Treadmill training and body weight support for walking after stroke

Review question: We wanted to assess whether walking practice on a treadmill with the body being supported by a harness as the only form of training versus in combination with other kinds of training, could improve walking when compared with other training methods for walking or no treatment. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.

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 56 relevant trials, involving 3105 participants, up to March 2017. Twenty-six studies (1410 participants) compared treadmill training with body weight support to another physiotherapy treatment; 20 studies (889 participants) compared treadmill training without body weight support to other physiotherapy treatment, no treatment, or sham treatment; 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 was 60 years, and the studies were carried out in both inpatient and outpatient settings.

Key results: The results of this review were partly inconclusive. 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 have no lasting positive effect. Unwanted events such as falls and dropouts were not more common in people receiving treadmill training.

Further analysis showed that treadmill training in the first three months after stroke produces only modest improvements in walking speed and endurance. For people treated at a later stage (more than six months after their stroke) the effects were smaller. More frequent treadmill training (for example, five times per week) appears to produce greater effects on walking speed and endurance; however, this was not conclusive. Brief periods of treadmill training (duration of four weeks) provided a modest improvement in walking speed but not enough to be clinically important.

Effects of the age of participants or the type of stroke were not investigated in this review.

In practice, 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. Future research should analyse age groups, gender, and type of stroke to see who might benefit most from this treatment.

Quality of the evidence
The quality of evidence for treadmill training for walking after stroke was low to moderate. It was moderate for walking speed and walking endurance at the end of treatment and low for improving the ability to walk independently.

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 slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance 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 participants, but not in dependent walkers.

Read the full abstract...
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 the Cochrane review first published in 2003 and updated in 2005 and 2014.

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 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). 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 review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency.

Main results: 

We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training 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; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.

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