Standing Balance Training
Standing Balance Training served as an active control and consisted of both static and dynamic standing tasks including quiet stance, dual-task with upper extremity (UE) manipulation, and reaching for targets both within and outside the patient's base of support. Standing Balance Training closely mimicked BWT in that it required upright postural control and provided a balance challenge. The study therapist chose initial tasks from a standardized task bank (Table 1) and progressed participants according to their ability to maintain standing balance during each task. Participants were encouraged to perform tasks without UE support; however, they were permitted to take support if needed. To ensure progression in exercise intensity levels, patients were advanced to a more difficult standing balance task if they were able to maintain stance without losing balance for a given task at least 50% of the time. To ensure participant engagement, at least 5 different tasks were included in each session. Somatosensory and visual systems were challenged by standing on foam and closing eyes as participants were progressed (Figure 1B and Table 1).
Participants' ability to complete each 30-minute intervention session and to progress in the daily intervention was recorded as well as participant recruitment, retention, and adverse event occurrence.
5-Meter Walk Test
Gait speed was assessed with the 5-Meter Walk Test which has demonstrated responsiveness in the stroke population.35 Time to ambulate was recorded with a stopwatch. Participants completed the distance 2 times at their self-selected speed to obtain an average gait speed. Balance assistance was provided if needed, but no assistance was provided for lower extremity advancement. At each study time point, the assessment was completed with the least restrictive assistive and orthotic device.
3-Meter Backward Walk Test
Backward walking speed was assessed with the 3-Meter Backward Walk Test.36 Time to ambulate backward 3 m was recorded with a stopwatch. Two trials at their self-selected speed were averaged. Balance assistance was provided if needed, but no assistance was provided at the lower extremities. At each study time point, the assessment was completed with the least restrictive assistive and orthotic device.
Berg Balance Scale
The 14-item scale assessed static and dynamic standing balance, ability to sit, stand up, and transfer. The BBS is valid,37 reliable,37 and sensitive to change38 in people with acute stroke.
Activities-Specific Balance Confidence Scale
This 16-item self-report questionnaire, reliable39 and valid40 in the stroke population, assessed self-efficacy (self-reported confidence) in maintaining balance for activities such as bending, reaching, and walking. This measure has good reliability and internal consistency.
Functional Independence Measure—Mobility41:
Mobility domains include locomotion, stairs, WC transfers, toilet transfers, and shower/tub transfers and are a reliable and valid measure in stroke rehabilitation.42
Sensory Organization Test43
Balance is assessed while participants stood on a force plate under 6 different conditions (three 20-second trials/conditions) that required integration of visual, somatosensory, and vestibular input to maintain postural control (NeuroCom Balance Master). The participant wore a safety harness to prevent falls.
While an inpatient, falls were recorded by participants' entire rehabilitation team, including nursing. Upon discharge, participants were provided monthly calendars to record any falls44 and self-addressed postcards to return to study personnel. If a postcard was received, participants were contacted and administered a Fall Characterization Questionnaire. In addition, participants were queried regarding fall incidence at their 3-month poststroke assessment. If a fall occurred at any time during study participation, a Fall Characterization Questionnaire was administered. This 16-item questionnaire was developed for a previous stroke randomized controlled trial8 and queried participants regarding extent of injury if any, type of medical attention sought if any, subsequent activity limitation, and fall location.
Descriptive statistics were calculated for all variables. Normality was confirmed by visual inspection of Q-Q plots. Average ±SD was reported for preintervention, postintervention, and the 3-month retention assessment for each of the outcome variables. Outcome variables were modeled using 2-way group (BWT, SBT) × Time analysis of variance with repeated measures on time (preintervention, postintervention, and 3-month retention). Mauchly Sphericity Test confirmed the appropriateness of the repeated measures analysis. As we had a small sample size for this feasibility study, effect sizes of group differences (BWT vs SBT) from preintervention to the 1-month retention session for each of the outcome measures were calculated as Cohen d.45
Eighteen individuals admitted to the inpatient stroke unit consented to participate. There were no differences between groups in demographics and preintervention measures except for age (Table 2) and Functional Independence Measure—Mobility (FIM-M) (Table 3) with the BWT group being younger with a higher initial FIM-M score (P < 0.05).
There was no significant difference in the amount of usual care physical therapy (BWT: 13 ± 3 hours, SBT: 15 ± 4 hours; P > 0.05), occupational therapy (BWT: 9 ± 5 hours, SBT: 8 ± 4 hours; P > 0.05), or speech therapy (BWT: 7 ± 3 hours, SBT: 8 ± 2 hours; P > 0.05) between groups over the 8-session study intervention.
The primary reasons for study ineligibility were (1) previous stroke and (2) inability to stand. This speaks to the challenge of conducting exercise-based intervention research acutely following stroke. Twelve participants who were eligible declined to participate as they were unable to commit to the added demands of study participation.
Participants in both intervention groups tolerated an additional 30 minutes of exercise, at just 1 week poststroke, in addition to their prescribed scheduled therapy. All participated in the full 30 minutes at session 1, were compliant with the intervention, and progressed throughout the 8 sessions as described. Individuals in the BWT group increased their distance walked 197 ± 155 m (range: 27-543 m) across the 8 sessions (Table 4). Individuals in the SBT group progressed, on average, 5 levels of exercise difficulty (Table 5). For example, a participant progressed from 1(a) Weight Shift side to side with feet apart on a firm surface to 7(a) Standing reaching for objects, within base of support, feet apart on a firm surface. There were no adverse events in either group. Two participants were withdrawn during the intervention phase, neither related to the study intervention—one due to uncontrolled hypertension and the other to unexpected, early discharge. Sixteen participants completed the study intervention and the immediate postintervention assessment.
Six participants, 3 from each group, were unable to return for their 3-month poststroke retention assessment (Figure 2). Two had moved from the area, 3 declined to come in for the retention assessment, and 1 was unable to be contacted. There was no significant difference (P > 0.05) in initial 5-Meter Walk Test or FIM-M scores between those who were retained for the 3-month assessment and those who were not, evidence that functional status did not play a role in study retention.
A 2-way analysis of variance (Group × Time) with repeated measures on time was conducted with data imputation used to replace missing values for those lost to follow-up at retention. For forward walking 5-Meter Walk Test, BWT participants improved from 0.23 ± 0.12 to 0.98 ± 0.48 m/s from preintervention to retention. This compares with an SBT group gain from 0.23 ± 0.15 to 0.64 ± 0.40 (Group × Time interaction; P = 0.05; Figure 3 and Table 5). The increase in forward walking speed was, therefore, 0.75 m/s for the BWT group compared with a 0.41 m/s increase for the SBT group, which constitutes a large effect size of d = 0.90. For backward walking 3MWT, BWT participants improved from 0.10 ± 0.06 to 0.63 ± 0.37 m/s from preintervention to retention compared with an SBT group gain of 0.10 ± 0.06 to 0.33 ± 0.27 m/s (Group × Time interaction; P = 0.03; Figure 4 and Table 5). The increase in backward walking speed was, therefore, 0.53 m/s for the BWT group compared with a 0.23 m/s increase for the SBT group, constituting a moderate effect size of d = 0.66. The BWT group's Activities-Specific Balance Confidence Scale score improved from 32.6 ± 23.4% to 68.1 ± 34.4% between preintervention and retention compared with a 39.2 ± 19.1% to 54.9 ± 29.4% gain for the SBT group (Figure 5 and Table 5). This BTW group 35.5% increase compared with an SBT group 15.7% increase constituted a large effect size of d = 1.1 The difference in BBS gains for the BWT group (11.4 ± 10.7-48.0 ± 12.5) compared with the SBT group (14.8 ± 12.5-43.2 ± 9.7) revealed a moderate effect size of d = 0.70 (P > 0.05; Table 5). Differences in the FIM-M change between preintervention and retention for the BWT group (8.0 ± 2.3-30.4 ± 6.1) compared with the SBT group (5.6 ± 2.1-26.8 ± 4.5) produced a moderate effect size of d = 0.47 (P > 0.05; Table 5). Sensory Organization Test between group differences constituted a small effect size of d = 0.37 (P > 0.05; Table 5).
There were too few falls over the study's short time course to draw comparisons between groups. During the intervention phase, there was 1 recorded fall in the BWT group and no falls in the SBT group. During the 3-month retention phase following discharge from inpatient rehabilitation, there were 2 recorded falls in the BWT group and 4 in the SBT group.
This pilot study assessed the feasibility of conducting a clinical trial in early poststroke rehabilitation and compared the effectiveness of BWT with SBT on walking speed, balance, and balance self-efficacy in acute stroke. Results indicate that BWT is a feasible intervention to conduct during inpatient rehabilitation. Participants were able to actively engage and systematically progress through this novel, additional intervention with no complaints of fear or excessive fatigue. During the intervention phase, 2 participants from the BWT group were withdrawn, neither explicitly related to the experimental intervention.
These results provide evidence that BWT early poststroke contributes to the acquisition of important functional skills and improved balance self-efficacy. Backward Walking Training improved both forward and backward gait speed significantly more than SBT, and this difference was retained nearly 2 months after completing the intervention (ie, at 3 months poststroke). The BWT group demonstrated greater improvement in balance self-efficacy (confidence) following intervention than the SBT group although this difference was not significant at 3 months poststroke. While BWT had a differential effect on balance self-efficacy, balance function as measured by the BBS improved equitably in both groups. Designing low-tech exercise options for individuals early poststroke is frequently a challenge. This pilot study demonstrated that BWT is a viable intervention early poststroke with the potential to provide gains in forward walking speed, balance, and balance self-efficacy.
The 2 interventions were similar in many respects. In addition to dose, both were delivered without external equipment, required upright posture with minimal to no upper extremity support, and were continually progressed. Despite these similarities, BWT preferentially transferred into greater walking function and balance confidence for patients early poststroke.
Backward Walking Training improved both forward and backward gait-speed significantly more than SBT. The increase in backward walking speed following BWT is in accordance with the motor learning theory of task-specific training. In contrast, greater improvements in balance were not observed in the SBT group—both groups improved equitably. This could be due to the postural control required to maintain balance during BWT transferred to the static and dynamic postural requirements assessed in our balance measure. In addition, greater utilization of sensory inputs that may benefit balance responses as well as greater muscle activation during BWT16,33 may have contributed to improved balance control.
Interestingly, forward walking speed also improved to a greater degree for the BWT group than for the SBT group. This result may seem to confound the task-specificity theory, but it actually provides empirical evidence to support previous evidence from both the animal literature46–48 and healthy adults49,50 that the neural control of forward and backward walking may largely originate from the same basic neural circuitry, thus facilitating performance gains across both tasks.
In addition, the increased cerebral activation inherent in backward walking may have better engaged damaged cerebral circuits, leading to neuroplastic recovery that generalized to gains in forward walking ability. Future studies should empirically measure cerebral activation in individuals poststroke during BWT compared with other rehabilitation approaches. Backward Walking Training may have also facilitated activation of key muscles such as hip extensors, which are important contributors to forward walking speed.51–53
Fritz et al54 determined that backward walking velocity in elderly adults was a better predictor of fall risk than forward walking velocity. In their cohort of 62, 100% of those identified as fallers (determined by self-reported falls in the previous 6 months) had a backward walk gait speed of less than 0.60 m/s, suggesting that this may be a critical threshold for the detection of fall risk. In our 3-month retention cohort, average backward walking gait speed for those trained in the BWT program was 0.63 m/s, compared with 0.33 m/s in the SBT group. Three of 5 BWT participants achieved a backward walking speed of greater than 0.60 m/s. In contrast, just 1 of 5 SBT participants achieved backward walking speed of greater than 0.60 m/s. Although study design did not permit following participants longitudinally for longer than 3 months to record fall incidence, we would hypothesize that our BWT group, who on average had exceeded this threshold for backward walking speed, would experience fewer falls than those in the SBT group.
Balance-related efficacy is an important variable to measure and address in poststroke rehabilitation secondary to its relationship to physical activity, mobility, and falls.13,55–57 The BWT group demonstrated greater improvement in balance-related efficacy as measured by the Activities-Specific Balance Confidence Scale than the SBT group despite not explicitly performing traditional balance exercises.
We specifically targeted this intervention for delivery early after stroke onset to assess whether participants could tolerate an additional 30 minutes of exercise in addition to their present rehabilitation plan of care. We recognize that natural recovery, observed within the first 3 months poststroke, may have contributed to observed improvements in both groups. The results from this small sample should be interpreted with caution as the BWT trained group was younger and had a higher initial FIM-M score.
While this study demonstrated feasibility of delivering this intervention in an inpatient rehabilitation facility, it also revealed challenges in enrolling patients in a clinical trial just days following stroke onset. Not all potential participants approached regarding study participation agreed, primarily secondary to being overwhelmed as to the acute onset of their disability and unsure of what to expect regarding the rehabilitation process. In this pilot study, without personnel dedicated to track participants after inpatient discharge when they are no longer in daily contact with the rehabilitation team, we were unable to obtain retention data on our full intervention cohort. A future full study to examine the retention effects of an acutely administered BWT program will need to include rigorous retention strategies. Finally, our outcome assessments were limited to those readily available and used in the clinical setting. Future studies will assess mechanisms underlying the observed improvements.
This study demonstrated patients in the acute phase of stroke recovery can tolerate and participate in a 30-minute exercise session beyond their inpatient rehabilitation plan of care. When this exercise is Backward Walking Training, it translates not only into faster backward walking speed, which may be a key to fall prevention, but also to improved forward gait speed and increased balance self-efficacy. Future areas of inquiry should include an examination of BWT as a preventative modality for future fall incidence.
The authors thank the study participants and Brooks Rehabilitation Hospital Stroke Service and Brooks Medical Director, Trevor Paris, MD. Funding for this study was provided by the Brooks Community Health Foundation.
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balance; gait; locomotion; rehabilitation; stroke
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