Title: There is no superior treatment in improving gait in patients with chronic stroke

Appraisers:
Natasha Monica R. Avenis, Racheleen Carla N. dela Rosa, Harjoland L. Obenieta,
Leslie Anne G. Santelices, Marilyn I. Tubon, Edward James R. Gorgon, MPhysio,
PTRP, Department of Physical Therapy, College of Allied Medical Professions,
University of the Philippines – Manila
Date of Review: August 2010
Clinical Scenario: ER is a 55-year-old male diagnosed with right cerebrovascular accident
currently receiving physical therapy at the UP-CAMP Clinic for Therapy Services for Adults and
Adolescents (CTS-AA).
In 2008, ER had undergone physical therapy at Philippine General Hospital and was
referred to CTS-AA in June 2009. Upon re- evaluation at CTS-AA, observational gait analysis
and 6-minute walk test showed that ER had slow gait speed which decreased further when
walking distance was increased, short step length, step asymmetry, and decreased walking
distance. Other activity limitations and participation restrictions were difficulty in engaging in
daily exercise, standing independently during bathing, playing basketball during weekends, and
fulfilling his role as manager of his family's sari-sari store.
Re-evaluation on December 2009 showed results similar to those of the June 2009
evaluation. Treatments have been geared toward addressing the gait problems from 2008 to the
present. However, little change has been noted in his gait.
Clinical Question:

Patient/Problem: Patients with chronic stroke

Intervention: Any treatment that targets gait and gait-related impairments
Outcomes: Gait speed and walking distance

Is there a superior treatment that can improve gait in patients with chronic stroke?
Clinical Bottom Line: There is no available evidence to suggest a superior treatment in
improving gait of patients with chronic stroke. Although, there is evidence to support the
effectiveness of gait-oriented training over cardiorespiratory fitness and lower limb strength
training in improving gait speed and walking distance. However, there is no evidence to suggest a
superior gait-oriented training strategy. Among gait-oriented strategies, overground gait training
may be recommended to ER considering the evidence for effectiveness as well as practical
aspects of administration, compared with treadmill training.
Search History:
The group searched the Cochrane Library Database for Systematic Review, Physiotherapy
Evidence Database (PEDro), Cumulative Index for Nursing and Allied Health Literature
(CINAHL) and PubMed using the key words listed below. To verify search results and ensure a
more comprehensive search, other databases (OTSeeker, Highwire, Tripdatabase) were also used.
For all searches, restriction to the English language was applied.
The following are the key terms used in the search:
Population/Condition stroke
“cerebrovascular accident”
“chronic stroke”
Intervention “gait training strategies”
“gait training”
 Outcome measures gait
walking
“gait speed”
“walking distance”
“gait speed” AND “walking
distance”

Identification of Relevant Articles

Inclusion Criteria
 Design: Systematic review of randomized controlled trials
 Participants: Patients with stroke
 Intervention: Specific gait training strategies
 Outcome measures: Measures related to walking competency, including gait speed and
distance covered during ambulation
 Studies published in the English language

Exclusion Criteria
 Studies that included only patients with acute or subacute stroke, i.e. <6months post-
stroke (States et al, 2009).
 Studies that did not present reasonable pooling of results.

Of the 12 articles obtained, four articles (Eng & Tang, States et al, Van de port et al, and
Wevers et al) were found to be potentially relevant after applying the inclusion and exclusion
criteria.
1. Van de port et al’s Effects of Exercise Training Programs on Walking Competency after
Stroke: A systematic review
2. Wevers et al’s Effects of task-oriented circuit class training on walking competency after
stroke: A systematic review
3. States et al’s Overground physical therapy gait training for chronic stroke patients with
mobility deficits
4. Eng & Tang’s Gait training strategies to optimize walking ability in people with stroke: a
synthesis of the evidence
Upon further evaluation of the articles, we found that the articles used by Wevers et al in
comparing gait speed as outcome were also included by States et al. Further, the States et al
review covered a greater number of studies in the area. To our mind, it was unnecessary to use
the Wevers et al review. The three remaining articles (Eng & Tang, States et al and Van de port
et al) were then appraised using the following criteria (Herbert et al, 2005): (1) Was it clear
which trials were to be reviewed? (2) Were most relevant studies reviewed? and (3) Was the
quality of the reviewed studies taken into account? We decided that the systematic reviews by
Van de Port et al, Eng & Tang, and States et al presented the best available evidence at this time.
Summary of Studies
Citation 1: Van de Port, I. G. L., Wood-Dauphinee S., Lindeman E., & Kwakkel G. (2007).
Effects of exercise training programs on walking competency after stroke: A systematic review.
American Journal of Physical Medicine & Rehabilitation, 86, 935–951.
Design: Systematic review of RCTs
Participants: Patients with stroke older than 18 years old
Studies included: 21 randomized controlled trials
Interventions: (1) Cardiorespiratory fitness - performed for an extended period of time on
ergometers without aiming to improve gait performance; (2) Lower-limb strength training -
carried out by making repeated muscle contractions resisted by body weight, elastic devices,
masses, free weights, specialize machine weights, or isokinetic devices; (3) Gait-oriented training
- intends to improve gait performance and walking competency in terms of stride and step
frequency and length, gait speed, and/or walking endurance.
Outcomes measured: Primary - gait speed, walking distance and balance; secondary - stair
climbing performance, functional ambulation, ADL, IADL and health-related QOL.

Conclusion: Gait-oriented training is more effective than cardiorespiratory fitness and lower
limb strengthening in improving gait speed and endurance.
Citation 2: States, R. A., Pappas, E., & Salem, Y. (2009). Overground physical therapy gait
training for chronic stroke patients with mobility deficits. The Cochrane Database of Systematic
Reviews, 3.

Design: Systematic review of RCTs

Participants: Patients with chronic stroke and mobility deficits older than 18 years old
Studies included: 9 randomized controlled trials
Interventions: Overground gait training* consisted of at least one of the following:
1. Real-time cueing of the patient's gait through the use of manual, verbal, positional, or
rhythmic cueing techniques;
2. Practice of the walking pattern overground;
3. Pre-gait activities such as step-up and step-down exercises, dynamic balance training,
weight-bearing exercises to strengthen the lower extremities, and other exercises that
require standing and weight shifting.
*Did not consider use of treadmills, complex technical equipment such as body weight supported
treadmill training, functional electrical stimulation, biofeedback based on electromyography
(EMG) or joint-position measurement, or virtual reality systems.
Outcomes measured: Primary - gait function and walking; secondary - gait speed and walking
distance

Conclusion: There is insufficient evidence to determine if overground gait training benefits gait
function in patients with chronic stroke, though limited evidence suggests small benefits for gait
speed or 6MWT.
Citation 3: Eng, J.J & Tang, P.F. (20007). Gait training strategies to optimize walking ability in
people with stroke: a synthesis of the evidence. Expert Rev. Neurotherapeutics, 7(10), 1417-
1436.

Design: Systematic review of RCTs

Participants: Patients with stroke older than 18 years old
Studies: 38 rand2omized controlled trials
Interventions: Neurodevelopmental techniques (NDT) – focused on inhibiting excessive tone,
stimulating muscle activity and facilitating normal movement patterns using hand on techniques;
strength training – used weights or machines to add a resistive component; task-specific training
– may refer to the use of treadmill training with or without a harness system or intensive practice
of a wide variety of functional mobility tasks; intensive mobility training
Outcomes measured: gait speed and endurance

Conclusion: Community-based intensive mobility exercise can improve walking abilities in the
chronic phase. Strengthening appears to be most effective when incorporated in functional
activities. Treadmill training, particularly at faster speeds, is effective for improving walking
speed. Neurodevelopmental approaches were equivalent or inferior to other approaches to
improve walking ability.

The Evidence

Table 2. Changes in gait speed and walking endurance

Gait Speed Walking endurance
Lower limb strength training
Van de port et al -0.13 SDU, CI -0.73 - 0.47 0.00 SDU, CI -0.28 - 0.28
Eng & Tang -0.11 SDU, CI -46 – 0.24 No available data
Cardiorespiratory fitness training 0.36 SDU, CI -0.03-0.75 No available data

Gait-oriented training 0.45 SDU, CI 0.27 - 0.63 (0.14 m/s) 0.62 SDU, CI 0.30 - 0.95 (41.2 m)

Overground gait training

States et al CI 0.05 - 0.10 (0.07 m/s) CI 7.14 - 44.97 (26.06 m)

Eng & Tang 0.17 SDU, CI -0.11 – 0.45 0.20 SDU, CI -.03 – 0.44

Treadmill training 0.31 SD, CI -0.06 - 0.69 No available data

Table 2 presents the summary of effect sizes (SES) of the gait training strategies expressed in standard deviation
units (SDUs) and confidence interval (CI). A smaller and more positive CI indicates a greater improvement for gait
speed and walking distance. To determine clinical significance, values in m/s and m were compared to the smallest
real differences for gait speed = 0.15-0.25 m/s and walking distance = 37.3-66.0 m reported by Flansbjer et al.

Though the mean changes in gait speed (0.14m/s) and walking distance (41.2m) for gait
oriented training presented by Van de Port et al were statistically significant, only the change in
walking distance were clinically significant. States et al reported mean changes in gait speed
(0.07 m/s) and walking distance (26.06 m) for overground training that were also statistically
significant but were not clinically significant. Treadmill training presented by Eng & Tang also
showed statistically significant changes in gait speed that are not considered clinically significant
Overall, however, gait oriented training appears to be more effective in improving gait than
cardiorespiratory fitness training and lower limb strengthening.

Comments:
 Van de Port et al (2007), States et al (2009) and Eng & Tang (2007) are systematic
reviews of RCTs considered as the highest level of evidence for answering intervention
questions.
  All three reviews satisfied the criteria by Herbert et al
 The characteristics (age, comorbidities, chronicity) of the participants in all reviews are
similar with that of ER. However, Van de Port’s review included studies which involved
patients in the acute and subacute stages of stroke, entailing a need to identify studies
involving patients in the chronic stage only.
 States et al’s review included studies involving only patients with chronic stroke.
 All studies from Van de Port et al involving chronic stroke were focused on overground
training and were also used by States et al.
 Only one study for cardiorespiratory fitness training presented results for walking
distance, hence SES could not be presented.
 Van de Port et al included studies involving treadmill training which is not always
available in Philippine clinical settings.
 Studies of treadmill training in van de Port et al did not present results for patients with
chronic stroke
 Eng and Tang’s review presents the best available results for treadmill training because
values for chronic stroke can be extracted.
 Intensive mobility training presented by Eng&Tang is similar to overground training
presented by States et al
 Overground gait training has been found to be easily applicable and readily available in
most clinical settings.

References

Eng, J.J & Tang, P.F. (20007). Gait training strategies to optimize walking ability in people with
stroke: a synthesis of the evidence. Expert Rev. Neurotherapeutics, 7(10), 1417-1436.
Herbert, R., Jamtvedt, G., Mead, J., & Hagen, K.B. (2005). Critical appraisal of evidence about
the effects of intervention. Practical evidence-based physiotherapy. Philadelphia:
Elsevier Limited.

States RA, Pappas E, & Salem, Y. Overground physical therapy gait training for chronic stroke
patients with mobility deficits. Cochrane Database of Systematic Reviews 2009, Issue 3.
Art. No.: CD006075. DOI: 10.1002/14651858.CD006075.pub2

Van de Port, I. G. L., Wood-Dauphinee S., Lindeman E., & Kwakkel G. (2007). Effects of
exercise training programs on walking competency after stroke: A systematic review.
American Journal of Physical Medicine & Rehabilitation, 86, 935–951.