM, CAD, CABG | | | 104 | T | H | L thalamus | HTN, DM | | | 106 | T | H | R thalamus and pons | Cardiomyopathy | | | 107 | T | I | L centrum ovale | Cardiomyopathy | | | 110 | T | I | L middle cerebral artery | HTN, hyperlipidemia, tobacco, | | | 111 | T | H | R basal ganglia, internal capsule | HTN | | | 202 | C | H | L parietal intracerebral | Chronic back and neck pain | | | 203 | C | I | L pons | DM, HTN, obesity, tobacco/ETOH | | | 204 | C | I | L precentral and postcentral gyrus | Noncontributory | | | 205 | C | H | R basal ganglia | DM, HTN, tobacco/ETOH | | | 206 | C | I | L internal capsule | HTN | | | 208 | C | I | Sup frontal, R parietal, sup occipital | Atherosclerosis | | | 209 | C | I | L basal ganglia | DM, HTN | | | | |
Interventions Treadmill group Thirty minutes of each subject’s daily scheduled 3-hour therapy program was allocated for gait training and implemented by a physical therapist trained in the research protocol. An additional 30 minutes of daily physical therapy was allocated for other nongait activities, such as bed mobility, transfers, strengthening, and balance training. All physical therapists involved in the study were trained in the protocol and documented participants’ daily compliance with the protocol. In addition, the entire rehabilitation team was educated concerning the experimental study protocol to ensure compliance when participants were not working with therapy staff. All participants received an identical lower-extremity orthosis to improve ankle and foot stability during treadmill and overground gait training. The orthosis of choice was a custom-fabricated polypropylene ankle-foot orthosis (AFO) with a double-adjustable ankle joint. This type of joint provided maximum adjustability to control forces during loading and stance while maintaining movement at the ankle, allowing for close replication of normative gait mechanics. The first gait training session for these participants was on the treadmill. No overground gait training was done before gait training on the treadmill. The initial BWS amount was set at 30%, and the speed of the treadmill was set at 1.12km/h (0.7mph). These initial training parameters were chosen based on the literature22, 23 as well as clinical experience. The goal in subsequent sessions (ie, days) was to reduce the amount of BWS by 5%. Efforts were also made to progressively increase the speed of the treadmill in .16-km/h (0.1-mph) increments after a participant could tolerate 2 consecutive bouts of at least 3 minutes minimum at the same speed. Speed and BWS were adjusted based on participant response to the progression, primarily the amount of assistance required to advance the more involved lower extremity. Participants were allowed to take rest breaks as needed during the treadmill training, with a goal of 3 minutes minimum for each gait effort or bout. Treadmill training was discontinued when participants were able to walk 10 continuous minutes at a speed of 2.4km/h (1.5mph) without a rest and without BWS (vest on for safety), upper-extremity support, or assistance for weight shift or lower-extremity control. All participants in the treadmill group continued treadmill training throughout their inpatient rehabilitation stays and all achieved full weight bearing on the treadmill—that is, 0% BWS. (Subject 104 reached 2.4km/h on the treadmill the day before discharge from rehabilitation.) During the training sessions, 2 trained staff members assisted each participant to facilitate normal loading, stance, and swing components for the affected lower extremity and to facilitate normal weight shift at the pelvis. Participants were not allowed to hold onto the treadmill railing once the target speed was reached during each training session. Liberal use of verbal cues was used during the training to facilitate the best gait pattern possible. To ensure participant safety, vital signs, including heart rate, blood pressure, and oxygen saturation were monitored before and after the training. Treatment was discontinued or deferred if abnormal vital signs were detected, and the participant’s physician was notified. All participants were instructed that they could terminate the treatment at any time during training. Overground gait was initiated when a participant walked for at least 3 minutes on the treadmill with no more than 10% BWS and with minimal assistance or less to advance the hemiparetic leg at a speed of 1.3km/h (0.8mph) or greater. A single-point cane was used when overground gait was initiated. No harness or other support apparatus was used during overground gait training. Once a participant began walking over ground, the 30-minute gait training session was divided, with 20 minutes allocated to practice on the treadmill and 10 minutes to overground gait training. Table 4 details the treadmill training parameters for all participants. All participants continued use of the AFO through the inpatient rehabilitation stay. At the time of the 6-month reassessment, all had discontinued use of the AFO, either by direction of a physical therapist or by personal choice. Likewise, all participants no longer used the single-point cane. Comparison group Participants in the comparison group received daily gait training in traditional gait training interventions during the scheduled 3-hour therapy program while inpatients on the rehabilitation unit (see table 2 for total number of minutes spent in gait training). The traditional gait training routine included activities such as pregait activities, including sitting balance, standing balance, weight shifting in standing, walking in the hemi-bar or parallel bars, strengthening, and walking with 1 of several types of assistive devices including hemi walkers, quad canes, and walkers. Progression with gait training, such as changing from 1 assistive device to another, was determined by participant improvement and therapist discretion. Participants in the comparison group were all fitted with a custom AFO during the inpatient rehabilitation stay. One participant was fitted with a polypropylene AFO with a double adjustable ankle joint, and the remaining participants were fitted with polypropylene AFOs with hinged ankle joints. The treating physician and physical therapist made the determination of AFO type. At the time of testing, all but 1 of the comparison group participants required use of the AFO for safe community gait. Data Collection Data collection was performed for all participants at least 6 months poststroke (see table 2 for details). Three-dimensional (3D) gait analysis was recorded using a 12-camera Vicon Motion Capture System,a and Vicon Bodybuilder softwarea was used to process the data. Reflective markers were placed bilaterally over the anterior superior iliac spine, the posterior superior iliac spine, the lateral and medial knee epicondyles, the lateral and medial ankle malleoli, the head of the third metatarsal, and the posterior portion of the heel level with the third metatarsal head marker. Markers were also attached laterally to the midthigh in line with the greater trochanter and lateral knee epicondyle markers and on the lower leg in line with the lateral knee epicondyle and lateral malleoli markers. Once markers were positioned, data were collected as participants walked over a level 12-m walkway without an AFO or assistive device or physical assistance from the physical therapist for a total of 10 trials. No practice was done before testing began for any of the participants. The total number of individual gait cycles was averaged together. Measurements included cadence, single- and double-limb support time, step length, and joint angles in the sagittal plane at the hip, knee, and ankle. To quantify symmetry between affected and unaffected limbs of the groups, the area between the sagittal plane curves was calculated, with a value of 0 indicating perfect symmetry. Figure 1 illustrates the gait symmetry of the 2 groups, with P values comparing the total area between the curves. Testing, including participant preparation, took approximately 45 minutes. Participants were given the opportunity to rest at any time throughout the testing. Two of the coauthors conducted the testing. The six-minute walk test (6MWT) has been used successfully to measure gait endurance with persons with stroke at 6 months after onset46; in this study, it was used to measure walking endurance and velocity. For the test, a trained physical therapist asked participants to walk indoors on a level surface as far as possible in a 6-minute time period. Participants were instructed to walk at a pace they felt they could sustain for 6 minutes but were also instructed that they could rest if needed. They were not given any verbal encouragement during the test. They were allowed to use AFOs and assistive devices for the test if they routinely used them in the community. Only participants in the comparison group required and used devices for safe gait in the community and for the test. Three participants used an AFO only, 3 used an AFO and a single-point cane, and one used no devices. None of the members of the treadmill group required or used an AFO or assistive device for safe gait in the community or for the test. A stopwatch was used to time the test, and distance was measured with a measuring wheel. Gait velocity was calculated from the distance measurement. Statistical Analysis Given the small sample size, the research design, and the ordinal scale FIM data, nonparametric statistics were used for all group comparisons. Data were analyzed using the Mann-Whitney U test.47 An independent t test was used to calculate the symmetry data for figure 1. Results were considered significant for a P value of less than .05. JMP by SASb was used for the statistical analysis. Results Demographic Data There were no significant statistical differences between the 2 groups with regard to key clinical characteristics (see table 2). Kinematic Data Specific kinematic parameters that are typically altered in gait after stroke and have been previously reported in the literature4, 12, 13, 14 were examined (table 5). Hip flexion at initial contact was greater in the treadmill group, although not significantly different. Maximum knee flexion was significantly greater during swing phase for the treadmill group versus the comparison group, as was maximum knee extension during stance. In addition, the ankle at initial contact in the treadmill group was closer to neutral than that of the comparison group. Last, there was increased maximum ankle dorsiflexion at terminal stance in the treadmill group versus the comparison group. Symmetry Data Figure 1 illustrates the symmetry between limbs in the treadmill and comparison groups. The P values indicate superior symmetry in the treadmill group at the hip and knee but not at the ankle. To further validate symmetry, various kinematic values were evaluated between groups (table 6). Single-limb support times were significantly different, meaning the participants in the treadmill group had more symmetric stance times between limbs than the comparison group. Hip flexion at initial contact between groups was significant, with less variation between limbs in the treadmill group. However, maximum hip flexion was not significant. The maximum knee flexion difference during swing between groups did reach statistical significance, as did maximum knee extension during stance. Last, there was no difference between limbs for maximum ankle dorsiflexion at terminal stance between groups. Discussion Participants poststroke who initiated gait training on the treadmill with partial BWS before the initiation of overground gait had better gait kinematics, symmetry, velocity, and endurance than participants who received traditional gait rehabilitation. The 3D data collected in this pilot study supported the hypothesis that the gait of the participants in the treadmill group was closer to a normative gait than that of the comparison group. Mean hip flexion at initial contact on the affected limb in the treadmill group was closer to the normative value of 30°48 than in the comparison group. Likewise, the mean maximum knee flexion of 46° observed in the treadmill group was closer to the normative average value of 60°49 during initial swing in healthy gait, allowing easier swing limb advancement.50 Knee hyperextension, which was noted in the comparison group and not in the treadmill group, is not routinely observed in normative gait, is considered to be counterproductive to forward progression and may lead to pain.50 Finally, the mean maximum dorsiflexion observed at terminal stance in the treadmill group (11.5°) was closer to the normative value of 10°,51 allowing for an improved trailing limb position and longer step length in the treadmill group.52 Gait after stroke is most notable for its asymmetry.4, 5, 6, 7, 8, 9, 10 Data collected in this pilot study confirmed that gait was more symmetric in the group of subjects who began gait training on the treadmill. This was validated in the analysis of single support time, hip flexion at initial contact, and maximum knee flexion and extension. Findings for gait endurance also supported the early treadmill intervention. The velocity of the participants in the treadmill group was significantly faster than that of the comparison group. Velocity in the treadmill group was 1.1±0.3m/s compared with 0.7±0.2m/s in the comparison group. Gait velocity after stroke during a 6MWT in the subacute phase of recovery (at least 3mo poststroke) has been observed between .73±.36m/s16 and .74±.25m/s,53 whereas comfortable gait velocity for healthy subjects at the same distance has been reported at 1.83±0.19m/s.16 The velocity of the treadmill group in the current study was closer to normative values, and the comparison group results were consistent with that of the 6MWT velocities previously reported in subjects after stroke. The treadmill group also walked significantly farther than the comparison group in the 6MWT, 382.9m versus 249.7m, respectively. Mean distances of 215.8±91.6m have been recorded for subjects in the acute phase of stroke (73.3±26.8d),54 and distances of 267.7±89.7m have been recorded for subjects at least 1 year poststroke.53 The treadmill subjects in this study exceeded the mean distance recorded by Eng et al,53 who evaluated subjects who were between 1 and 11 years poststroke (mean, 4.4y). We believe that these encouraging outcomes with respect to gait symmetry, kinematics, velocity, and endurance in the treadmill group can be attributed to the nature and timing of the treadmill training intervention, as well as to the introduction and integration of the overground gait component. Previous work22, 23 has established the efficacy of locomotor treadmill training with BWS in improving gait velocity after stroke. However, to our knowledge, this study is the first to report improved gait kinematics after locomotor treadmill training with BWS in subjects with acute stroke. We believe the treadmill environment provided optimum learning conditions at a critical time in the recovery of participants in the treadmill group. Recent research in neuroscience has provided new insight into neural plasticity and neural recovery after neurologic injury, with evidence of functional reorganization of the motor cortex resulting from behavioral experience.55, 56, 57 Fisher and Sullivan35 highlighted some of the essential components of training that must be addressed for learning after neurologic injury, including task complexity, task intensity, and task specificity. Locomotor treadmill training with partial BWS has been identified as an intervention that maximizes many of these key variables,35 and its application with people poststroke may have the most impact when applied before overground gait training. Gait training on the treadmill was initiated as early as 6 days after stroke for participants in the treadmill group. The treadmill environment provided the opportunity to practice early gait efforts with more normative kinematic and temporal features than what is common in clinical practice. With evidence that gait returns to an automatic, or subcortical, activity after stroke,58 establishing early effective gait patterns may be key in relearning gait after stroke. In this pilot study, the treadmill group participants did not develop many of the gait qualities often seen after stroke, thus eliminating the need for remediation at a later time when research has shown the gait pattern to be resistant to change.59 Nilsson et al30 compared treadmill training with more traditional methods in the early period after stroke but did not attempt to initiate gait training exclusively on the treadmill before the overground component was introduced, as was the case in this pilot study. This difference may explain the difference in outcomes between the 2 studies. As with other studies, efforts were made to progressively reduce the amount of BWS as gait skill improved. Exactly what role BWS played in the gait recovery of participants was not clear. The use of BWS in early training facilitates the replication of normative loading responses and weight shifting by the therapists and thus eases the physical burden of the intervention for both subject and therapist. The extent to which the unweighting actually facilitated stepping, as others have postulated,60 was not determined in this study. Also not evaluated in this pilot study was the role of the lower-extremity bracing. As noted, each of the participants in the treadmill group was fit and trained with the same AFO, which was designed to closely replicate normative gait kinematics. At the time of follow-up testing, none of the treadmill group participants required the AFO for independent community gait. However, the exact role of the brace used in this study cannot be known, given the sample size and experimental design. The intervention was completed during 30-minute treatment sessions on a typical inpatient rehabilitation unit. Previously, it has been argued that locomotor treadmill training is too difficult for the therapists.61 Therefore, the protocol was designed with controlled training parameters to decrease the effort for both participants and therapists. There were no adverse effects for any participant on the treadmill. The literature has little guidance to offer with regard to the progression from the treadmill to overground gait, because no study has withheld overground gait until the basic components have been established on the treadmill. The decision to progress to overground gait as defined in the protocol was based primarily on clinical experience but appeared to be an appropriate starting point. Gait training without upper-extremity support on the treadmill appeared to make the transition to overground walking using a single-tip cane a successful experience. Study Limitations This was a small pilot study with very encouraging results. Despite a nonrandomized design, there were no statistical differences between the groups. In addition, the groups represented a variety of lesion locations and distribution of right- and left-sided lesions. There was no attempt to control for therapeutic activities after discharge from rehabilitation. As is common after discharge from inpatient rehabilitation, all participants in both groups received continued physical therapy. It was not possible to blind the therapists or testers to group allocation. However, the kinematic testing was all computerized and therefore was not subject to tester bias. The therapists involved in treatment of the participants did not perform the 6MWT with anyone for whom they were the primary therapist. Conclusions Gait after stroke is often slow, asymmetric, and inefficient, affecting the person’s ability to resume meaningful roles in society. The results of this study support utilization of locomotor treadmill training with BWS before overground gait training. Given the apparent difficulty in changing an established gait pattern,59, 62 the potential to restore gait without the typical asymmetries would represent significant progress in the rehabilitation of people after stroke. Further research is needed to replicate these findings in a larger cohort of participants. In addition, the optimum training parameters for this acute application of locomotor training with BWS will have to be established. It is not known, for example, if the current progression to overground gait is ideal or if a better model exists. Likewise, it has yet to be determined if additional training beyond the inpatient setting would further enhance outcomes. The role of bracing will also need to be evaluated to determine the impact on the kinematic variables. Suppliers Acknowledgments We thank Milton D. Thomas, MD, and Helen Z. Patel, MD, for their invaluable advice and support on this project. References 1. 1Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics—2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85–e151.
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Supported by Baylor Research Institute (fund no. 56905) and the Joseph and Gail Deering Family Foundation. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. PII: S0003-9993(08)00029-4 doi:10.1016/j.apmr.2007.09.050 © 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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