Combined effects of backward treadmill training and botulinum toxin type A therapy on gait and balance in patients with chronic stroke: A pilot,single-blind,randomized controlled trial

Abstract

BACKGROUND:

Backward walking is recommended to improve the components of physiological gait in neurological disease. Botulinum toxin type A is an effective safe first line-treatment for post-stroke spasticity.

OBJECTIVE:

To compare the effects of backward treadmill training (BTT) versus standard forward treadmill training (FTT) on motor impairment in patients with chronic stroke receiving botulinum toxin type A therapy.

METHODS:

Eighteen chronic stroke patients were randomly assigned to receive BTT (n = 7) or FTT (n = 11) as adjunct to botulinum toxin type A therapy. A total of twelve 40-minute sessions (3 sessions/week for 4 weeks) of either BTT or FTT were conducted. A blinded assessor evaluated the patients before and after treatment. The primary outcome was the 10-meter Walking Test (10 MWT). Secondary outcomes were the modified Ashworth Scale, gait analysis, and stabilometric assessment.

RESULTS:

Between-group comparison showed a significant change on the 10 MWT (P = 0.008) and on stabilometric assessment [length of centre of pressure CoP (P = 0.001) and sway area (P = 0.002) eyes open and length of CoP (P = 0.021) and sway area (P = 0.008) eyes closed] after treatment.

CONCLUSIONS:

Greater improvement in gait and balance was noted after BTT than after FTT as an adjunct to botulinum toxin therapy in patients with chronic stroke.

Keywords

Postural balance locomotion muscle spasticity rehabilitation stability cerebral stroke

Get full access to this article

View all access options for this article.

References

Abdel-Aziem,

A. A.

, & El-Basatiny,

H. M.

(2017) Effectiveness of backward walking training on walking ability in children with hemiparetic cerebral palsy: a randomized controlled trial. Clinical Rehabilitation, 31, 790–797.

Blackburn,

, van Vliet.

, & Mockett,

S. P.

(2002) Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke. Physical Therapy, 82, 25–34.

Cattaneo,

, Jonsdottir,

, Zocchi,

, & Regola,

(2007) Effects of balance exercises on people with multiple sclerosis: a pilot study. Clinical Rehabilitation, 21, 771–781.

Cherng,

R. J.

, Liu,

C. F.

, Lau,

T. W.

, & Hong,

R. B.

(2007) Effect of treadmill training with body weight support on gait and gross motor function in children with spastic cerebral palsy. American Journal of Physical Medicine and Rehabilitation, 86, 548–555.

Cinone,

, Letizia,

, Santoro,

, Facciorusso,

, Armiento,

, Picelli,

, Ranieri,

, & Santamato,

(2019) Combined effects of isokinetic training and botulinum toxin type A on spastic equinus foot in patients with chronic stroke: a pilot, single-blind, randomized controlled trial. Toxins (Basel), 11, 210.

Cipriani,

D. J.

, Armstrong,

C. W.

, & Gaul,

(1995) Backward walking at three levels of treadmill inclination: an electromyographic and kinematic analysis. Journal of Orthopaedic & Sports Physical Therapy, 22, 95–102.

Duysens,

, De Groote,

, & Jonkers,

(2013) The flexion synergy, mother of all synergies and father of new models of gait. Frontiers in Computational Neuroscience, 7, 14.

Gandolfi,

, Dimitrova,

, Nicolli,

, Modenese,

, Serina,

, Waldner,

, Tinazzi,

, Squintani,

, Smania,

, & Geroin,

(2015) Rehabilitation procedures in the management of gait disorders in the elderly. Minerva Medica, 106, 287–307.

Grobbelaar,

, Venter,

, & Welman,

K. E.

(2017) Backward compared to forward over ground gait retraining have additional benefits for gait in individuals with mild to moderate Parkinson’s disease: a randomized controlled trial. Gait & Posture, 58, 294–299.

10.

Hoogkamer,

, Meyns,

, & Duysens,

(2014) Steps forward in understanding backward gait: from basic circuits to rehabilitation. Exercise and Sport Sciences Reviews, 42, 23–29.

11.

Kim,

C. M.

, Eng,

J. J.

, MacIntyre,

D. L.

, & Dawson,

A. S.

(2001) Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study. Journal of Stroke & Cerebrovascular Diseases, 10, 265–273.

12.

Lamontagne,

, Richards,

C. L.

, & Malouin,

(2000) Coactivation during gait as an adaptive behavior after stroke. Journal of Electromyography & Kinesiology, 10, 407–415.

13.

Langhorne,

, Coupar,

, & Pollock,

(2009) Motor recovery after stroke: a systematic review. Lancet Neurology, 8, 741–754.

14.

Menz,

H. B.

, Latt,

M. D.

, Tiedemann,

, Mun San Kwan,

, & Lord,

S. R.

(2004) Reliability of the GAITRite walkway system for the quantification of temporo-spatial parameters of gait in young and older people. Gait & Posture, 20, 20–25.

15.

Paltamaa,

, West,

, Sarasoja,

, Wikström,

, & Mälkiä,

(2005) Reliability of physical functioning measures in ambulatory subjects with MS. Physiotherapy Research International, 10, 93–109.

16.

Picelli,

, Bacciga,

, Melotti,

, La Marchina,

, Verzini,

, Ferrari,

, Pontillo,

, Corradi,

, Tamburin,

, Saltuari,

, Corradini,

, Waldner,

, & Smania,

(2016) Combined effects of robot-assisted gait training and botulinum toxin type A on spastic equinus foot in patients with chronic stroke: a pilot, single blind, randomized controlled trial. European Journal of Physical and Rehabilitation Medicine, 52, 759–766.

17.

Picelli,

, Bonetti,

, Fontana,

, Barausse,

, Dambruoso,

, Gajofatto,

, Tamburin,

, Girardi,

, Gimigliano,

, & Smania,

(2012) Accuracy of botulinum toxin type A injection into the gastrocnemius muscle of adults with spastic equinus: manual needle placement and electrical stimulation guidance compared using ultrasonography. Journal of Rehabilitation Medicine, 44, 450–452.

18.

Picelli,

, Tamburin,

, Bonetti,

, Fontana,

, Barausse,

, Dambruoso,

, Gajofatto,

, Santilli,

, & Smania,

(2012) Botulinum toxin type A injection into the gastrocnemius muscle for spastic equinus in adults with stroke: a randomized controlled trial comparing manual needle placement, electrical stimulation and ultrasonography-guided injection techniques. American Journal of Physical Medicine and Rehabilitation, 91, 957–964.

19.

Rose,

D. K.

, DeMark,

, Fox,

E. J.

, Clark,

D. J.

, & Wludyka,

(2018) A backward walking training program to improve balance and mobility in acute stroke. Journal of Neurologic Physical Therapy, 42, 12–21.

20.

Roth,

E. J.

, Merbitz,

, Mroczek,

, Dugan,

S. A.

, & Suh,

W. W.

(1997) Hemiplegic gait. Relationships between walking speed and other temporal parameters. American Journal of Physical Medicine and Rehabilitation, 76, 128–133.

21.

Santamato,

, Cinone,

, Panza,

, Letizia,

, Santoro,

, Lozupone,

, Daniele,

, Picelli,

, Baricich,

, Intiso,

, & Ranieri,

(2019) Botulinum toxin type A for the treatment of lower limb spasticity after stroke. Drugs, 79, 143–160.

22.

Smania,

, Picelli,

, Gandolfi,

, Fiaschi,

, & Tinazzi,

(2008) Rehabilitation of sensorimotor integration deficits in balance impairment of patients with stroke hemiparesis: a before/after pilot study. Neurological Sciences, 29, 313–319.

23.

Smania,

, Picelli,

, Munari,

, Geroin,

, Ianes,

, Waldner,

, & Gandolfi,

(2010) Rehabilitation procedures in the management of spasticity. European Journal of Physical and Rehabilitation Medicine, 46, 423–438.

24.

Sousa,

A. S.

, Silva,

, & Santos,

(2015) Ankle anticipatory postural adjustments during gait initiation in healthy and post-stroke subjects. Clinical Biomechanics, 30, 960–965.

25.

Thomas,

K. S.

, Hammond,

, & Magal,

(2018) Graded forward and backward walking at a matched intensity on cardiorespiratory responses and postural control. Gait & Posture, 65, 20–25.

26.

Thomas,

K. S.

, VanLunen,

B. L.

, & Morrison,

(2013) Changes in postural sway as a function of prolonged walking. European Journal of Applied Physiology, 113, 497–508.

27.

Thorstensson,

(1986) How is the normal locomotor program modified to produce backward walking? –. Experimental Brain Research, 61, 664–668.

28.

Uchiyama,

, Koyama,

, Wada,

, Katsutani,

, Kodama,

, & Domen,

(2018) Botulinum toxin type A treatment combined with intensive rehabilitation for gait poststroke: a preliminary study. Journal of Stroke & Cerebrovascular Diseases, 27, 1975–1986.

29.

Wang,

, Xu,

, & An,

(2019) Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis. Gait & Posture, 68, 466–475.

30.

Wang,

, Yuan,

, & An,

(2018) Effectiveness of backward walking training on spatial-temporal gait characteristics: A systematic review and meta-analysis. Human Movement Science, 60, 57–71.

31.

Wein,

, Esquenazi,

, Jost,

W. H.

, Ward,

A. B.

, Pan,

, & Dimitrova,

(2018) OnabotulinumtoxinA for the treatment of poststroke distal lower limb spasticity: a randomized trial. PM R, 10, 693–703.

32.

Yang,

Y. R.

, Yen,

J. G.

, Wang,

R. Y.

, Yen,

L. L.

, & Lieu,

F. K.

(2005) Gait outcomes after additional backward walking training in patients with stroke: a randomized controlled trial. Clinical Rehabilitation, 19, 264–273.