effects of exercise training

Authors:Ingrid G.L van de Port, MScSharon Wood-Dauphinee, PhD, PTEline Lindeman, PhD, MDGert Kwakkel, PhD

Affiliations:From the Center of Excellence forRehabilitation Medicine Utrecht,Rehabilitation Center De Hoogstraat,Utrecht, The Netherlands (IGLvdP,EL, GK); Rudolf Magnus Institute ofNeuroscience, Department ofNeurology and Neurosurgery,University Medical Center, Utrecht,The Netherlands (IGLvdP, EL, GK);Vrije Universiteit Medical Center,Department of Rehabilitation,Amsterdam, The Netherlands (GK);and School of Physical andOccupational Therapy, Departmentof Epidemiology and Biostatistics,McGill University, Montreal, Canada(SW-D).

Correspondence:All correspondence and requests forreprints should be addressed to I.G.L.van de Port, MS, RehabilitationCenter De Hoogstraat,Rembrandtkade 10, NL-3583 TMUtrecht, The Netherlands.

Disclosures:This study was undertaken as partof the Long-Term Prognosis ofFunctional Outcome in NeurologicalDisorders program, supervised by theDepartment of RehabilitationMedicine of the VU Medical Center,Amsterdam and supported by theNetherlands Organisation for HealthResearch and Development (projectno. 1435.0020).

0894-9115/07/8611-0935/0American Journal of PhysicalMedicine & RehabilitationCopyright 2007 by LippincottWilliams & Wilkins

DOI: 10.1097/PHM.0b013e31802ee464

Effects of Exercise TrainingPrograms on Walking CompetencyAfter StrokeA Systematic Review

ABSTRACT

van de Port IGL, Wood-Dauphinee S, Lindeman E, Kwakkel G: Effects ofexercise training programs on walking competency after stroke: a systematicreview. Am J Phys Med Rehabil 2007;86:935951.

To determine the effectiveness of training programs that focus on lower-limbstrengthening, cardiorespiratory fitness, or gait-oriented tasks in improving gait,gait-related activities, and health-related quality of life after stroke. Randomizedcontrolled trials (RCTs) were searched for in the databases of Pubmed, Co-chrane Central Register of Controlled Trials, Cochrane Database of SystematicReviews, DARE, Physiotherapy Evidence Database (PEDro), EMBASE, Data-base of the Dutch Institute of Allied Health Care, and CINAHL. Databases weresystematically searched by two independent researchers. The following inclusioncriteria were applied: (1) participants were people with stroke, older than 18 yrs;(2) one of the outcomes focused on gait-related activities; (3) the studiesevaluated the effectiveness of therapy programs focusing on lower-limb strength-ening, cardiorespiratory fitness, or gait-oriented training; and (4) the study waspublished in English, German, or Dutch. Studies were collected up to November2005, and their methodological quality was assessed using the PEDro scale.Studies were pooled and summarized effect sizes were calculated. Best-evidencesynthesis was applied if pooling was impossible. Twenty-one RCTs were in-cluded, of which five focused on lower-limb strengthening, two on cardiorespi-ratory fitness training (e.g., cycling exercises), and 14 on gait-oriented training.Median PEDro score was 7. Meta-analysis showed a significant medium effect ofgait-oriented training interventions on both gait speed and walking distance,whereas a small, nonsignificant effect size was found on balance. Cardiorespira-tory fitness programs had a nonsignificant medium effect size on gait speed. Nosignificant effects were found for programs targeting lower-limb strengthening. Inthe best-evidence synthesis, strong evidence was found to support cardiorespi-ratory training for stair-climbing performance. Although functional mobility waspositively affected, no evidence was found that activities of daily living, instru-mental activities of daily living, or health-related quality of life were significantlyaffected by gait-oriented training. This review shows that gait-oriented training iseffective in improving walking competency after stroke.

Key Words: Cerebrovascular Diseases, Systematic Review, Exercise Therapy,Gait-Related Activities

November 2007 Exercise Training After Stroke 935

LITERATURE REVIEW

Exercise

Stroke is a major cause of disability in thedeveloped world, often resulting in difficulties inwalking. According to the Copenhagen StrokeStudy, 64% of survivors walk independently at theend of rehabilitation, 14% walk with assistance,and 22% are unable to walk.1 Because independentgait is closely related to independence in activitiesof daily living (ADL), achieving and maintainingthe ability to walk in the home and in the commu-nity is an important aim of stroke rehabilitation.2

Saunders and colleagues3 evaluated the evi-dence for the effects of strength training, cardio-respiratory training, and mixed training programson gait. They suggested that programs concentrat-ing on cardiorespiratory fitness resulted in im-proved scores for walking ability and maximumwalking speed. They also noted that there havebeen few studies including strength and mixedtraining, and these studies have been inconclusive.

Recently, there has been increasing interest incombinations of strength and cardiorespiratorytraining, in which gait and gait-related tasks arepracticed using a functional approach.46 Salbachand colleagues5 suggested that high-intensity task-oriented practice may enhance walking competencyin patients with stroke better than other methods,even in those patients in which the intervention wasinitiated beyond 6 mos after stroke.5,7 Walking com-petency was defined as the level of walking abilitythat allows individuals to navigate their commu-nity proficiently and safely.5 In addition, there isgrowing evidence that the link between physicaltraining and improved cardiorespiratory fitness, asestablished in the general population, can be ex-trapolated to persons who are disabled by stroke.8

To optimize the treatment of those withstroke, it is necessary to systematically evaluate theeffects of the different training programs that aimto restore walking competency. We conducted asystematic review of the literature on the effects oflower-limb strength training, cardiorespiratory fit-ness training, and gait-oriented training on gait,gait-related activities, and health-related quality oflife in those who had sustained a stroke.

METHODSLiterature Search

Potentially relevant studies were identifiedthrough computerized and manual searches. Elec-tronic databases (Pubmed, Cochrane Central reg-ister of Controlled Trials, Cochrane Database ofSystematic Reviews, DARE, Physiotherapy Evi-dence Database (PEDro), EMBASE, Database of theDutch Institute of Allied Health Care, and CINAHL(1980 through November 2005)) were systemati-

cally searched by two independent researchers(IvdP, WE). The following MeSH headings and keywords were used for the electronic databases: ce-rebrovascular accident, gait, walking, exercisetherapy, rehabilitation, neurology, and randomizedcontrolled trial. Bibliographies of review articles,narrative reviews, and abstracts published in pro-ceedings of conferences were also examined. Ran-domized controlled trials (RCTs) were included ifthey met the following inclusion criteria: (1) par-ticipants were patients with stroke older than 18yrs; (2) one of the study outcomes focused ongait-related activities; (3) the studies evaluated theeffectiveness of therapy programs focusing on lower-limb strengthening, cardiorespiratory fitness, orgait-oriented training; (4) the study was publishedin English, German, or Dutch; and (5) the designwas an RCT. Studies were collected up to Novem-ber 2005. Studies evaluating specific neurologicaltreatment approaches applying gait manipulations(e.g., by using specific devices such as body weightsupported training, virtual reality, or electrical stim-ulation) were excluded. Crossover designs weretreated as RCTs by taking only the outcomes after thefirst intervention phase. The full search strategy isavailable on request from the corresponding author.

DefinitionsIn the present review, stroke was defined ac-

cording to the World Health Organization defini-tion as an acute neurological dysfunction of vascu-lar origin with sudden (within seconds) or at leastrapid (within hours) occurrence of symptoms andsigns corresponding to the involvement of focalareas in the brain.9

RCT was defined as a clinical trial involving atleast one test treatment and one control treatment,in which concurrent enrollment and follow-up ofthe test- and control-treated groups is ensured, andthe treatments to be administered are selected by arandom process, such as a random-numbers tableor concealed envelopes (Pubmed 1990).

Gait-related activities were defined in thepresent study as activities involving mobility-re-lated tasks, such as stair walking, turning, makingtransfers, walking quickly, and walking for speci-fied distances. Lower-limb strength training wasdefined as prescribed exercises for the lower limbs,with the aim of improving strength and muscularendurance, that are typically carried out by makingrepeated muscle contractions resisted by bodyweight, elastic devices, masses, free weights, spe-cialized machine weights, or isokinetic devices.3

Cardiorespiratory fitness training was defined astraining intended to improve the cardiorespiratorycomponent of fitness, typically performed for ex-tended periods of time on ergometers (e.g., cycling,rowing), without aiming to improve gait perfor-

936 van de Port et al. Am. J. Phys. Med. Rehabil. Vol. 86, No. 11

mance as such.3 We defined gait-oriented trainingas training intended to improve gait performanceand walking competency in terms of different pa-rameters of gait (e.g., stride and stepping fre-quency, stride and step length), gait speed, and/orwalking endurance.

Methodological QualityTwo independent reviewers (IvdP and WE) as-

sessed the methodological quality of each studyusing the PEDro scale10,11 (Table 1). In the case ofpersistent disagreement, a third reviewer made thefinal decision after discussions with the primaryreviewers. PEDro scores were used as a basis forbest-evidence syntheses and to discuss the meth-odological strengths and weaknesses of the studies.

Quantitative AnalysisData contained in the abstract (numbers of

patients in the experimental and control groups,mean difference in change score, and standard de-viation [SD] of the outcome scores in the experi-mental and control groups at baseline) were en-tered in Excel for Windows. If necessary, pointestimates were derived from graphs presented inthe article.

Outcomes were pooled if the studies were com-parable in terms of the type of intervention (i.e.,lower-limb strengthening, cardiorespiratory fit-ness, or gait-oriented training) and if they assessedthe same construct. Pooled SDi was estimated us-ing the baseline SDs of the control and experimen-tal groups. The effect size gi (Hedges g) for indi-vidual studies was assessed by calculating thedifference in mean changes between the experi-mental and control groups, divided by the pooledSDi of the experimental and control groups at base-line.12 If additional information was required, wecontacted the authors or derived SDs from t or Fstatistics, P values, or postintervention distribu-tions.

Because gi tends to overestimate the popula-tion effect size in studies with a small number ofpatients, a correction was applied to obtain anunbiased estimate: gu (unbiased Hedges g). Theimpact of sample size was addressed by estimatinga weighting factor wi for each study and applyinggreater weight to effect sizes from studies withlarger samples, which resulted in smaller vari-ances. Subsequently, gu values of individual studieswere averaged to obtain a weighted summarizedeffect size (SES), and the weights of each studywere combined to estimate the variance of theSES.13 SES was expressed as the number of stan-dard deviation units (SDUs) and a confidence in-terval (CI). The fixed-effects model was used todecide whether the SES was statistically signifi-cant. The homogeneity (or heterogeneity) test sta-tistic (Q statistic) of each set of effect sizes wasexamined to determine whether studies shared acommon effect size from which the variance couldbe explained by sampling error alone.14,15 Becausethe Q statistic underestimates the heterogeneity ina meta-analysis, the percentage of total variationacross the studies was calculated as I2, which givesa better indication of the consistency between tri-als.16 When significant heterogeneity was found (I2

values 50%),16 a random-effects model was ap-plied.14 For all outcome variables, the critical valuefor rejecting H0 was set at a level of 0.05 (twotailed). On the basis of the classification by Cohen,effect sizes below 0.2 were classified as small, thosefrom 0.2 to 0.8 as medium, and those above 0.8 aslarge.15

Best-Evidence SynthesisA best-evidence synthesis was conducted if

pooling was impossible because of differences inoutcomes, intervention category, and/or numbersof studies found. Using criteria based on the meth-odological quality score of the PEDro scale, weclassified the studies as high quality (four points ormore) or low quality (three points or less).7 Sub-

TABLE 1 The 11 items of the Physiotherapy Evidence Database (PEDro) scale for methodologicalquality

1. Eligibility criteria specified Yes/No2. Random allocation Yes/No3. Concealed allocation Yes/No4. Baseline prognostic similarity Yes/No5. Participant blinding Yes/No6. Therapist blinding Yes/No7. Outcome assessor blinding Yes/No8. More than 85% follow-up for at least one primary outcome Yes/No9. Intention-to-treat analysis Yes/No

10. Between- or within-group statistical analysis for at least one primary outcome Yes/No11. Point estimates of variability given for at least one primary outcome Yes/No


sequently, studies were categorized into four levelsof evidence, based on van Tulder et al.17

1) Strong evidence: provided by generally consis-tent findings in multiple relevant high-qualityRCTs

2) Moderate evidence: provided by generally con-sistent findings in one relevant high-qualityRCT and one or more relevant low-quality RCTs

3) Limited evidence: provided by generally consis-tent findings in one relevant high-quality RCTor in one or more relevant low-quality RCTs

4) No or conflicting evidence: no RCTs are avail-able, or the results are conflicting

If the number of studies showing evidence was lessthan 50% of the total number of studies foundwithin the same methodological quality category,this was regarded as no evidence.18

RESULTSThe initial search strategy identified 486 rele-

vant citations. On the basis of title and abstract, weexcluded 440 studies; reasons for exclusion in-cluded studies not being randomized, using anintervention that did not fit within our definition,or being conducted in a different patient popula-tion. Forty-six full-text articles were selected. Ofthese, three more were excluded because the stud-ies were not RCTs1921 and three were excludedbecause the outcome measures did not reflect gait-related activities.2224 Another 20 studies were ex-cluded because the intervention did not meet thecriteria,2544 and one study was excluded because itfocused on a subgroup of a larger RCT.45 Screeningof references of the articles led to another fourstudies4649 being included. In total, 23 studies wereincluded in the present systematic review (Fig. 1).The selection included six RCTs that focused onstrength training of the lower limb,4648,5052 threethat concentrated on cardiorespiratory fitness,5355

and 14 that targeted gait-oriented training.4,5,49,5666

Two RCTs concentrating on the effects of cardio-respiratory fitness employed the same popula-tion.53,54 One of these53 was used in our meta-analysis, and the second study was used to obtainadditional information. Despite being an RCT, thestudy by Lindsley et al.48 was excluded because of alack of information. Table 2 shows the main char-acteristics of the 21 studies included in the presentmeta-analysis.

The studies centering on lower-limb strengthtraining included 240 participants, of whom 121were assigned to the intervention group. Samplesizes ranged from 2046,47 to a maximum of 133participants.51 Time between stroke onset and thestart of the intervention ranged from 3 mos46 to a

mean of 4 yrs.47 Studies focusing on cardiorespi-ratory fitness training included 104 participants, ofwhom 53 were assigned to the intervention group.Individual study sample sizes were 1255 and 92participants,53 respectively. Time between strokeonset and the start of the intervention ranged froma mean of 16 days53 to more than 1 yr.55 Thestudies focusing on gait-related training included574 participants, of whom 332 were assigned to theintervention group. Individual sample sizes rangedfrom 958 to a maximum of 100 participants.4 Timebetween stroke onset and the start of the interven-tion varied between 8 days65 to a mean of 8 yrs.66

Methodological QualityPEDro scores ranged from four to eight points,

with a median score of seven points (Table 3). Allstudies, except for one,46 specified the eligibilitycriteria. In no study was the therapist blind togroup status. This was as expected, because thetherapists had to conduct the therapy, and there-fore they could be blinded. All studies applied sta-tistical analysis to group differences and reportedpoint estimates and measures of variability. Allstudies, except the work by Glasser,46 Teixeira-Salmela,66 Dean,58 and Macko and colleagues63,scored a minimum of six points. RCTs centering onlower-limb strengthening scored a median of sevenpoints (range four to eight). The two RCTs focus-ing on cardiorespiratory fitness both scored sixpoints.53 A median of seven points (range four toeight) was scored by RCTs targeting gait-orientedtraining.

Quantitative AnalysisPooling was possible for balance (four RCTs,

n 274),4,5,49,59 gait speed (17 RCTs, n 692),4,5,46,47,50,52,53,55,56,58,59,6166 and walking dis-tance (13 RCTs, n 743).4,5,49-53,5660,63 Balancewas determined by the Berg Balance Scale (BBS)67

in all studies. Gait speed was measured over dis-tances ranging from 5 to 30 m.65 Walking distancewas assessed by the 2-min51 or 6-min4,5,49,52,5660,68

walk test. Only Katz and colleagues53 asked thepatients to walk as far as they could.

One study on cardiorespiratory training53

failed to report baseline SDs, so we used the SD ofthe postintervention measurement to calculate gi(Figs. 2 and 3). Another study59 on gait-orientedtraining did not provide baseline SDs either, so SDswere derived from P values. The study by Richardsand colleagues65 included two control groups. Wedecided to include the early control group in ourreview because the number of patients who com-pleted this trial was larger than that in the othercontrol group.65


Lower-Limb Strengthening

Four studies46,47,50,52 targeting lower-limbstrengthening (n 107) measured gait speed. Aheterogeneous nonsignificant SES was found com-pared with the control groups (SES [random],0.13 SDU; CI, 0.73 to 0.47; Z 0.43, P 0.667, I2 57.1%). Three studies (n 200)5052

determined walking distance and found a homog-enous nonsignificant SES compared with control

groups (SES [fixed], 0.00 SDU; CI, 0.28 to 0.28;Z 0.02, P 0.98, I2 21%).

Cardiorespiratory Fitness TrainingTwo studies involving cardiorespiratory train-

ing53,55 (n 104) assessed gait speed. A homoge-neous nonsignificant SES was found comparedwith control groups (SES [fixed], 0.36 SDU; CI,0.03 to 0.75; Z 1.83, P 0.07, I2 0%).

FIGURE 1 Inclusion and exclusion criteria for the present review.


TAB

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ks;

five

tim

esa

wee

k;40

min

s

Bala

nce

(FM

-B),

mot

orfu

nctio

n(F

M),

ambu

latio

n(B

I),

bala

nce

(BBS

),ga

itsp

eed

Gro

upre

sults

dem

onst

rate

dth

atga

itve

loci

tyw

assi

mila

rin

the

thre

egr

oups

.

Dun

can

etal

.59

20(1

0/10

)Su

bacu

te(6

1)I:

Ther

apis

t-su

perv

ised

hom

e-ba

sed

exer

cise

prog

ram

toim

prov

est

reng

th,

bala

nce,

and

endu

ranc

e.C

:U

sual

care

.

12w

ks;

thre

eti

mes

aw

eek;

90m

ins

Mot

orfu

ncti

on(F

M),

bala

nce

(BB

S),

gait

spee

d,w

alki

ngdi

stan

ce,

ADL,

inst

rum

enta

lAD

L,qu

alit

yof

life

The

expe

rim

enta

lgr

oup

show

edgr

eate

rim

prov

emen

tof

neur

olog

ical

impa

irm

ent

and

low

er-e

xtre

mit

yfu

ncti

on.

Low

er-e

xtre

mit

ysc

ores

and

gait

velo

city

wer

esi

gnifi

cant

lydi

ffere

nt.


TAB

LE2

Con

tinue

d

Stud

yn(

E/C

)

Tim

eSi

nce

Stro

ke,

Mea

nD

ays

atIn

clus

ion

Inte

rven

tion

Inte

nsit

yO

utco

me

Aut

hor

sC

oncl

usio

n

Teix

eira

-Sa

lmel

aet

al.6

6

13(6

/7)

9

mos

(279

9)I:

Prog

ram

cons

isti

ngof

war

m-u

p,ae

robi

cex

erci

ses

(gra

ded

wal

king

plus

step

ping

orcy

clin

g),

low

er-e

xtre

mit

ym

uscl

est

reng

then

ing,

and

cool

-dow

n.C

:N

oin

terv

enti

on.

10w

ks,

thre

eti

mes

aw

eek;

609

0m

ins

Mus

cle

stre

ngth

and

tone

,le

vel

ofph

ysic

alac

tivi

ty(H

AP),

qual

ity

oflif

e(N

HP)

,ga

itsp

eed

The

com

bine

dpr

ogra

mof

mus

cle

stre

ngth

enin

gan

dph

ysic

alco

ndit

ioni

ngre

sult

edin

gain

sin

all

mea

sure

sof

impa

irm

ent

and

disa

bilit

y.D

ean

etal

.58

12(6

/6)

3

mos

(658

)I:

Cir

cuit

prog

ram

incl

udin

gw

orks

tati

ons

desi

gned

tost

reng

then

the

mus

cles

inth

eaf

fect

edle

gin

afu

ncti

onal

way

and

prac

tici

nglo

com

otio

n-re

late

dta

sks.

C:

Sim

ilar

orga

niza

tion

and

deliv

ery

asth

eex

peri

men

tal

grou

p,ex

cept

that

itw

asde

sign

edto

impr

ove

the

func

tion

ofth

eaf

fect

edup

per

limb.

4w

ks;

thre

eti

mes

aw

eek;

60m

ins

Gai

tsp

eed,

wal

king

dist

ance

,ti

med

upan

dgo

,si

tto

stan

d,st

epte

st

This

task

-rel

ated

circ

uit

trai

ning

impr

oved

loco

mot

orfu

ncti

onin

chro

nic

stro

ke.

Wal

king

dist

ance

,ga

itsp

eed,

and

the

step

test

show

edsi

gnifi

cant

impr

ovem

ents

betw

een

grou

ps.

List

onet

al.6

218

(10/

8)I:

Trea

dmill

retr

aini

ngw

ith

the

inst

ruct

ion

tow

alk

for

aslo

ngas

pati

ents

felt

com

fort

able

.C

:C

onve

ntio

nal

phys

ioth

erap

y.

4w

ks;

thre

eti

mes

aw

eek;

60m

ins

Sit

tost

and,

gait

spee

d,ba

lanc

e,AD

L,ni

ne-

hole

peg

test

Impr

ovem

ents

wer

ese

en,

but

ther

ew

ere

nost

atis

tica

llysi

gnifi

cant

diffe

renc

esin

gait

betw

een

the

conv

enti

onal

and

trea

dmill

retr

aini

nggr

oups

.La

ufer

etal

.61

25(1

3/12

)

90da

ys(3

4.2)

I:Ph

ysio

ther

apy

trea

tmen

tpl

usam

bula

tion

ona

mot

or-d

rive

ntr

eadm

illat

aco

mfo

rtab

lew

alki

ngsp

eed.

C:

Phys

ioth

erap

ytr

eatm

ent

plus

ambu

lati

onon

aflo

orsu

rfac

eat

aco

mfo

rtab

lesp

eed

usin

gw

alki

ngai

ds,

assi

stan

ce,

and

rest

ing

peri

ods

asne

eded

.

3w

ks,

five

tim

esa

wee

k;8

20m

ins

Stan

ding

bala

nce,

func

tion

alm

obili

ty(F

AC),

gait

spee

d,ga

itcy

cle

Trea

dmill

trai

ning

may

bem

ore

effe

ctiv

eth

anco

nven

tion

alga

ittr

aini

ngin

impr

ovin

gga

itpa

ram

eter

ssu

chas

func

tion

alam

bula

tion

,st

ride

leng

th,

perc

enta

geof

pare

tic

sing

le-s

tanc

epe

riod

,an

dga

stro

cnem

ius

mus

cula

rac

tivi

ty.


TAB

LE2

Con

tinue

d

Stud

yn(

E/C

)

Tim

eSi

nce

Stro

ke,

Mea

nD

ays

atIn

clus

ion

Inte

rven

tion

Inte

nsit

yO

utco

me

Aut

hor

sC

oncl

usio

n

Pohl

etal

.64

60(2

0/20

/20)

4

wks

(114

.6)

I1:

Con

vent

iona

lph

ysio

ther

apy

plus

limit

edpr

ogre

ssiv

etr

eadm

illtr

aini

ng(L

TT).

I2:

Con

vent

iona

lph

ysio

ther

apy

plus

stru

ctur

edsp

eed-

depe

nden

ttr

eadm

illtr

aini

ng(S

TT).

C:

Phys

ioth

erap

euti

cga

itth

erap

yba

sed

onth

ela

test

prin

cipl

esof

prop

rioc

epti

vene

urom

uscu

lar

faci

litat

ion

and

Bob

ath

conc

epts

.

4w

ks,

12se

ssio

ns;

30m

ins

Gai

tsp

eed,

cade

nce,

stri

dele

ngth

,fu

ncti

onal

mob

ility

(FAC

)

Stru

ctur

edST

Tin

post

stro

kepa

tien

tsre

sult

edin

bett

erw

alki

ngab

iliti

esth

anLT

Tor

conv

enti

onal

phys

ioth

erap

y.

Ada

etal

.56

27(1

3/14

)6

mos

to5

yrs

(822

)I:

Bot

htr

eadm

illan

dov

ergr

ound

wal

king

,w

ith

the

prop

orti

onof

trea

dmill

wal

king

decr

easi

ngby

10%

each

wee

k.C

:Lo

w-i

nten

sity

,ho

me

exer

cise

prog

ram

cons

isti

ngof

exer

cise

sto

leng

then

and

stre

ngth

enlo

wer

-lim

bm

uscl

esan

dto

trai

nba

lanc

ean

dco

ordi

nati

on.

4w

ks;

thre

eti

mes

atw

eek;

30m

ins

Gai

tsp

eed,

step

leng

than

dw

idth

,ca

denc

e,qu

alit

yof

life

(SA-

SIP3

0)

The

inte

rven

tion

prog

ram

sign

ifica

ntly

incr

ease

dw

alki

ngsp

eed

and

wal

king

capa

city

com

pare

dw

ith

the

cont

rol

grou

p.

Dun

can

etal

.492

(44/

48)

301

50da

ys(7

6)I:

Exe

rcis

epr

ogra

mde

sign

edto

impr

ove

stre

ngth

and

bala

nce

and

toen

cour

age

mor

eus

eof

the

affe

cted

extr

emit

y.C

:U

sual

care

.

12w

ks;

thre

eti

mes

aw

eek;

90m

ins

Low

er-e

xtre

mit

ym

uscl

ean

dgr

ipst

reng

th,

mot

orfu

ncti

on(F

M),

uppe

r-ex

trem

ity

func

tion

,ba

lanc

e(B

BS)

,en

dura

nce,

gait

spee

d,w

alki

ngdi

stan

ce

This

stru

ctur

ed,

prog

ress

ive

exer

cise

prog

ram

prod

uced

gain

sin

endu

ranc

e,ba

lanc

e,an

dm

obili

tybe

yond

thos

eat

trib

utab

leto

spon

tane

ous

reco

very

and

usua

lca

re.

Ble

nner

hass

ett

etal

.57

30(1

5/15

)Su

bacu

te(4

3)I:

Mob

ility

-rel

ated

grou

pac

tivi

ties

incl

udin

gen

dura

nce

task

san

dfu

ncti

onal

task

s.C

:U

pper

-lim

bgr

oup

acti

viti

esin

clud

ing

func

tion

alta

sks.

4w

ks;

five

tim

esa

wee

k;60

min

sU

pper

-lim

bfu

ncti

on(M

AS,

JTH

FT),

step

test

,ti

med

upan

dgo

,w

alki

ngdi

stan

ce

Find

ings

supp

ort

the

use

ofad

diti

onal

task

-rel

ated

prac

tice

duri

ngin

pati

ent

stro

kere

habi

litat

ion.

The

mob

ility

grou

psh

owed

sign

ifica

ntly

bett

erlo

com

otor

abili

tyth

anth

eup

per-

limb

grou

p.


TAB

LE2

Con

tinue

d

Stud

yn(

E/C

)

Tim

eSi

nce

Stro

ke,

Mea

nD

ays

atIn

clus

ion

Inte

rven

tion

Inte

nsit

yO

utco

me

Aut

hor

sC

oncl

usio

n

Eic

het

al.6

050

(25/

25)

6

wks

(44)

I:In

divi

dual

phys

ioth

erap

y,B

obat

h-or

ient

edpl

ustr

eadm

illtr

aini

ng.

C:

Indi

vidu

alph

ysio

ther

apy,

Bob

ath-

orie

nted

.

6w

ks;

five

tim

esa

wee

k;60

min

sG

ait

spee

d,w

alki

ngdi

stan

ce,

gros

sm

otor

func

tion

(RG

MF)

,w

alki

ngqu

alit

y

Addi

tion

ofae

robi

ctr

eadm

illtr

aini

ngto

Bob

ath-

orie

nted

phys

ioth

erap

yre

sult

edin

sign

ifica

ntim

prov

emen

tin

gait

spee

dan

dw

alki

ngdi

stan

ce.

Salb

ach

etal

.591

(44/

47)

Chr

onic

(228

)I:

Ten

func

tion

alta

sks

desi

gned

tost

reng

then

the

low

erex

trem

itie

san

den

hanc

ew

alki

ngba

lanc

e,sp

eed,

and

dist

ance

.C

:U

pper

-ext

rem

ity

acti

viti

es.

6w

ks;

thre

eti

mes

aw

eek

Tim

edup

and

go,

bala

nce

(BB

S),

gait

spee

d,w

alki

ngdi

stan

ce

The

task

-ori

ente

din

terv

enti

onsi

gnifi

cant

lyim

prov

edga

itsp

eed

and

wal

king

dist

ance

.

Mac

koet

al.6

361

(32/

29)

6

mos

afte

rst

roke

(112

5)I:

Prog

ress

ive

task

-ori

ente

dm

odal

ity

toop

tim

ize

loco

mot

orre

lear

ning

,pr

ovid

ing

card

iova

scul

arco

ndit

ioni

ng.

C:

Con

vent

iona

lth

erap

y.

6m

onth

s;th

ree

tim

esa

wee

k;40

min

s

Gai

tsp

eed,

wal

king

dist

ance

,en

dura

nce,

func

tion

alm

obili

ty(R

MI)

,W

alki

ngIm

pair

men

tQ

uest

ionn

aire

(WIQ

)

Bot

hfu

ncti

onal

mob

ility

and

card

iova

scul

arfit

ness

impr

oved

mor

eaf

ter

the

inte

rven

tion

than

afte

rco

nven

tion

alca

re.

Pang

etal

.49

63(3

2/31

)

1yr

(188

1)I:

Prog

ress

ive

fitne

ssan

dm

obili

tyex

erci

sepr

ogra

mde

sign

edto

impr

ove

card

iore

spir

ator

yfit

ness

,ba

lanc

e,le

gm

uscl

est

reng

th,

and

mob

ility

.C

:Se

ated

uppe

r-ex

trem

ity

prog

ram

.

19w

ks;

thre

eti

mes

aw

eek;

60m

ins

Mus

cle

stre

ngth

,ba

lanc

e(B

BS)

,en

dura

nce,

wal

king

dist

ance

,ph

ysic

alac

tivi

ty(P

AS)

The

inte

rven

tion

grou

pha

dsi

gnifi

cant

lygr

eate

rga

ins

inca

rdio

resp

irat

ory

fitne

ss,

mob

ility

,an

dpa

reti

cle

gst

reng

th.

E/C

,exp

erim

enta

lvs

.con

trol

grou

p;I,

inte

rven

tion

grou

p;C

,con

trol

grou

p;E

CO

N,e

arly

cont

rol

grou

p;FA

P,Fu

ncti

onal

Ambu

lati

onPr

ofile

;SF3

6,So

cial

Func

tion

ing

36;F

M,F

ugl

Mey

er;B

BS,

Ber

gba

lanc

esc

ale;

FM-B

,Fug

lMey

erba

lanc

e;C

MSA

,Che

doke

McM

aste

rst

roke

asse

ssm

ent;

LLFD

I,La

teLi

feFu

ncti

onan

dD

isab

ility

Inst

rum

ent;

GD

S,G

eria

tric

Dep

ress

ion

Scal

e;SI

P,Si

ckne

ssIm

pact

Profi

le;

BI,

Bar

thel

inde

x;H

AP,H

uman

Acti

vity

Profi

le;N

HP,

Not

thin

gham

heal

thpr

ofile

;SA-

SIP3

0,St

roke

Adap

ted-

Sick

ness

Impa

ctPr

ofile

30;M

AS,m

odifi

edAs

hwor

thsc

ale;

JTH

FT,J

ebse

nTa

ylor

hand

func

tion

test

;R

GM

F,R

iver

mea

dgr

oss

mot

orfu

ncti

on;

RM

I,R

iver

mea

dm

obili

tyin

dex;

WIQ

,W

alki

ngIm

pair

men

tQ

uest

ionn

aire

;PA

S,Ph

ysic

alAc

tivi

tySc

ale.


Because only one study analyzed the effect ofcardiorespiratory training on balance55 and one onwalking distance,53 these results are described inthe best-evidence syntheses.

Gait-Oriented TrainingFour studies assessed balance after gait-oriented

training4,5,49,59 and found a homogenous nonsignificantSES (SES [fixed], 0.19 SDU; CI, 0.05 to 0.43; Z 1.59,P 0.11, I2 0%). Twelve studies centered on gait-oriented training (n 501)4,5,56,58,5966 evaluatedgait speed and found a homogenous significant SES(SES [fixed], 0.45 SDU; CI, 0.270.63; Z 4.84, P 0.01, I2 31.3%). In addition, nine studies (n 451)4,5,49,5660,63 assessed the effect of gait-orientedtraining on walking distance. A heterogeneous signif-icant SES was found compared with the controlgroups (SES [random], 0.62 SDU; CI, 0.300.95; Z 3.73, P 0.01, I2 61.2%).

Best-Evidence SynthesesLower-Limb Strengthening

Two high-quality studies on lower-limb strength-ening47,52 selected stair climbing as a secondary out-come measure. Although they used different mea-sures to determine stair-climbing performance, bothstudies concluded that changes in stair climbing didnot significantly differ between the experimental andcontrol groups. One study also evaluated health-re-lated quality of life by means of the Short Form 36and concluded that there was no significant differ-

ence between groups.47 These findings provide strongevidence that programs focusing on lower-limbstrengthening do not produce greater improvementin stair-climbing ability than conventional care.Moreover, there was limited evidence that programsof lower-limb strengthening are not superior to con-ventional care in improving health-related quality oflife.

Cardiorespiratory Fitness TrainingThere is limited evidence that cardiorespira-

tory training negatively affects balance,55 and thereis limited evidence for a positive impact of cardio-respiratory training on walking distance.53 Onehigh-quality study53 on cardiorespiratory fitnesstraining also assessed stair climbing by asking thepatients to climb as many stairs as possible atcomfortable speed. The experimental group per-formed significantly better than the control group,suggesting limited evidence in favor of cardiorespi-ratory training for improving stair climbing.

Gait-Oriented TrainingStanding balance showed no statistically sig-

nificant differences between control and experi-mental groups in two high-quality studies focusingon gait-oriented training.61,62 Two high-qualitystudies, however, presented statistically significantdifferences between groups on the functional am-bulation category,61,64 whereas another high-qual-ity study failed to find significant results in favor of

TABLE 3 Physiotherapy Evidence Database (PEDro) scores for each RCT

Study 1 2 3 4 5 6 7 8 9 10 11 Total Score

Lower-limb strength trainingGlasser46 No 1 0 0 0 0 0 1 0 1 1 4Kim et al.47 Yes 1 0 1 1 0 1 1 1 1 1 8Bourbonnais et al.50 Yes 1 1 1 0 0 0 1 0 1 1 6Moreland et al.51 Yes 1 1 1 0 0 1 1 1 1 1 8Ouellette et al.52 Yes 1 0 1 0 0 1 1 1 1 1 7

Cardiorespiratory fitness trainingKatz-Leurer et al.53 Yes 1 0 1 0 0 1 1 0 1 1 6Chu et al.55 Yes 1 0 1 0 0 1 1 0 1 1 6

Gait-oriented trainingRichards et al.65 Yes 1 0 1 0 0 1 1 0 1 1 6Duncan et al.59 Yes 1 1 1 0 0 0 1 1 1 1 7Teixeira-Salmela et al.66 Yes 1 0 0 0 0 0 1 0 1 1 4Dean et al.58 Yes 1 1 0 0 0 0 0 0 1 1 4Liston et al.62 Yes 1 0 1 0 0 1 1 1 1 1 7Laufer et al.61 Yes 1 0 1 0 0 1 1 0 1 1 6Pohl et al.64 Yes 1 0 1 0 0 1 1 0 1 1 6Ada et al.56 Yes 1 1 1 0 0 1 1 1 1 1 8Duncan et al.4 Yes 1 1 1 0 0 1 1 1 1 1 8Blennerhassett et al.57 Yes 1 1 1 0 0 1 1 1 1 1 8Eich et al.60 Yes 1 1 1 0 0 1 1 1 1 1 8Salbach et al.5 Yes 1 1 1 0 0 1 1 1 1 1 8Macko et al.63 Yes 1 1 1 0 0 0 0 0 1 1 5Pang et al.49 Yes 1 1 1 0 0 1 1 1 1 1 8


gait-oriented training on the Rivermead MobilityIndex.63 The high-quality studies also found nosignificant effects of gait-oriented training on out-comes such as ADL,59,62,65 instrumental ADL,4,62 orhealth-related quality of life,56,59 although one low-quality study did find significant differences in qualityof life between groups.66 Finally, one high-qualitystudy concluded that there were no significant differ-ences in walking quality between the control andexperimental groups.60

The above findings provide strong evidencethat standing balance, ADL, IADL, or quality of lifeare not significantly more improved by gait-ori-ented training than by conventional care. Strongevidence was found for improved functional mobil-ity after gait-oriented training, whereas limited ev-idence was found that there is no effect of gait-oriented training on walking quality.

DISCUSSIONThis systematic review included 21 high-qual-

ity RCTs. The results showed positive, significanteffects of gait-oriented training on gait speed and

walking distance, whereas no significant effectswere found on balance control as measured by theBBS. Although there is evidence that the BBS is aresponsive tool,69 there is some discussion aboutthe clinical implication of the changes assessed bythe BBS.70 The significant SES for gait-orientedtraining programs corresponds to a mean improve-ment of 0.14 m/sec for gait speed and 41.2 m on the6-min walk test. The small number of studies thatevaluated cardiorespiratory fitness training usingnonfunctional approaches, by means of leg cycleergometers and water-based exercises, also foundpositive effects on gait speed. In contrast, programsfocusing on lower-limb strengthening alone failedto show significant effects on gait speed and walk-ing distance.

In agreement with the above findings, a best-evidence synthesis showed that lower-limb strengthtraining did not affect outcomes such as stair climb-ing or health-related quality of life, whereas strongevidence was found for a favorable effect of cardiore-spiratory training on stair-climbing performance. Inaddition, there is some evidence that cardiorespira-

FIGURE 2 Summarized effect of gait speed (mean and 95% CI).


tory training negatively affects balance55 and has apositive impact on walking distance.53 Finally, strongevidence was found that balance, ADL, IADL, orhealth-related quality of life were not significantlyaffected by gait-oriented training, although func-tional mobility was positively impacted. However,these conclusions need to be interpreted with somecaution, because the authors used ordinal scales toassess balance and ADL, and they treated these ascontinuous scales, reporting means and CIs.

The main finding of the present review is thatprograms focusing on cardiorespiratory and gait-oriented training are more beneficial in improvingwalking competency than programs centered onstrengthening. This finding supports the generalview of motor learning that exercise regimensmainly induce specific treatment effects, suggest-ing that gait and gait-related activities should bedirectly targeted. In other words, the training pro-grams need to focus primarily on the relearning offunctional gait-related skills that are relevant tothe individual patients needs.7,71 Because gaitspeed over a short distance overestimates walkingdistance in a 6-min walk test,72 one should realizethat improving gait speed does not automaticallyresult in improvements in walking distance. This

underscores the fact that training should be taskspecific. The lack of evidence to support the rela-tionship between strength gains and improvementsin walking ability47,64 also suggests that, despite thesignificant improvement in strength, therapy-in-duced improvements do not automatically generalizeto significant gains in gait performance.47,52,73

The mechanisms underlying therapy-inducedimprovements in gait performance are not yet wellunderstood. Recent electroneurophysiologicalstudies in which the EMG activity of the pareticmuscles was serially recorded45 and studies record-ing improvements in standing balance74,75 haveshown that task-related improvements were poorlyrelated to physiologic gains on the paretic side.Closer associations have been found with compen-satory adaptive changes on the nonparetic side,such as increased anticipatory activation of mus-cles of the nonparetic leg,75 strategies using in-creased weight bearing above the nonparetic legduring standing,74 or stride lengthening of thenonparetic leg32 during walking. In other words,there is growing evidence that functional improve-ments are closely related to the use of compensa-tory movement strategies in which patients learnto adapt to existing impairments.45 Because it is

FIGURE 3 Summarized effect size of walking distance (mean and 95% CI).


still unclear which compensatory characteristicsare most closely related to gains in walking com-petency, longitudinal kinematic and neurophysio-logic studies are needed for a better understandingof the underlying mechanisms of functional im-provement.

Although only two studies focusing on theeffect of cardiorespiratory fitness interventions(without walking) on gait speed could be included,a positive effect on walking speed was found; how-ever, this effect was not statistically significant.This is in accordance with the Cochrane review ofSaunders and colleagues.3 The only study that as-sessed the effect of cardiorespiratory training onwalking distance showed that cardiorespiratorytraining was beneficial in improving distancewalked.53 These results are in agreement with thefindings in the recently conducted review of Panget al.76 Obviously, improving aerobic capacity as areflection of physical condition is an importantfactor in restoring walking competency, because ithas been suggested that the energy costs of walkingare substantially higher in people with stroke thanin normal individuals.77 These high energy de-mands are frequently associated with less efficientmotor control in hemiplegic compared withhealthy subjects, resulting from the use of com-pensatory or adaptive movement strategies to per-form functional tasks such as walking.77,78 Energyexpenditure required to perform routine ambula-tion is increased approximately 1.5- to 2.0-fold inhemiparetic stroke patients compared with normalcontrol subjects.79 The lower walking speeds ob-served in patients with hemiparesis (30 m/min)consume approximately the same amount of oxy-gen (10 ml/kg per minute)80 as healthy peoplerequire when walking approximately twice as fast(i.e., 60 m/min).81 However, the number of studiesinvestigating energy expenditure after stroke islimited.

The present review also suggests that enhanc-ing walking endurance by improving physical con-dition seems to be less specific, because progressivebicycling programs resulted in significant gains inwalking endurance.45 Progression in training pro-grams seems to be an important aspect of improv-ing walking endurance.5 The fact that balance isalso improved by cardiorespiratory training mightalso suggest that it would be beneficial in improv-ing gait speed and walking distance, because bal-ance is highly related to independent gait.53,82

However, more RCTs are needed to allow conclu-sions on the effects of nonspecific cardiorespiratorytraining on walking competence.

Further improvement of stroke rehabilitationcould be achieved by identifying which patientsbenefit most from supervised83 physical fitnesstraining programs. Salbach et al.5 indicated that

most effects were gained in the group of patientswith a moderate walking deficit. Another studysuggested that persons with severe depressivesymptoms may be particularly responsive to ther-apeutic intervention.22 Recently, Lai and cowork-ers84 concluded that depressive symptoms do notrestrict gains in functional outcome as a result ofphysical exercise. They also suggested that exercisemay help reduce poststroke depressive symptoms.Recently, we found that the presence of depressivesymptoms, fatigue, reduced cognitive status, andan inactive lifestyle are important factors related toa gradual decline in mobility over time.85 In otherwords, these variables can be used to identify thosepatients who are at risk for mobility decline, be-cause function-oriented training is effective in im-proving walking competency. The moment atwhich these gait-oriented treatments are intro-duced seems not to be restricted to a particularphase after stroke or to a particular type of stroke.

Although this systematic review aimed at iden-tifying all relevant trials, the study was subject tocertain limitations. First, the review did not in-clude papers written in languages other than En-glish, German, or Dutch or studies focusing onbody weightsupport treadmill-training programs.In addition, the definitions of strengthening, car-diorespiratory fitness, and gait-oriented trainingwe used were arbitrary.

CONCLUSION

This review shows that gait-oriented training,targeting improved strength and cardiorespiratoryfitness, is the most successful method to improvegait speed and endurance. This is an importantfinding for clinical practice, because about 20% ofall chronic stroke patients show a significant de-cline in mobility status in the long run.85 Futurestudies should elucidate whether a functionaltraining program can improve walking competencyin patients who are susceptible to a decline inmobility such as the very old, those severely com-promised, and those who are depressed. In addi-tion, current debate has concentrated on whetherthe critical variable for therapeutic efficacy is taskspecificity or the intensity of the effort involved intherapeutic activities (increased volume, increasedlevel of participation, increased intensity)86as-pects that need further investigation. Future stud-ies should establish whether the improvements ingait speed and walking distance that have beendescribed are of clinical relevance for independentcommunity ambulation. In addition, the long-termeffects of these training interventions need to beinvestigated.


ACKNOWLEDGMENTSWe wish to thank Wieteke Ermers (WE) from

the University of Maastricht and Hans Ket from theVU Medical Library for the literature search.

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