Walking and balance outcomes for stroke survivors: a randomized clinical trial comparing body-weight-supported treadmill training with versus without challenging mobility skills.
Sarah A Graham, Elliot J Roth, David A Brown
PMID 30382860WHAT IT FOUND
Adding challenging mobility skills to hands-free body-weight-supported treadmill training did not improve walking speed more than hands-free training alone.
Both groups improved walking speed and more participants were community or limited community ambulators after six weeks.
Key findings
01Hands-free plus challenging mobility skills did not produce greater change in comfortable walking speed than hands-free training alone.
02Across both groups, comfortable walking speed improved from a median of 0.35 m/s to a median of 0.54 m/s, and the number of participants classified as limited community or community ambulators increased.
03Fast walking, six-minute distance, balance, and balance confidence improved over training, but the challenge group did not differ from hands-free on these secondary outcomes.
STILL TO COME
How it was doneWhat they foundWhat it means for PTs
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What it does not show
The analysis included 29 participants, with 15 in hands-free and 14 in challenge, below the estimated 16 per group. Thirty-nine participants were randomized, but only 29 were analysed after removing participants who did not complete the first week. About 13.3% of hands-free and 14.2% of challenge post measurements were missing and were carried forward from the mid assessment. Six-month follow-up comfortable walking speed data were missing for 40% of the hands-free group and 57% of the challenge group, so follow-up conclusions relied on 9 hands-free and 6 challenge participants. Groups differed at baseline in age and depression scores, although neither was related to change in comfortable walking speed. Training staff were not blinded, and the trial used a specialized KineAssist self-driven treadmill, so results may not transfer to ordinary clinic equipment. The challenge group practised each skill once per week for ten minutes, which may have been too little dose to show an advantage. The study did not include overground training or a skills-only group, so it cannot say whether overground practice plus skills would help more than hands-free treadmill training. The 0.16 m/s responder threshold is described by the authors as intended for subacute stroke, with no agreed clinically important difference for chronic stroke. Participants could already walk at least 14 m with or without a device and were at least five months poststroke, so findings do not address nonambulatory or acute patients. Average gains did not reach the 0.16 m/s minimal clinically important difference, although walking classification changed.
Declared interests
The supplied article text does not include a funding or conflict-of-interest declaration. The publication metadata lists Research Support, U.S. Gov't, Non-P.H.S.
The easy way to misread this
Do not read the significant pre-to-post speed gain as proof that the challenge protocol is better. The primary comparison found no group difference, and the gain was from collapsing both groups.