Treadmill training to improve mobility for people with sub-acute stroke: a phase II feasibility randomized controlled trial.

OBJECTIVE: This phase II study investigated the feasibility and potential effectiveness of treadmill training versus normal gait re-education for ambulant and non-ambulant people with sub-acute stroke delivered as part of normal clinical practice. DESIGN: A single-blind, feasibility randomized controlled trial. SETTING: Four hospital-based stroke units. SUBJECTS: Participants within three months of stroke onset. INTERVENTIONS: Participants were randomized to treadmill training (minimum twice weekly) plus normal gait re-education or normal gait re-education only (control) for up to eight weeks. MAIN MEASURES: Measures were taken at baseline, after eight weeks of intervention and at six-month follow-up. The primary outcome was the Rivermead Mobility Index. Other measures included the Functional Ambulation Category, 10-metre walk, 6-minute walk, Barthel Index, Motor Assessment Scale, Stroke Impact Scale and a measure of confidence in walking. RESULTS: In all, 77 patients were randomized, 39 to treadmill and 38 to control. It was feasible to deliver treadmill training to people with sub-acute stroke. Only two adverse events occurred. No statistically significant differences were found between groups. For example, Rivermead Mobility Index, median (interquartile range (IQR)): after eight weeks treadmill 5 (4-9), control 6 (4-11) p = 0.33; or six-month follow-up treadmill 8.5 (3-12), control 8 (6-12.5) p = 0.42. The frequency and intensity of intervention was low. CONCLUSION: Treadmill training in sub-acute stroke patients was feasible but showed no significant difference in outcomes when compared to normal gait re-education. A large definitive randomized trial is now required to explore treadmill training in normal clinical practice.

Inter- and Intrarater Reliability of the Infant Motor Profile in 3- to 18-Month-Old Infants.

PURPOSE: To investigate inter- and intrarater reliability scoring the Infant Motor Profile (IMP). METHODS: A total of 20 infants at risk for motor developmental delay were assessed using the IMP. Six infants were born at term (gestational age: 38-42 weeks), and 14 infants were preterm (gestational age: 24-35 weeks). Videos were analyzed twice with an interval of 1 month by 4 assessors after 2 days of IMP training. RESULTS: Spearman rank scores demonstrated strong interrater and intrarater reliability for total IMP scores (inter: r = 0.80-0.96; intra: r = 0.85-0.97) and the domain of performance (r = 0.95-0.99). Reliability for the domains of variation, variability, and fluency was satisfactory (inter: r = 0.15-0.85; intra: r = 0.30-0.92). The weakest agreement was found in the domain of symmetry (inter: r = 0.20-0.69; intra: r = 0.33-0.65). CONCLUSION: Therapists naive to the IMP demonstrate good intra and interrater reliability (after 2 days of training) for most domains with the exception of symmetry.

A comparison of treadmill walking and overground walking in independently ambulant stroke patients: a pilot study.

Purpose. The purpose of the study was to compare the spatio-temporal and joint kinematic gait parameters of stroke patients walking on a treadmill and overground, to examine the assumption that patients walking on a treadmill will approximate the requirements of walking overground. Methods. Ten independently ambulant chronic stroke patients were included in the study. Vicon was used to collect spatio-temporal and joint kinematic data during overground walking at comfortable speed and at matched speed on the treadmill. Results. Walking on the treadmill demonstrated statistically significantly lower cadence, and longer step times of the non-hemiplegic and hemiplegic limbs. Absolute stance times of both limbs, absolute double support time, relative stance time and relative double support time were significantly longer during treadmill walking. Compared to overground walking, the inter-limb symmetries of step time, stance time, and stance/swing time ratio were significantly greater on the treadmill. During treadmill walking, joint kinematic data showed statistically significant changes with greater flexion of the nonhemiplegic knee and hip at initial contact, and less hip extension of the hemiplegic limb. Maximal ankle plantarflexion and knee extension of the hemiplegic limb occurred later in the gait cycle on the treadmill. Conclusion. These differences suggest it may be useful to use treadmill in conjunction with overground walking to focus on improving specific walking deficits in patients with stroke.

Stepping onto a single step: a kinematic study.

BACKGROUND AND PURPOSE: To describe the timings and ranges of linear displacements of the pelvis and feet occurring in a healthy older population when stepping up onto a step, and to describe variations noted in a small sample of subjects with hemiplegia. METHOD: An observational case series study design was used and the study took place in a gait laboratory in a general hospital. A convenience sample of 54 healthy volunteers (mean age 57.6 years, range 40-90 years; 26 males, 28 females) and six subjects with chronic hemiplegia (mean age 61.7 years, range 47-70 years; five males, one female) was recruited. Participants stepped up onto an 18 cm step. The following outcome measures were made: kinematic measures of stepping up cycle time; pelvic lateral displacement; width of foot base; and height of heel clearance by use of CODA (a three-dimensional movement analysis system). RESULTS: The mean (standard deviation, SD) stepping up cycle of healthy subjects was 1.68 seconds (+/- 0.22 seconds). The total range of pelvic lateral displacement during one stepping up cycle was 70 mm. Pelvic lateral displacement was asymmetrical, being significantly greater towards the initial weightbearing leg (p<0.0001). Older subjects (aged 60+ years) had less heel clearance (p<0.03) than younger subjects (aged <60 years). Stepping up performance by subjects with hemiplegia showed wide inter-subject variability, and was observed to be as much as three times slower to use as much as four times the range of pelvic lateral displacement and twice the foot base, and to be asymmetrical in timing of the stepping up cycle. CONCLUSIONS: This kinematic study describes a healthy stepping up pattern not previously reported. Age and hemiplegia influenced the amount and speed of movement adopted during the task. Information about the movement strategies used by the elderly and those with hemiplegia should guide physiotherapists in their management of physical function.

Establishing the reliability of Mobility Milestones as an outcome measure for stroke.

UNLABELLED: Baer GD, Smith MT, Rowe PJ, Masterton L. Establishing the reliability of mobility milestones as an outcome measure for stroke. Arch Phys Med Rehabil 2003;84:977-81. OBJECTIVE: To establish intrarater, interrater, and test-retest reliability of a standardized measure of mobility, "mobility milestones," incorporating sitting balance, standing balance, and walking ability. DESIGN: Repeated-measures reliability study by using video data of patients with stroke. SETTING: Physiotherapy and rehabilitation departments in Scotland. PARTICIPANTS: Forty physiotherapists recruited from within the Lothian region: 20 senior physiotherapists with at least 3 years of experience working with neurologic patients and 20 staff grade physiotherapists with less than 12 months of experience working with neurologic patients. INTERVENTION: Videotape comprising 40 clips (36 original clips, 4 repeated clips) of stroke patients of differing levels of ability attempting the mobility milestones was produced. After a short training session in the interpretation and application of the mobility milestones, each physiotherapist viewed the tape separately and scored whether the milestone had been achieved or not. This was repeated at a separate test session 2 weeks later. MAIN OUTCOME MEASURE: Score for each mobility milestone. RESULTS: Kappa statistics were used to determine interrater reliability and showed good (.61-.80) to very good (.81-1.0) reliability for 3 of 4 milestones. Intraclass correlation coefficients (ICCs) were used to determine intrarater reliability of the 4 repeated clips and showed 75% of all subjects had high (ICC(2,1)=.91-1.0) reliability. The ICC(2,1) for test-retest reliability showed a similar pattern, with 70% of subjects showing good (.81-.90) or high (.91-1.0) reliability. CONCLUSIONS: The mobility milestones showed favorable levels of reliability when used by experienced or novice physiotherapists. The milestones can be adopted as a simple clinical outcome measure for use with stroke. Further research is required to establish reliability levels when the measure is used by different rehabilitation professionals.