Treadmill training and body weight support for walking after stroke

Question: We wanted to assess whether treadmill training and body weight support, individually or in combination, could improve walking when compared with other gait training methods, placebo or no treatment.

Background: About 60% of people who have had a stroke have difficulties with walking, and improving walking is one of the main goals of rehabilitation. Treadmill training, with or without body weight support, uses specialist equipment to assist walking practice.

Study characteristics: We identified 44 relevant trials, involving 2658 participants, up to June 2013. Twenty-two studies (1588 participants) compared treadmill training with body weight support to another physiotherapy intervention; 16 studies (823 participants) compared treadmill training without body weight support to other physiotherapy intervention, no intervention or sham; two studies (100 participants) compared treadmill training with body weight support to treadmill training without body weight support; and four studies (147 participants) did not state whether they used body weight support or not. The average age of the participants ranged from 50 to 75 years, and the studies were carried out in both inpatient and outpatient settings.

Key results and quality of the evidence: The results of this review were partly conclusive. People after stroke who receive treadmill training with or without body weight support are not more likely to improve their ability to walk independently. The quality of this evidence was low. However, treadmill training with or without body weight support may improve walking speed and walking capacity compared with people not receiving treadmill training. The quality of this evidence was moderate. More specifically, people after stroke who are able to walk at the start of therapy appear to benefit most from this type of intervention, but people who are not able to walk independently at therapy onset do not benefit. This review found that improvements in walking speed and endurance in people who can walk may have persisting beneficial effects. However, our review suggests that stroke patients who are not able to walk independently at the start of treatment may not benefit from treadmill training with or without body weight support. Adverse events and drop outs did not occur more frequently in people receiving treadmill training. Subgroup analysis showed that treadmill training in the first three months after stroke produces statistically and clinically relevant improvements in walking speeds and endurance. For people treated in the chronic phase (i.e. more than six months post-stroke) the effects were lower. Treadmill training at higher frequencies may produce greater effects on walking speed and endurance; however, this was not significant.

In practice, treadmill training should be used when stroke patients can walk independently. Therapists should be aware that treadmill training may be used as an option but not as a stand-alone treatment to improve walking speed and endurance in people who are able to walk independently. It appears that people who can walk after stroke, but not those who cannot, may profit from treadmill training (with and without body weight support) to improve their walking abilities. Further research should specifically investigate the effects of different frequencies, durations or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails. Future trials should include people who can already walk, but not dependent walkers who are unable to walk unaided.

Authors' conclusions: 

Overall, people after stroke who receive treadmill training with or without body weight support are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve. Specifically, stroke patients who are able to walk (but not people who are not able to walk) appear to benefit most from this type of intervention. This review found that improvements in walking endurance in people able to walk may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory patients, but not in dependent walkers.

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Background: 

Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane review first published in 2005.

Objectives: 

To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (last searched June 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (The Cochrane Library 2013, Issue 7), MEDLINE (1966 to July 2013), EMBASE (1980 to July 2013), CINAHL (1982 to June 2013), AMED (1985 to July 2013) and SPORTDiscus (1949 to June 2013). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists and contacted trialists to identify further trials.

Selection criteria: 

Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.

Data collection and analysis: 

Two authors independently selected trials, extracted data and assessed methodological quality. The primary outcomes investigated were walking speed, endurance and dependency.

Main results: 

We included 44 trials with 2658 participants in this updated review. Overall, the use of treadmill training with body weight support did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; P = 0.94; I² = 0%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.07 m/s (95% CI 0.01 to 0.12; P = 0.02; I² = 57%) and the pooled MD for walking endurance was 26.35 metres (95% CI 2.51 to 50.19; P = 0.03; I² = 60%). Overall, the use of treadmill training with body weight support in walking rehabilitation for patients after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up significantly. The pooled MD (random-effects model) for walking velocity was 0.04 m/s (95% CI -0.06 to 0.14; P = 0.40; I² = 40%) and the pooled MD for walking endurance was 32.36 metres (95% CI -3.10 to 67.81; P = 0.07; I² = 63%). However, for ambulatory patients improvements in walking endurance lasted until the end of scheduled follow-up (MD 58.88 metres, 95% CI 29.10 to 88.66; P = 0.0001; I² = 0%). Adverse events and drop outs did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.