|Year : 2021 | Volume
| Issue : 3 | Page : 104-108
Effect of backward walking and side walking training on walking speed and endurance in patients with stroke: An experimental randomized controlled study
Damayanti Sethy, Ameed Equebal, Eva S Kujur, Eshani Mallick
Department of Occupational Therapy, National Institute for Locomotor Disabilities, Kolkata, West Bengal, India
|Date of Submission||28-Jan-2021|
|Date of Acceptance||18-Sep-2021|
|Date of Web Publication||12-Oct-2021|
National Institute for Locomotor Disabilities, Kolkata - 700 090, West Bengal
Source of Support: None, Conflict of Interest: None
Background: There is a direct relationship exists between hemiplegic walking speed and functional limitations, both in household and community ambulation. Walking after stroke is characterized by slow gait speed, poor endurance, and change in the quality and adaptability of walking patterns. Side stability, symmetrical weight-bearing, and backward motor control ability are required to improve walking function. Objective: To investigate whether a combination of backward and side walking training is effective in improving walking speed and walking endurance in patients with poststroke hemiparesis. Study Design: An experimental randomized controlled study design. Methods: A total of 56 patients with poststroke hemiparesis fulfilling inclusion criteria were recruited for the study. Patients in the experimental group received 30 min of backward and side walking training of 15 min each. The patients in the control group received conventional occupational therapy for 30 min. Walking speed was assessed by walking endurance was evaluated by 10-m walk test (MWT) (and walking endurance was evaluated by 6MWT. Follow-up assessment was performed after 6 weeks of intervention. Results: In the within-group comparisons, both experimental and control groups showed significant differences postintervention (P < 0.05). In the between-group comparison, patients in the experimental group showed more improvement than the control group for walking speed (P = 0.001, 95% confidence interval [CI]: 7.86 to 9.73) and walking endurance (P = 0.004, 95% CI: 8.32 to 9.47) after 6-weeks of intervention. Conclusions: This study concluded that combined backward and side walking training has a better effect on walking speed and endurance than conventional therapy.
Keywords: Endurance, Stroke, Walking Speed
|How to cite this article:|
Sethy D, Equebal A, Kujur ES, Mallick E. Effect of backward walking and side walking training on walking speed and endurance in patients with stroke: An experimental randomized controlled study. Indian J Occup Ther 2021;53:104-8
|How to cite this URL:|
Sethy D, Equebal A, Kujur ES, Mallick E. Effect of backward walking and side walking training on walking speed and endurance in patients with stroke: An experimental randomized controlled study. Indian J Occup Ther [serial online] 2021 [cited 2022 Aug 15];53:104-8. Available from: http://www.ijotonweb.org/text.asp?2021/53/3/104/328126
| Introduction|| |
Walking is an important human activity which enables us to be productive and participative members of a community. There is a direct relationship exists between hemiplegic walking speed and functional limitations, both in household and community ambulation. Walking speed of community-dwelling individuals after stroke has been reported to be around 0.5 m/s with studies reporting a range between 0.3 and 0.8 m/s.,,,,
Walking after stroke is characterized by slow gait speed and poor endurance. Factors like poor speed, reduced endurance, fatigue put individuals with stroke at great risk of falling during prolonged walking. Walking speed, gait stability, and endurance should be hence quantitatively assessed and improved during rehabilitation in order to allow patients to walk functionally and safely.
Backward walking (BW) has been reported to increase stroke patients' motor control ability, lower limb muscle strength, balance ability, and gait ability. Forward and BW focus on the improvement of forward and backward stability during walking and have no significant effect on the improvement of lateral stability during walking. Sideways walking effectively improves balance and walking abilities, and reduces asymmetrical weight bearing on the lower limbs, because it emphasizes side stability more and encourages more dynamic weight shifts to the affected side in the coronal plane compared to forward and BW.
The ability to walk independently in the community depends on the speed of walking and the level of endurance the person has. Both backward and side walking requires a greater level of energy expenditure and demands more oxygen consumption and it also improves the movement components required for forward walking. In conventional occupational therapy, backward and side walking training are given as components of circuit training for generalized improvement in the walking function whereas in the present study improving speed and endurance are specifically targeted to make the patient with stroke hemiparesis independent in walking. Therefore, this study was aimed at investigating the combined effect of BW training and side walking training on walking speed and endurance in patients with stroke hemiparesis.
| Methods|| |
A convenience sample of 56 patients with poststroke hemiparesis attending the Department of Occupational Therapy, National Institute for Locomotor Disabilities, Kolkata, West Bengal, India, were recruited in the study. The inclusion criteria were: Patients who had stroke for 6 months and more; age from 35 to 65 years; Mini-Mental State Examination score of at least 25 points, lower extremity Brunnstrom recovery stage ≥3, individuals who could walk independently for at least 10 m. Patients having severe cognitive and other orthopedic problems of the lower limb were excluded from the study. All participants provided written informed consent before participation in the study. The participants who fulfilled the inclusion criteria were randomly assigned to the experimental and control group. Blank folders were numbered from 1 to 56 and were given concealed codes for group assignment by an independent researcher. When a participant was eligible and gave consent to participate in the study, the next folder was drawn by an independent therapist, and accordingly, a group was assigned to the participants. All the measurements were recorded by a researcher who was blinded to group allocation.
The patients in the experimental group received 30 min of backward and sidewise walking training of 15 min each for a total of 30 min. Patients in the control group received conventional occupational therapy for 30 min. The duration of therapy was 5 days a week for 6 weeks, a total of 30 sessions. Posttreatment measurements for all the outcome measures were taken after 6 weeks of intervention. The study was conducted for a total of 19 months from June 2015 to January 2017. To collect data on walking speed, 10-m walk test (MWT) was used and for evaluating walking endurance 6MWT was used.
Ten-meter walk test
The patients were instructed to walk a total of 14 m at their fastest speed, and the speed for the 10 m excluding the first 2 m and the last 2 m was measured. The unit of gait speed was expressed as meter/second (m/s). The 10MWT has excellent test-retest reliability (intraclass correlation coefficient [ICC] = 0.95–0.99) and excellent reliability for comfortable (ICC = 0.94) and fast (ICC = 0.97) gait speeds.
Six min walk test
6MWT was used to examine the subjects' walking endurance. A tape was attached to the floor along a 50-m course, and the distance covered back and forth in 6 min was measured. When necessary, the participants took a rest in a chair. The test was performed three times, with the subjects resting for at least 2 min between tests, and an average value was derived.
Patients of the experimental group had finished 30 sessions of backward and side walking training program. Initially, during the first 2–4 sessions, the participants were asked to take a few steps backward with the therapist's assistance. Then, they were asked to walk actively without assistance. They were instructed to walk at their comfortable speed without following a specific pattern of walking. Gradually, the distance of walking was increased progressively. During the first few sessions, they were asked to walk within the department in a 10 m long straight track, and gradually, the distance was increased to a maximum of 60 m. For side walking training, the same procedure was used except here the participant had to walk sideways.
The gait speed and pace were not imposed. There was no constraint or indication about head and trunk position during backward and side walking training. Stand-by assistance was provided to all the participants for safety purposes. For side walking training, participants were instructed to step laterally with feet together while balancing and supporting the body mass on one leg. The participants were also given assistance to keep the hip in neutral extension while stepping in the swing and stance phase of walking. Participants were asked to walk sideways in both the directions (from affected to the less affected side and less affected side to affected side).
Participants in the control group received conventional therapy including preambulation activities, strengthening of the lower limb, and forward walking training. Perambulatory activities such as kneeling, half kneeling, and sitting to standing activities were given before walking. Weight-bearing, weight shifting activities, and stepping were also practiced. Walking inside the therapy room was performed during the 1st week. In the 2nd week, walking outside of the room, in the department corridor was performed. Walking with obstacle crossing was performed along with other pre-ambulatory activities till the 5th week. In the 6th week, walking on-ramp was performed.
Data were analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp.). The homogeneity of the baseline characteristics was tested using independent t-test. Paired t-test was used to compare the differences between the outcome measures post 6 weeks of the training within each of the groups and an independent t-test was used to compare the difference between both the experimental and control group. The statistical significance level of all data was set at P < 0.05.
| Results|| |
Both experimental and control groups in the study were compared pretest and posttest. Homogeneity of the groups was tested for all the demographic characteristics and pretraining outcome measures. Baseline participant characteristics were comparable across these two groups. The general characteristics of the study sample are shown in [Table 1].
According to the results of this study, there were significant changes in walking speed (P < 0.05) within each group and significant changes in walking endurance in the experimental group (P < 0.05). In the conventional therapy group, there was no significant change seen in walking endurance. There were significant differences found in gait speed and endurance between the groups (P < 0.05).
The 10MWT scores showed significant improvement on the posttest. Paired t-test revealed that the posttest score was significantly higher than the pretest score in the experimental group (P = 0.00). The conventional group had also showed improvement on 10MWT scores (P = 0.02). The 6MWT scores showed significant improvement in the experimental group (P = 0.001) and showed nominal improvement in the control group (P = 0.293) which is not significant. The within-group analysis shows that there is a significant improvement in walking speed and endurance in the experimental group. Although participants in the control group had improvement in walking speed, improvement in walking endurance was very minimal. The result of the within-group analysis is shown in [Table 2].
|Table 2: Descriptive and Inferential Statistics for the Outcome Measures Within Each Group|
Click here to view
The result of between-group analysis showed that there is a significant difference found between the experimental and control group in 10MWT (P = 0.001) and 6MWT. The result of this study showed better improvement in walking speed as well as walking endurance in the experimental group than the conventional therapy group. The result of between-group analyses is shown in [Table 3].
|Table 3: Descriptive and Inferential Statistics for the Outcome Measures between Experimental and Control Group|
Click here to view
| Discussion|| |
Walking speed has become an important, sensitive, and reliable marker for the functional deficit severity in post stroke patients or in post Cerebro Vascular Accident (CVA) patients. The result of this study shows that a combination of backward and sidewalk training improved walking speed in chronic stroke hemiplegics. Walking speed was increased both in the experimental group and control group, but the experimental group showed a better improvement over the control group (P = 0.001). The change score (mean difference) of walking speed in the experimental group was 0.14 m/s that is found to be higher than the walking speed of 0.13 m/s that is the minimal clinically important difference for comfortable speed as a measure of walking performance worth detecting. In the control group, the change score was 0.01 m/s that is lesser than 0.13 m/s. The result of this study is supported by a study conducted by Lin et al., 2005 that showed increase in gait speed after BW training in addition to conventional therapy in stroke hemiplegics. The improvement in gait speed may be attributed to the decrease in the predominance of hip extensor synergy through practice of BW, improved balance, and improved symmetry of gait. It has been reported that prolonged backward exercise causes neural adaptations. The reorganization of the muscle synergies or neuromotor control in lower limbs during BW might be a possible reason for the improvement of balance and thereby improving walking speed. Of the common impairments, muscle strength, motor control, and balance appear to have the strongest relation with walking. The hip abductor muscles play an important biomechanical role in humans and are an essential pivotal point in the mobilization of body weight. Backward and sidewalk training might have improved the strength of gluteus maximus and hamstrings (hip extensors) and gluteus medius (hip abductors) muscles respectively. These muscles are the primary hip stabilizers and the improved strength might have contributed for improved stability at the hip and resulting in improved walking speed in the experimental group. Sideways gait exercise effectively improves balance and walking abilities and reduces asymmetrical weight bearing on the lower limbs, because it emphasizes side stability more and encourages more dynamic weight shifts to the affected side in the coronal plane, thus improved walking speed in the experimental group was achieved.
Walking endurance remains the most striking area of difficulty among individuals with chronic stroke. Poor walking endurance (6MWT) in people with stroke correlates to lower paretic hip bone density, which leads to hip fracture. The results of this study indicated that walking endurance of the subjects with stroke hemiparesis in the experimental group had been significantly improved with a change score of 30.35 m which is similar to the minimal clinically important difference for change in 6MWT for adults with pathology after 6 weeks of backward and side walk training in comparison to the minimal improvement in the control group (change score of 3.68 m) that received conventional therapy. It is well established that repetitions play a major role in structural re-organization of the brain and task-orientated activities are a key to functional recovery. Hence, activities of daily living -related activities such as walking may be used to influence aerobic performance. In this study repetitive backward and sidewalk training in the experimental group might have improved aerobic performance than conventional therapy alone. It has been found that, during BW, oxygen consumption and heart rate are much greater than during matched speed forward walking, suggesting that backward need more metabolic cost, and provide more stimulus to maintain the fitness of the cardiovascular system. The repetitive backward and sidewalk training in the experimental group might have improved the peak oxygen uptake level, thereby improving the walking endurance over the conventional therapy group.
The study has many limitations. First, participants may have suffered fatigue due to the repetitive nature of walking training. Only walking speed and endurance have been considered as the outcome measures. In future studies, new study designs are needed to address these limitations and other outcome measures of walking ability can be included as measures of walking ability.
| Conclusions|| |
This study indicates that backward and sidewalk training can improve the walking speed and endurance of patients with stroke hemiparesis. Improved speed and endurance might improve the ability to walk independently. These are very simple forms of daily activities that can be included in the daily routine of patients with stroke hemiparesis.
We thank all our patients those participated in the study.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Ada L, Dean CM, Lindley R, Lloyd G. Improving community ambulation after stroke: The AMBULATE trial. BMC Neurol 2009;9:8.
Weerdesteyn V, de Niet M, van Duijnhoven HJ, Geurts AC. Falls in individuals with stroke. J Rehabil Res Dev 2008;45:1195-1213.
Hill K, Ellis P, Bernhardt J, Maggs P, Hull S. Balance and mobility outcomes for stroke patients: A comprehensive audit. Aust J Physiother 1997;43:173-180.
Duncan P, Richards L, Wallace D, Stoker-Yates J, Pohl P, Luchies C, et al
. A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke 1998;29:2055-2060.
Eng JJ, Chu KS, Dawson AS, Kim CM, Hepburn KE. Functional walk tests in individuals with stroke: Relation to perceived exertion and myocardial exertion. Stroke 2002;33:756-761.
Green J, Forster A, Bogle S, Young J. Physiotherapy for patients with mobility problems more than 1 year after stroke: A randomised controlled trial. Lancet 2002;359:199-203.
Pohl M, Mehrholz J, Ritschel C, Rückriem S. Speed-dependent treadmill training in ambulatory hemiparetic stroke patients: A randomized controlled trial. Stroke 2002;33:553-558.
Lamontagne A, Fung J. Faster is better: Implications for speed-intensive gait training after stroke. Stroke 2004;35:2543-2548.
Simpson LA, Miller WC, Eng JJ. Effect of stroke on fall rate, location and predictors: A prospective comparison of older adults with and without stroke. PLoS One 2011;6:e19431.
Iosa M, Morone G, Fusco A, Pratesi L, Bragoni M, Coiro P, et al.
Effects of walking endurance reduction on gait stability in patients with stroke. Stroke Res Treat 2012;2012:810415.
Threlkeld AJ, Horn TS, Wojtowicz G, Rooney JG, Shapiro R. Kinematics, ground reaction force, and muscle balance produced by backward running. J Orthop Sports Phys Ther 1989;11:56-63.
Brown TH, Mount J, Rouland BL, Kautz KA, Barnes RM, Kim J. Body weight-supported treadmill training versus conventional gait training for people with chronic traumatic brain injury. J Head Trauma Rehabil 2005;20:402-415.
Fujisawa H, Takeda R. A new clinical test of dynamic standing balance in the frontal plane: The side-step test. Clin Rehabil 2006;20:340-346.
Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: A systematic review. Clin Rehabil 2009;23:1018-1033.
Straudi S, Manca M, Aiello E, Ferraresi G, Cavazza S, Basaglia N. Sagittal plane kinematic analysis of the six-minute walk test: A classification of hemiplegic gait. Eur J Phys Rehabil Med 2009;45:341-347.
Dickstein R. Rehabilitation of gait speed after stroke: A critical review of intervention approaches. Neurorehabil Neural Repair 2008;22:649-660.
Bohannon RW, Andrews AW, Glenney SS. Minimal clinically important difference for comfortable speed as a measure of gait performance in patients undergoing inpatient rehabilitation after stroke. J Phys Ther Sci 2013;25:1223-1225.
Lin PY, Yang YR, Cheng SJ, Wang RY. The relation between ankle impairments and gait velocity and symmetry in people with stroke. Arch Phys Med Rehabil 2006;87:562-568.
Eng JJ, Tang PF. Gait training strategies to optimize walking ability in people with stroke: A synthesis of the evidence. Expert Rev Neurother 2007;7:1417-1436.
Kak HB, Park SJ, Park BJ. The effect of hip abductor exercise on muscle strength and trunk stability after an injury of the lower extremities. J Phys Ther Sci 2016;28:932-935.
Pang MY, Eng JJ, Dawson AS. Relationship between ambulatory capacity and cardiorespiratory fitness in chronic stroke: Influence of stroke-specific impairments. Chest 2005;127:495-501.
French B, Thomas LH, Leathley MJ, Sutton CJ, McAdam J, Forster A, et al.
Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev 2007;(4):CD006073.
Flynn TW, Connery SM, Smutok MA, Zeballos RJ, Weisman IM. Comparison of cardiopulmonary responses to forward and backward walking and running. Med Sci Sports Exerc 1994;26:89-94.
[Table 1], [Table 2], [Table 3]