CASE REPORT I
BACKGROUND
Mrs PG is 65 and lives with her husband, who is still working part time. She woke up not being able to speak coherently and not being able to move the right side of her body. The ambulance was called and she was admitted to hospital. It is now Day Six.
MEDICAL STATUS
Diagnosed having had a stroke. Conscious. On blood pressure lowering medication.
IMPAIRMENTS
Weakness – severe in most lower limb muscles and all upper limb muscles.
Incoordination – unable to be assessed due to severe weakness.
Spasticity – no spasticity – Tardieu scale score X = 0 at V3 (fast velocity) during ankle dorsiflexion and elbow extension.
Sensation – normal.
Language – expressive aphasia so she understands 90 % but can only communicate about 40 % of what she wants to say.
Cognition – normal.
Perception – normal.
ACTIVITY LIMITATIONS
Standing – cannot stand independently, needs help from one person.
Walking – cannot walk independently, needs substantial help from two people.
Use of upper limb – no voluntary movement at any joint.
QUESTION 1
Should treadmill training with body weight support (BWS) be used to retrain walking?
The first step in answering this question is to decide on the outcomes of interest.
Given that Mrs PG is non-ambulatory, whether or not treadmill training with BWS is effective at establishing walking will be of prime interest. Furthermore, the quality of the walking produced by the training will be of interest. There are numerous outcome measures which evaluate walking, ranging from performance-based tests (such as the 10-m Walk Test (Wade 1992)) to ordinal scales (such as Item 5 of the Motor Assessment Scale for Stroke (Carr et al. 1985)). The most commonly used measure in clinical trials is the 10-mWalk Test, probably because it is simple to carry out, reliable, and yields continuous data. Furthermore, the most common parameter reported is walking speed and, while not measuring quality of walking directly, it nevertheless reflects qualitative gait parameters such as step length and cadence. This relationship is described in the equation:
Speed = (stride length × cadence)/120
Therefore, proportion of patients walking and the 10-m Walk Test are probably the best measures reflecting the outcomes of interest.
The next step in answering the question is to look for evidence of whether treadmill training improves the proportion of people walking independently, or the quality of walking. Considering the highest levels of evidence first, there are two systematic reviews assessing the efficacy of treadmill training with BWS after stroke. The efficacy of treadmill training with BWS was considered in a review by Van Peppen and colleagues (2004 A). They concluded that treadmill training with BWS does not improve walking speed or ability although it does appear to improve walking endurance.
However, most of the participants in the trials included in this review were already walking and so this finding is of limited use in answering the question. The efficacy of treadmill training with BWS was also considered in a Cochrane review by Moseley and colleagues (2005 A). They did separate their analyses into those who were non-ambulatory versus those who were ambulatory. They report that there is no greater risk of being non-ambulatory or a dependent walker if treadmill training with BWS is used than if other more conventional interventions are used (RR 1.1, 95 % CI 0.9 to 1.3). This finding was based on 178 participants in five randomised trials (da Cunha Filho et al. 2002, Kosak et al. 2000, Nilsson et al. 2001, Scheidtmann et al. 1999, Werner et al. 2002 A). Furthermore, walking speed was no different as a result of the interventions (WMD –0.01 m/s, 95 % CI –0.08 to 0.06). This finding was based on 148 participants in four randomised trials (da Cunha Filho et al. 2002; Kosak et al. 2000; Nilsson et al. 2001;Werner et al. 2002 A). The more conventional therapy used in these trials was always exactly matched for frequency and duration and was usually carried out for 20–45 minutes, five days a week. Two trials used a motor learning approach (da Cunha Filho et al. 2002; Nilsson et al. 2001 A), while one trial used a neurophysiologic approach (Scheidtmann et al. 1999), one used an orthopaedic approach (Kosak et al. 2000 A), and one used another walking device (Werner et al. 2002 A).
Given that treadmill walking with BWS is no more or less effective than the same amount of conventional therapy, the decision of whether to undertake it with Mrs PG will have to be made on other factors. Such factors are the efficient use of staff time, the amount of practice likely to be undertaken during overground walking versus treadmill walking, and Occupational Health and Safety. At the moment, it takes two therapists to help Mrs PG practise the whole task of walking overground. While this was controlled in the randomised trials, it is unlikely two staff members will be free to help her for very long in ordinary clinical practice. Walking on the treadmill with BWS means that she may only need the help of one therapist to move her affected leg forward in swing phase, even if it takes two people to assist her onto the treadmill. It is likely to be easier to move Mrs PG’s leg during swing when she is in one place on a treadmill than to support it during swing and stance while she is trying to progress overground (since it does not matter if the knee flexes during stance, as the body is supported). Treadmill walking with partial weight support via an overhead harness provides the opportunity to complete larger amounts ofwalking practice, for example, even if patients only walk for five minutes at a slow speed of 0.2 m/s supported on a treadmill, they will ‘walk’ 60 m (Crompton et al. 1999 C). It is likely, therefore, that Mrs PG will undertake more practice of the whole task of walking if she does treadmill training with BWS.
Taking into account all the evidence, treadmill training with BWS should be an intervention capable of establishing walking in Mrs PG.
QUESTION 2
How should treadmill training with BWS be applied to improve the likelihood of the patient becoming ambulatory with good quality of walking?
To answer this question, observational studies of treadmill and overground walking after stroke can be examined. These studies compare walking overground with walking on a treadmill with BWS in stroke patients who are just walking or walking with difficulty (Chen et al. 2005a, 2005b; Hassid et al. 1997; Hesse et al. 1997 A). One of the common findings is that by adding BWS, the symmetry of walking is improved, due to the increased time the affected leg spends in single stance phase. However, there may be a limit to how much support should be given. Hesse and colleagues (1997 A) compared 0, 15, 30, 45 and 60 % BWS. They found that over 30 % BWS resulted in markedly abnormal muscle activity in six lower limb muscles they examined. This has resulted in a maximum of 30 % BWS becoming something akin to an industry standard. Perhaps the most useful information comes from Chen and colleagues (2005a, 2005b A), who systematically varied BWS, speed of treadmill, stiffness of the support harness, and support from a handrail. They found that different factors were helpful in different aspects of walking. For example, increasing BWS combined with support from a handrail produced the most symmetrical walking in orthopaedic approach (Kosak et al. 2000 A), and one used another walking device (Werner et al. 2002 A).
Given that treadmill walking with BWS is no more or less effective than the same amount of conventional therapy, the decision of whether to undertake it with Mrs PG will have to be made on other factors. Such factors are the efficient use of staff time, the amount of practice likely to be undertaken during overground walking versus treadmill walking, and Occupational Health and Safety. At the moment, it takes two therapists to help Mrs PG practise the whole task of walking overground. While this was controlled in the randomised trials, it is unlikely two staff members will be free to help her for very long in ordinary clinical practice. Walking on the treadmill with BWS means that she may only need the help of one therapist to move her affected leg forward in swing phase, even if it takes two people to assist her onto the treadmill. It is likely to be easier to move Mrs PG’s leg during swing when she is in one place on a treadmill than to support it during swing and stance while she is trying to progress overground (since it does not matter if the knee flexes during stance, as the body is supported). Treadmill walking with partial weight support via an overhead harness provides the opportunity to complete larger amounts ofwalking practice, for example, even if patients only walk for five minutes at a slow speed of 0.2 m/s supported on a treadmill, they will ‘walk’ 60 m (Crompton et al. 1999 C). It is likely, therefore, that Mrs PG will undertake more practice of the whole task of walking if she does treadmill training with BWS.
If the affected arm has no voluntary muscle activity, use a firm sling to support it, but if there is some activity, put the hand to the handrail using a bandage or a weightlifting splint (see Figure 1).
When the knee can be held straight during stance phase, we reduce the BWS.We have found that an easy transition is made to overground walking when the patient can walk on the treadmill at 0.5 m/s with ≤ 10 % BWS.
PLAN: TO ESTABLISH GOOD QUALITY WALKING IN MRS PG
A specific intervention plan, based on the above evidence, to carry out treadmill training with BWS for Mrs PG using a treadmill and overgound BWS system, is outlined below:
Gain medical clearance and consent to participate in exercise programme Consult with Mrs PG’s treating doctor to organise medical clearance to participate in treadmill walking training with BWS. Put harness on in lying and make sure Mrs PG is wearing shoes. Apply triangular sling to affected arm. Wheel Mrs PG onto treadmill in a wheelchair. Use the automatic lift function to lift her into standing. Given that Mrs PG has communication problems, modified safety procedures will have to be put in place. Attach safety strap, have relative or aide standing by emergency stop switch and teach Mrs PG a signal to indicate that the treadmill should be stopped.
Initial treadmill and BWS programme
To begin with, do not run the treadmill. Allow Mrs PG to hang on to a handrail. Increase BWS to 30%in standing and make sure knee of affected leg is bent no more than 15 degrees. If it is, increase BWS. Put Mrs PG’s affected foot in a pillow slip and twist at the front. Turn on a metronome at a frequency which matches the highest cadence that Mrs PG can manage. Sit on a low stool and help Mrs PG to walk on the spot in time with the rhythm by using the right hand to flex the knee and the left hand to lift the twisted part of the pillowcase. Then turn the treadmill on as slowly as possible. Mrs PG should keep walking in time with the metronome – the metronome frequency and the treadmill speed will determine her step length. Lift the affected leg forward during swing phase but encourage Mrs PG to extend her lower limb during stance and allow the BWS to hold her up. Count steps for encouragement and take a rest every two minutes at first.
Progressing treadmill and BWS programme Increase step length by slowing down the metronome. When step length is increased, increase the speed until step length is compromised. When Mrs PG can straighten her knee from the 15 degrees, reduce the BWS. Continue to alternate these two strategies until she is walking at 0.5 m/s with≤10%BWS. At this stage begin to do overground walking with BWS.
Overground and BWS programme
Lock the wheels of the support frame so that it will only run in one direction. Put markers on the floor to increase step length and constrain step width. Apply only the trunk/pelvis part of harness, firmly. Push the support frame as Mrs PG walks forwards and then backwards overground. Progress by loosening the vertical support straps, getting Mrs PG to push the frame herself, and increasing step length and decreasing step width (see Figure 3).
Monitoring progression and enhancing compliance
At the beginning, record the number of steps to provide encouragement. Then, as ability improves, record distance covered on treadmill, highest speed and lowest amount of BWS – graph to provide motivation to improve. Record distance, step length and width during overground walking with BWS. As independent walking overground is possible, use 10-m Walk Test at the same time every week to monitor progress. As well as timing over the 10-m, count the number of steps and calculate average step length and cadence.
CASE REPORT II
BACKGROUND
Mr IB is 70 and lives alone. He has a very supportive daughter nearby, although she is busy bringing up four children. He suffered a stroke two years ago. Recently he has felt that his walking has deteriorated, and has approached a physiotherapy ambulatory care service for help.
Figure 3. Using a portable system to practise overground walking. Harness is for safety only. Markers on the floor encourage a long step length and narrow step width (refers to Case Report II).
MEDICAL STATUS
On blood pressure lowering medication.
IMPAIRMENTS
Weakness – moderately strong in lower limb muscles.
Incoordination – slight problem with incoordination in both upper limb and lower limb.
Spasticity – mild spasticity – Tardieu scale score X = 1 at V3 (fast velocity) during ankle dorsiflexion and X = 2 during elbow extension. Contracture – loss of 10◦ ankle dorsiflexion.
Sensation – tactile and kinaesthetic sensation moderately impaired.
Language – normal.
Cognition – slight memory loss.
Perception – normal.
ACTIVITY LIMITATIONS
Standing – can stand with feet together and look over both shoulders without falling or having to take a step, but uses arms.
Walking – can walk independently, but very slowly and carefully at 0.6 m/s and 190m in six min.
Use of upper limb – can use for support but not manipulation of objects (mostly due to loss of sensation).
In addition to the trials that match Mr IB’s characteristics, there is more evidence (although at a weaker level) which suggests treadmill walking may be a useful intervention to improve both the speed and capacity of walking in such patients. In uncontrolled trials of chronic stroke patients, treadmill walking has been associated with increases in strength (Smith et al. 1998, 1999 A), decreases in energy expenditure(Macko et al. 1997, 2001 A), as well as increases in walking speed and quality (Silver et al. 2000 A).
Taking into account all the evidence, treadmill training should be an intervention capable of improving Mr IB’s community ambulation.
QUESTION 2
How should treadmill training be applied to improve community ambulation?
The most logical approach to answering this question is to examine how the intervention was implemented in the two trials which provided evidence that treadmill walking was effective in improving six minute distance (Ada et al. 2003; Macko et al. 2005 A). Macko and colleagues’ training programme was six months, 10–40 minute sessions, three times a week. The sessions were characterised by progressive increases in duration (five minutes per session every two weeks) and in aerobic intensity (5 % Heart Rate Reserve every two weeks, achieved by increasing the speed
of the treadmill). Training speed increased from 0.48 ± 0.3 m/s at baseline to 0.75 ± 0.3 m/s at six months, and training duration increased from 12 ± 6 minutes to 41 ± 10 minutes at six months.
Ada and colleagues implemented a training programme three times a week for only four weeks. The training sessions comprised 30 minutes of walking, which took about 45 minutes to accomplish. Each session consisted of both treadmill and overground walking, with the proportion of treadmill walking decreasing by 10 % each week, from 80%inWeek One to 50%inWeek Four. Subjects received individual training from a physical therapist; however, there was some opportunity for social interaction since two subjects were trained concurrently. The programme was carried out in a community setting and transport was provided if necessary. The treadmill walking componentwas structured to increase step length, speed, balance, fitness, and automaticity. To increase step length, the treadmill was run at a comfortable speed and instructions such as ‘walk as slowly as possible’ or ‘take as few steps as possible’ were used. When a normal step length was observed, the speed of the treadmill was increased (until step length was compromised). When maximum speed was achieved, balance was challenged by reducing the degree of hand support, and fitness encouraged by increasing the incline of the treadmill, thereby increasing workload.
Finally, automaticity was promoted by presenting the subjects with a concurrent cognitive task (Canning et al. 2006 A; Paul et al. 2005). The cognitive task consisted of matching the word ‘red’ with the response ‘yes’, or the word ‘blue’ with the response ‘no’ (Bowen et al. 2001 A).
The overground walking component aimed to reinforce improvements in walking pattern and speed achieved on the treadmill. To reinforce the increased step length, visual cues were used in the form of non-slip footprints, which were laid at intervals normal for that subject’s height. As step length approximated normal, subjects were encouraged to walk faster and were timed for feedback. Step width was reduced and balance challenged by forcing subjects to walk within one floor tile or walk along a line forwards, sideways and backwards. Workload was increased by introducing stairs and slopes to overground walking practice, and automaticity was promoted by the introduction of dual tasks. Subjects walked continuously around an outdoor circuit, which included curbs, slopes, stairs and rough terrain, while conversing with the trainer. The immediate improvement in walking capacity measured by the 6-min. Walk Test was greater in the Ada and colleagues study than in Macko and colleagues.
As described above there were differences in the programmes, which may account for these results. Macko and colleagues only used treadmill training, with increasing speed and session duration, whereas Ada and colleagues’ programme involved treadmill and overground walking, focusing not only on fitness but also on quality and automaticity of walking. There is other evidence to suggest that the content of a treadmill walking programme is important in determining effectiveness. For example, Pohl and colleagues (2002 A) have shown the importance of manipulating the speed of the treadmill to achieve increases in overground walking speed. However, it has been shown that stroke patients generally achieve higher walking velocities by increasing their cadence rather than step length (Wagenaar et al. 1992 A). We therefore suggest that treadmill training programmes should include overground walking components where increases in walking speed and step length are encouraged. The improvements in walking capacity were not maintained in the Ada and colleagues study, which suggests that the one month duration was insufficient and that treadmill programmes should be of longer duration, such as the six months used by Macko and colleagues.
Based on the strategies implemented by Macko and colleagues and Ada and colleagues, we would recommend a treadmill and overground programme of 30 to 40 minutes three times a week for four to six months, with training aimed to increase speed, step length, aerobic intensity and automaticity.
PLAN: TO IMPROVE MR IB’S COMMUNITY AMBULATION
Aspecific intervention plan for Mr IB, based on the above evidence, is outlined below:
Gain medical clearance and consent to participate in exercise programme Consult with Mr IB’s treating doctor to organise medical clearance or stress test (as per ASCM guidelines) to participate in a treadmill and overground walking programme aimed at improving walking capacity and aerobic fitness.
Clinical facility: supervised treadmill overground walking programme focused on improving step length
Arrange for Mr IB to attend ambulatory care/out-patient setting three times a week for two weeks. Negotiate with his daughter to provide transport or organise community transport. At the initial session, determine if other impairments are interfering with walking and if so recommend treatment or adaptation. Mr IB’s impaired sensation may be a reason he cannot walk backwards, since in this situation he has no peripheral vision of his feet. Commence a supervised treadmill and overground walking programme focusing on increasing step length and then increasing speed and step length. Include a warm up, involving stretches of the calf and hip flexor muscles against a wall, before Mr IB gets on treadmill.
Local gym: treadmill training focusing on aerobic training
Consult with Mr IB and his daughter to find a local gym with a treadmill which Mr IB can access without relying on her for transport. Use a heart rate monitor (pulse monitor on treadmill) and aim to build up to training at 60–70 % of heart rate reserve for 30–40 minutes, three days a week for 8–12 weeks. Involve a personal trainer if Mr IB can afford it, and have the trainer monitor frequency, intensity and duration as well as encourage long steps. Therapist to call Mr IB one to two days a week to monitor the programme and enhance compliance.
Clinical facility: supervised treadmill and overground programme focused on automaticity
Arrange for Mr IB’s daughter to bring him into the ambulatory care setting three days a week for two weeks. In these sessions, work on automaticity by introducing dual tasks, both on the treadmill and on an outdoor circuit with slopes, curbs and gutters.
Home visit
Devise a maintenance programme which Mr IB is contracted to complete. It should involve walking in his own community, for example, to the shops, around the block, accessing public transport. It may include continued attendance at the gym.
Monitoring progression and enhancing compliance
Organise regular weekly phone calls to discuss and progress monitoring programme.
Institute formal reviews either in the community or at the facility to measure his walking using the 6 min. Walk Test every one to two months and progress his programme accordingly. In addition, a maintenance programme needs to be instituted and regularly reviewed to ensure that gains in walking capacity and improvements in physical activity are maintained over the long term.
CONCLUSION
In this chapter we have presented two cases in which treadmill training has been considered as an intervention to improve walking after stroke. We have highlighted the fact that the challenge for clinicians is to determine the most appropriate intervention in light of current high level evidence (systematic reviews, randomised controlled trials), weaker evidence (uncontrolled trials), observational studies, clinical experience and common sense. We argue that, while there is no conclusive high level evidence that treadmill training is effective, for other reasons treadmill training is worthy of implementation, and have given practical advice about how to implement treadmill training, both to establish walking in a non-ambulatory patient and to improve ambulation in a person residing in the community. The intervention plans reflect a balance between current evidence, clinical experience and common sense. It is essential they are regularly reviewed and updated as new evidence comes to light.
ACKNOWLEDGEMENTS
We would like to acknowledge the contribution of the clinicians, particularly Stephanie Potts and Ohnmar Aung, who are helping us undertake the randomised trial of the effectiveness of using treadmill and BWS in establishing walking in nonambulatory patients after stroke. We thank them for sharing their experiences of implementing this intervention.
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