Although randomization reduces the risk of selection bias and eliminates the source of bias in treatment assignments (Suresh, 2011), only some of these interventions were randomized. Among randomized studies, some used either control groups exclusively or control groups but no pretest (Harris et al., 2006); some were single-blind interventions, whereas others were cross-over randomized.
Studies had different outcome variables, including the 6-min timed walk or the 10-min timed walk, the Short Physical Performance Battery, the Berg Balance Scale, the Stroke Impact Scale, the Barthel Index, and the Fugl Meyer Assessment, which measured the impact of walking training on walking function.
There seems, however, to be divergent results associated with the use of overground compared with body weight-supported treadmill in walking trainings. For instance, when comparing the impact of overground versus body weight-supported treadmill trainings, overground training showed a more significant impact on improving physical function (Combs-Miller et al., 2014). Conversely, Ada et al. (2013) reported that treadmill training performed over 4 months showed significant walking improvements compared with overground training. Mayo et al. (2013) found no significant effect on physical function between two groups of participants (i.e. one group exercised on a stationary bicycle and the other group performed brisk walking). In addition, effective walking training did not prevent falls among stroke survivors (Dean et al., 2012).
Gait training through treadmill, especially with biofeedback, not only improved gait and walking function but also gait cycle length, duration of gait phases, and swing phase speed (Drużbicki et al., 2015). Similarly, Sousa et al. (2011) reported that gait training performed overground also significantly improved walking function. High-intensity aerobic training significantly improved gait and peak oxygen consumption rate alike (Mackay-Lyons, 2012).
Significantly, although most interventions yielded improvements in physical functioning among poststroke individuals, many studies reported that the maintenance of these improvements faded after a certain period of time (Ada et al., 2013 ; Severinsen et al., 2014).
Nonetheless, the majority of studies reported improvements among poststroke individuals, consistent with previous studies. For instance, An and Shaughnessy (2011) found that gait training was effective in improving walking function after stroke, especially when it was initiated early, similar to the findings obtained by Mackay-Lyons et al. (2013). Early initiation of rehabilitation may also improve the overall quality of life of stroke survivors (Chaiyawat et al., 2009 ; An and Shaughnessy, 2011), although perhaps only for certain types of rehabilitation, for example, gait training (Combs et al., 2010).
These temporary gains could signal three major situations: (a) that there is a lack of programs for stroke survivors to participate to maintain their improvements; (b) that after stroke survivors lack the personal motivation to continue engaging in intervention programs; (c) or that stroke survivors may have other priorities in terms of what they would like to experiance improvements in terms of their after stroke condition. For instance, Combs et al. (2013) reported that 76% of stroke survivors would like to observe improvements in their walking distance rather than their walking speed. This underscores the importance of knowing the goals or aspirations of poststroke individuals in relation to walking function before implementing rehabilitation.
Like other research, which reported gait speed and spatiotemporal parameters as the most used outcome measures (Mudge and Stott, 2007 ; Van Bloemendaal et al., 2012), the current review similarly reported such outcome measures across different walking trainings. In so doing, this review also highlights the relationships between specific walking trainings and related outcomes to propose new intervention strategies and potential outcome measures for use in future research. Hancock et al. (2012), for example, have reported beneficial effects on balance, physical function, and muscle strength in stroke survivors through the use of reciprocal pedaling exercise. In a subsequent review by Obembe and Eng (2016), they found a small beneficial effect from physical intervention trainings on socialization. Overall, these kinds of outcome measures – balance, physical function, muscle strength, and socialization – range across physical and emotional outcomes that suggest improvements to quality of life. In general, these findings and our review alike point to a need for maintained improvement of quality of life and physical function following rehabilitation participation after stroke.
There are many limitations to this review that we would like to highlight. One is related to the fact that we relied on studies that have been published in English, ignoring other major studies published in languages other than English. In addition, participants were exposed to several treatments that make it difficult to focus solely on the impact of walking trainings alone. We did not identify a single longitudinal study that could effectively capture the impact of participating in walking trainings.
There are no conflicts of interest.
Ada L, Dean CM, Lindley R (2013). Randomized trial of treadmill training to improve walking
in community-dwelling people after stroke
: the AMBULATE trial. Int J Stroke
An M, Shaughnessy M (2011). The effects of exercise-based rehabilitation on balance and gait for stroke
patients: a systematic review. J Neurosci Nurs 43:298–307.
Bang D-H, Cho H-S (2016). Effect of body awareness training on balance and walking
ability in chronic stroke
patients: a randomized controlled trial. Journal of physical therapy science 28:198–201.
Billinger SA, Mattlage AE, Ashenden AL, Lentz AA, Harter G, Rippee MA (2012). Aerobic exercise in subacute stroke
improves cardiovascular health and physical performance. Journal of neurologic physical therapy: JNPT 36:159.
Billinger SA, Arena R, Bernhardt J, Eng JJ, Franklin BA, Johnson CM, et al (2014). Physical activity and exercise recommendations for stroke
Boyne P, Dunning K, Carl D, Gerson M, Khoury J, Rockwell B, et al (2016). High-intensity interval training and moderate-intensity continuous training in ambulatory chronic stroke
: Feasibility Study. Physical therapy 96:1533–1544.
Chaiyawat P, Kulkantrakorn K, Sritipsukho P (2009). Effectiveness of home rehabilitation for ischemic stroke
. Neurol Int 1:e10.
Combs SA, Dugan EL, Passmore M, Riesner C, Whipker D, Yingling E, Curtis AB (2010). Balance, balance confidence, and health-related quality of life in persons with chronic stroke
after body weight–supported treadmill training. Arch Phys Med Rehabil 91:1914–1919.
Combs SA, Van Puymbroeck M, Altenburger PA, Miller KK, Dierks TA, Schmid AA (2013). Is walking
faster or walking
farther more important to persons with chronic stroke
? Disabil Rehabil 35:860–867.
Combs-Miller SA, Kalpathi Parameswaran A, Colburn D, Ertel T, Harmeyer A, Tucker L, Schmid AA (2014). Body weight-supported treadmill training vs. overground walking
training for persons with chronic stroke
: a pilot randomized controlled trial. Clin Rehabil 28:873–884.
Danks KA, Pohlig R, Reisman DS (2016). Combining fast-walking
training and a step activity monitoring program to improve daily walking
activity after stroke
: a preliminary study. Archives of physical medicine and rehabilitation 97:S185–S193.
Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al (2012). Exercise to enhance mobility and prevent falls after stroke
: the community stroke
club randomized trial. Neurorehabil Neural Repair 26:1046–1057.
Dowla N, Chan L (2010). Improving quality in stroke
rehabilitation. Top Stroke
Drużbicki M, Guzik A, Przysada G, Kwolek A, Brzozowska-Magoń A (2015). Efficacy of gait training using a treadmill with and without visual biofeedback in patients after stroke
: a randomized study. J Rehabil Med 47:419–425.
Hancock NJ, Shepstone L, Winterbotham W, Pomeroy V (2012). Effects of lower limb reciprocal pedalling exercise on motor function after stroke
: a systematic review of randomized and nonrandomized studies. Int J Stroke
Harris AD, Mcgregor JC, Perencevich EN, Furuno JP, Zhu J, Peterson DE, Finkelstein J (2006). The use and interpretation of quasi-experimental studies in medical informatics. J Am Med Inform Assoc 13:16–23.
Jeong Y-G, Koo J-W (2016). The effects of treadmill walking
combined with obstacle-crossing on walking
ability in ambulatory patients after stroke
: a pilot randomized controlled trial. Topics in stroke
Jeon S-H, Lee S-M, Kim J-H (2015). Therapeutic effects of reaching with forward bending of trunk on postural stability, dynamic balance, and gait in individuals with chronic hemiparetic stroke
. J Phys Ther Sci 27:2447–2451.
Johnson BH, Bonafede MM, Watson C (2016). Short-and longer-term health-care resource utilization and costs associated with acute ischemic stroke
. Clinicoecon Outcomes Res 8:53.
Krishnamoorthy V, Hsu W-L, Kesar TM, Benoit DL, Banala SK, Perumal R, et al (2008). Gait training after stroke
: a pilot study combining a gravity-balanced orthosis, functional electrical stimulation, and visual feedback. Journal of neurologic physical therapy 32:192–202.
Lloréns R, Gil-Gómez JA, Alcañiz M, Colomer C, Noé E (2015). Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke
. Clinical rehabilitation 29:261–268.
Mackay-Lyons M (2012). Aerobic treadmill training effectively enhances cardiovascular fitness and gait function for older persons with chronic stroke
. J Physiother 58:271.
Mackay-Lyons M, Mcdonald A, Matheson J, Eskes G, Klus M-A (2013). Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking
ability early after stroke
: a randomized controlled trial. Neurorehabil Neural Repair 27:644–653.
Mayo NE, Mackay-Lyons MJ, Scott SC, Moriello C, Brophy J (2013). A randomized trial of two home-based exercise programmes to improve functional walking
. Clin Rehabil 27:659–671.
Moore JL, Roth EJ, Killian C, Hornby TG (2009). Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a ‘plateau’ in recovery. Stroke
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al (2016). Executive summary: Heart Disease and Stroke
Statistics-2016 update: a report from the American Heart Association. Circulation 133:447.
Mudge S, Stott NS (2007). Outcome measures to assess walking
ability following stroke
: a systematic review of the literature. Physiotherapy 93:189–200.
Murata K, Asai H, Inaoka PT, Nakaizumi D (2016). Walking
gait changes after stepping-in-place training using a foot lifting device in chronic stroke
patients. Journal of physical therapy science 28:1170–1177.
Obembe AO, Eng JJ (2016). Rehabilitation interventions for improving social participation after stroke
: a systematic review and meta-analysis. Neurorehabil Neural Repair 30:384–392.
Olawale O, Jaja S, Anigbogu C, Appiah-Kubi K, Jones-Okai D (2011). Exercise training improves walking
function in an African group of stroke
survivors: a randomized controlled trial. Clin Rehabil 25:442–450.
Pang MY, Eng JJ (2008). Determinants of improvement in walking
capacity among individuals with chronic stroke
following a multi-dimensional exercise program. Journal of rehabilitation medicine 40:284–290.
Park J, Park S-Y, Kim Y-W, Woo Y (2015). Comparison between treadmill training with rhythmic auditory stimulation and ground walking
with rhythmic auditory stimulation on gait ability in chronic stroke
patients: A pilot study. NeuroRehabilitation 37:193–202.
Park JM, Lim HS, Song CH (2015). The effect of external cues with vibratory stimulation on spatiotemporal gait parameters in chronic stroke
patients. Journal of physical therapy science 27:377–381.
Rensink M, Schuurmans M, Lindeman E, Hafsteinsdottir T (2009). Task‐oriented training in rehabilitation after stroke
: systematic review. J Adv Nurs 65:737–754.
Salbach NM, Mayo NE, Robichaud‐Ekstrand S, Hanley JA, Richards CL, Wood‐Dauphinee S (2005). The effect of a task‐oriented walking intervention
on improving balance self‐efficacy poststroke: A randomized, controlled trial. Journal of the American Geriatrics Society 53:576–582.
Severinsen K, Jakobsen JK, Pedersen AR, Overgaard K, Andersen H (2014). Effects of resistance training and aerobic training on ambulation in chronic stroke
. Am J Phys Med Rehabil 93:29–42.
Smith PS, Thompson M (2008). Treadmill training post stroke
: are there any secondary benefits? A pilot study. Clinical rehabilitation 22:997–1002.
Sousa CO, Barela JA, Prado-Medeiros CL, Salvini TF, Barela AM (2011). Gait training with partial body weight support during overground walking
for individuals with chronic stroke
: a pilot study. J Neuroeng Rehabil 8:48.
Srivastava A, Taly AB, Gupta A, Murali T (2015). Rehabilitation interventions to improve locomotor outcome in chronic stroke
survivors: A prospective, repeated-measure study. Neurology India 63:347.
Stuart M, Benvenuti F, Macko R, Taviani A, Segenni L, Mayer F, et al (2009). Community-based adaptive physical activity program for chronic stroke
: feasibility, safety, and efficacy of the Empoli model. Neurorehabil Neural Repair 23:26–34.
Sullivan KJ, Klassen T, Mulroy S (2006). Combined task‐specific training and strengthening effects on locomotor recovery post-stroke
: a case study. J Neurol Phys Ther 30:130–141.
Suresh K (2011). An overview of randomization techniques: an unbiased assessment of outcome in clinical research. J Hum Reprod Sci 4:8.
Tomey KM, Sowers MR (2009). Assessment of physical functioning: a conceptual model encompassing environmental factors and individual compensation strategies. Phys Ther 89:705.
Vahlberg B, Cederholm T, Lindmark B, Zetterberg L, Hellström K (2016). Short-term and long-term effects of a progressive resistance and balance exercise program in individuals with chronic stroke
: a randomized controlled trial. Disability
and rehabilitation 39:1615–1622.
Van Bloemendaal M, Van De Water AT, Van De, Port IG (2012). Walking
tests for stroke
survivors: a systematic review of their measurement properties. Disabil Rehabil 34:2207–2221.
Van Duijnhoven HJ, Heeren A, Peters MA, Veerbeek JM, Kwakkel G, Geurts AC, Weerdesteyn V (2016). Effects of exercise therapy on balance capacity in chronic stroke