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

Effectiveness of backward gait training on body composition, cardiopulmonary fitness, inflammation, and metabolic marker in adults: A systematic review and meta-analysis

Walking is a fundamental physical activity with significant health implications. Backward gait training (BGT) has emerged as a novel approach with potential benefits, yet its effects in comparison to traditional forward gait training (FGT) remain uncertain. This systematic review and meta-analysis aimed to evaluate the effects of BGT on body composition, cardiopulmonary fitness, and inflammatory and metabolic markers in adults. A comprehensive search across electronic databases was conducted following the Preferred Publishing Items for Systematic Reviews and Meta-Analyses guidelines. Randomized clinical trials (RCTs) comparing BGT with FGT in adults were included. Methodological quality was assessed using the Cochrane risk-of-bias tool. The certainty of evidence was evaluated using the Grading of Recommendation, Assessment, Development, and Evaluation approach. The analysis included a total of 379 male participants across the studies. The meta-analysis demonstrated significant changes in body composition and inflammatory marker outcomes, which included waist-to-height ratio (standardized mean difference [SMD]-1.18, 95% confidence interval [CI]-1.89-0.48, I2 = 83%, P < 0.01), body mass index (SMD-0.55, 95% CI-0.77-0.32, I2= 0%, P < 0.01), and C-reactive protein (SMD-0.98, 95% CI-1.28-0.70, I2= 0%, P < 0.01). In addition, the qualitative review revealed potential enhancements in cardiopulmonary fitness and metabolic markers following BGT. While the results suggest potential benefits of BGT on body composition and inflammatory markers, the evidence remains limited and heterogeneous. Further robust research with diverse populations, longer intervention periods, and comprehensive outcome assessments is essential to elucidate the true impact of BGT and its utility for promoting overall health and well-being in adults.

Effects of backward walking training on balance, gait, and functional mobility in people with multiple sclerosis: A randomized controlled study

BACKGROUND

Backward walking training (BWT) can have a positive effect on balance, gait, and functional mobility in neurological diseases; however, the effectiveness of BWT has not been examined in multiple sclerosis (MS). Therefore, the study aimed to investigate the effects of BWT on balance, gait, and functional mobility in people with MS (PwMS).

METHOD

Nineteen PwMS were randomly allocated to either the experimental group (n=10) and the control group (n=9). The experimental group received BWT in addition to conventional walking training (CWT) while the control group only received CWT. Both groups performed training three times a week for 8 weeks. Participants were assessed with the Berg Balance Scale (BBS), four square step test (FSST), activities-specific balance confidence scale (ABC), timed 25-foot walk test (T25FW), dynamic gait index (DGI), 3-meter backward walk test (3MBWT), Multiple Sclerosis Walking Scale-12 (MSWS-12), and timed up and go test (TUG) before and after training.

RESULTS

After training, both groups showed significant improvements on the T25FW, and TUG (p<0.05) while only the experimental group showed significant improvements on the BBS, FSST, ABC, DGI, 3MBWT, and MSWS-12 (p<0.05). The experimental group significantly improved more than the control group in all outcomes (p<0.05) except for the T25FW (p=0.202).

CONCLUSION

BWT in addition to CWT is an effective way to improve balance, gait, and functional mobility for PwMS. These results suggest that BWT may be a potentially useful treatment approach when added to CWT in the rehabilitation of MS.

Effect of Backward and Forward Walking on Lower Limb Strength, Balance, and Gait in Multiple Sclerosis: A Randomized Feasibility Trial

BACKGROUND

Backward walking (BW) interventions have improved gait and balance in persons with stroke, cerebral palsy, and Parkinson disease but have not been studied in persons with multiple sclerosis (MS). We examined the feasibility of a BW intervention and how it affected strength, balance, and gait vs forward walking (FW) in persons with MS.

METHODS

Sixteen persons with MS with a Patient-Determined Disease Steps (PDDS) scale score of 3 to 5 (gait impairment-late cane) were randomized to the FW (n = 8) or BW (n = 8) group. Participants did 30 minutes of FW or BW on a treadmill 3 times per week for 8 weeks (24 visits). Enrollment, adherence rate, and safety were tracked. The Timed Up and Go test, Six-Spot Step Test, single-leg stance, and abbreviated Activities-specific Balance Confidence scale were used to measure balance. Hip and knee flexion and extension strength (isometric peak torque), gait speed, and spatiotemporal gait parameters were measured. A 2×2 factorial multivariate analysis of covariance was used to examine changes in strength, balance, and gait, with the PDDS scale score as the covariate.

RESULTS

Treatment adherence rate was 99.7%, with no safety concerns. After controlling for baseline differences in disability (PDDS scale score; P = .041), the BW group improved dominant hip flexion strength preintervention to postintervention compared with the FW group (F 1,13 = 9.03; P = .010). No other significant differences were seen between groups.

CONCLUSIONS

This was the first study to look at BW as an intervention in persons with MS. Based on its feasibility, safety, and significant finding, BW should be studied in a larger, definitive trial in the future.

Case report: Backward gait training combined with gait-synchronized cerebellar transcranial alternating current stimulation in progressive supranuclear palsy

Progressive supranuclear palsy (PSP) is characterized by recurrent falls caused by postural instability, and a backward gait is considered beneficial for postural instability. Furthermore, a recent approach for rehabilitation combined with gait-oriented synchronized stimulation using non-invasive transcranial patterned stimulation could be promising for balance function. Here, we present a case of PSP with backward gait training combined with gait-synchronized transcranial alternating current stimulation (tACS). A 70-year-old woman with PSP-Richardson's syndrome underwent backward gait training combined with synchronized cerebellar tACS. Initially, she underwent short-term intervention with combined training of backward gait with synchronized cerebellar tACS, asynchronized, or sham stimulation according to the N-of-1 study design. Synchronized tACS training demonstrated a decrease in postural instability, whereas asynchronized or sham stimulation did not. The additional long-term interventions of combined backward gait training with synchronized cerebellar tACS demonstrated further decrease in postural instability with improvements in gait speed, balance function, and fall-related self-efficacy in daily life. The present case describes a novel approach for motor symptoms in a patient with PSP. Backward gait training with synchronized cerebellar tACS may be a promising therapeutic approach.

The Immediate Effect of Backward Walking on External Knee Adduction Moment in Healthy Individuals

Backward walking (BW) has been recommended as a rehabilitation intervention to prevent, manage, or improve diseases. However, previous studies showed that BW significantly increased the first vertical ground reaction force (GRF) during gait, which might lead to higher loading at the knee. Published reports have not examined the effects of BW on medial compartment knee loading. The objective of this study was to investigate the effects of BW on external knee adduction moment (EKAM). Twenty-seven healthy adults participated in the present study. A sixteen-camera three-dimensional VICON gait analysis system, with two force platforms, was used to collect the EKAM, KAAI, and other biomechanical data during BW and forward walking (FW). The first (P < 0.001) and second (P < 0.001) EKAM peaks and KAAI (P =0.02) were significantly decreased during BW when compared with FW. The BW significantly decreased the lever arm length at the first EKAM peak (P =0.02) when compared with FW. In conclusion, BW was found to be a useful strategy for reducing the medial compartment knee loading even though the first peak ground reaction force was significantly increased.

Interventions for preventing falls in Parkinson's disease

BACKGROUND

Most people with Parkinson's disease (PD) experience at least one fall during the course of their disease. Several interventions designed to reduce falls have been studied. An up-to-date synthesis of evidence for interventions to reduce falls in people with PD will assist with informed decisions regarding fall-prevention interventions for people with PD.

OBJECTIVES

To assess the effects of interventions designed to reduce falls in people with PD.

SEARCH METHODS

CENTRAL, MEDLINE, Embase, four other databases and two trials registers were searched on 16 July 2020, together with reference checking, citation searching and contact with study authors to identify additional studies. We also conducted a top-up search on 13 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce falls in people with PD and reported the effect on falls. We excluded interventions that aimed to reduce falls due to syncope.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review procedures. Primary outcomes were rate of falls and number of people who fell at least once. Secondary outcomes were the number of people sustaining one or more fall-related fractures, quality of life, adverse events and economic outcomes. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

This review includes 32 studies with 3370 participants randomised. We included 25 studies of exercise interventions (2700 participants), three studies of medication interventions (242 participants), one study of fall-prevention education (53 participants) and three studies of exercise plus education (375 participants). Overall, participants in the exercise trials and the exercise plus education trials had mild to moderate PD, while participants in the medication trials included those with more advanced disease. All studies had a high or unclear risk of bias in one or more items. Illustrative risks demonstrating the absolute impact of each intervention are presented in the summary of findings tables. Twelve studies compared exercise (all types) with a control intervention (an intervention not thought to reduce falls, such as usual care or sham exercise) in people with mild to moderate PD. Exercise probably reduces the rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.63 to 0.87; 1456 participants, 12 studies; moderate-certainty evidence). Exercise probably slightly reduces the number of people experiencing one or more falls by 10% (risk ratio (RR) 0.90, 95% CI 0.80 to 1.00; 932 participants, 9 studies; moderate-certainty evidence).  We are uncertain whether exercise makes little or no difference to the number of people experiencing one or more fall-related fractures (RR 0.57, 95% CI 0.28 to 1.17; 989 participants, 5 studies; very low-certainty evidence). Exercise may slightly improve health-related quality of life immediately following the intervention (standardised mean difference (SMD) -0.17, 95% CI -0.36 to 0.01; 951 participants, 5 studies; low-certainty evidence). We are uncertain whether exercise has an effect on adverse events or whether exercise is a cost-effective intervention for fall prevention. Three studies trialled a cholinesterase inhibitor (rivastigmine or donepezil). Cholinesterase inhibitors may reduce the rate of falls by 50% (RaR 0.50, 95% CI 0.44 to 0.58; 229 participants, 3 studies; low-certainty evidence). However, we are uncertain if this medication makes little or no difference to the number of people experiencing one or more falls (RR 1.01, 95% CI 0.90 to 1.14230 participants, 3 studies) and to health-related quality of life (EQ5D Thermometer mean difference (MD) 3.00, 95% CI -3.06 to 9.06; very low-certainty evidence). Cholinesterase inhibitors may increase the rate of non fall-related adverse events by 60% (RaR 1.60, 95% CI 1.28 to 2.01; 175 participants, 2 studies; low-certainty evidence). Most adverse events were mild and transient in nature.  No data was available regarding the cost-effectiveness of medication for fall prevention. We are uncertain of the effect of education compared to a control intervention on the number of people who fell at least once (RR 10.89, 95% CI 1.26 to 94.03; 53 participants, 1 study; very low-certainty evidence), and no data were available for the other outcomes of interest for this comparisonWe are also uncertain (very low-certainty evidence) whether exercise combined with education makes little or no difference to the number of falls (RaR 0.46, 95% CI 0.12 to 1.85; 320 participants, 2 studies), the number of people sustaining fall-related fractures (RR 1.45, 95% CI 0.40 to 5.32,320 participants, 2 studies), or health-related quality of life (PDQ39 MD 0.05, 95% CI -3.12 to 3.23, 305 participants, 2 studies). Exercise plus education may make little or no difference to the number of people experiencing one or more falls (RR 0.89, 95% CI 0.75 to 1.07; 352 participants, 3 studies; low-certainty evidence). We are uncertain whether exercise combined with education has an effect on adverse events or is a cost-effective intervention for fall prevention.  AUTHORS' CONCLUSIONS: Exercise interventions probably reduce the rate of falls, and probably slightly reduce the number of people falling in people with mild to moderate PD.  Cholinesterase inhibitors may reduce the rate of falls, but we are uncertain if they have an effect on the number of people falling. The decision to use these medications needs to be balanced against the risk of non fall-related adverse events, though these adverse events were predominantly mild or transient in nature. Further research in the form of large, high-quality RCTs are required to determine the relative impact of different types of exercise and different levels of supervision on falls, and how this could be influenced by disease severity. Further work is also needed to increase the certainty of the effects of medication and further explore falls prevention education interventions both delivered alone and in combination with exercise.

Differences in backward and forward treadmill locomotion in decerebrated cats

Locomotion in different directions is vital for animal life and requires fine-adjusted neural activity of spinal networks. To compare the levels of recruitability of the locomotor circuitry responsible for forward and backward stepping, several electromyographic and kinematic characteristics of the two locomotor modes were analysed in decerebrated cats. Electrical epidural spinal cord stimulation was used to evoke forward and backward locomotion on a treadmill belt. The functional state of the bilateral spinal networks was tuned by symmetrical and asymmetrical epidural stimulation. A significant deficit in the backward but not forward stepping was observed when laterally shifted epidural stimulation was used but was not observed with central stimulation: only half of the cats were able to perform bilateral stepping, but all the cats performed forward stepping. This difference was in accordance with the features of stepping during central epidural stimulation. Both the recruitability and stability of the EMG signals as well as inter-limb coordination during backward stepping were significantly decreased compared with those during forward stepping. The possible underlying neural mechanisms of the obtained functional differences of backward and forward locomotion (spinal network organisation, commissural communication and supraspinal influence) are discussed.

The effect of backward walking observational training on gait parameters and balance in chronic stroke: randomized controlled study

BACKGROUND

Backward walking (BW) and action observation training may potentially help people at risk of falls. Moreover, action observation training could be a potential intervention to improve gait after a stroke.

AIM

We aimed to identify the effects of BW action observational training (BWOT) on gait parameters and balance in chronic stroke patients.

DESIGN

Randomized, controlled study.

SETTING

Rehabilitation center.

POPULATION

Twenty-four chronic stroke patients were randomly assigned to BWOT (N.=12) and landscape observational training (LOT) (N.=12) groups.

METHODS

The BWOT group performed BW after watching a video of a BW, while the LOT group performed BW training after watching a video of a landscape. Both groups received traditional therapy for 5 days per week and BWOT for 3 days a week for 4 weeks. The primary and secondary outcomes were gait and balance, respectively. Static balance was measured using the 5 Times Sit-To-Stand Test (5TSTS), the center of pressure (COP) displacement, and weight distribution (WD) of the affected side. Dynamic balance was measured using the activity-specific balance confidence (ABC) scale.

RESULTS

The BWOT group showed significant improvements in gait velocity (p=0.001, η²=0.470), step length (P=0.007, η²=0.313), stride lengths (P<0.002, η²=0.431), 5TSTS (P=0.021, η²=0.231), COP velocity (P=0.022, η²=0.226), length (P=0.001, η²=0.504), WD of the affected side (P=0.033, η²=0.193), and ABC score (P=0.023, η²=0.226) than the LOT group.

CONCLUSIONS

The 4-week BWOT training program significantly improved the gait parameters and static and dynamic balance in stroke patients.

CLINICAL REHABILITATION IMPACT

BWOT is an accessible and effective method of rehabilitation training that can also be applied to conventional therapy as a useful method for improving the gait and balance after stroke.

Persons with Parkinson's disease show impaired interlimb coordination during backward walking

INTRODUCTION

Although there is growing literature supporting the implementation of backward walking as a potential rehabilitation tool, moving backwards may precipitate falls for persons with Parkinson's disease. We sought to better understand interlimb coordination during backward walking in comparison to forward walking in persons with Parkinson's disease and healthy controls.

METHODS

We assessed coordination using point estimate of relative phase at each participant's preferred walking speed.

RESULTS

Persons with Parkinson's disease demonstrated impaired interlimb coordination between the more affected arm and each leg compared to controls, which worsened during backward walking.

CONCLUSION

For those with Parkinson's disease, inability to output smooth coordinated movement of the more affected shoulder may impair coordination during forward and, especially, backward walking. Our findings provide new information about backward walking that can allow clinicians to make safer, more effective therapeutic recommendations for persons with Parkinson's disease.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

The effect of a multi-modal boxing exercise program on cognitive locomotor tasks and gait in persons with Parkinson disease

BACKGROUND

Parkinson disease (PD) is a progressive neurological disease resulting in motor impairments, postural instability, and gait alterations which may result in self-care limitations and loss of mobility reducing quality of life.

OBJECTIVE

This study's purpose was to determine the impact of a community-based boxing program on gait parameters, dual task and backwards walking in individuals with PD.

METHODS

This study included 26 community dwelling individuals with PD who participated in 12-week boxing classes (1 hour, 2 times a week). The focus was on upper/lower extremity exercises using punching bags, agility drills, and strengthening activities. Pre/post testing was performed for dual task and gait parameters and was analyzed using t-tests.

RESULTS

Analysis of the scores indicated participants performed significantly better at post-test compared to pre-test on self-selected walking velocity (P = 0.041), cadence (P = 0.021); backwards walking velocity (P = 0.003), step length (P = 0.022); dual task walking velocity (P = 0.044), step length (P = 0.023), and gait variability index (P = 0.008). No significant differences for fast walking.

CONCLUSIONS

Multi-modal boxing produced improvements in gait velocity, dual task velocity, step length, and gait variability, as well as backwards walking velocity and step length. These improvements may impact independence with functional mobility and may improve safety but require further studies.

Acute effects of acupuncture in balance and gait of Parkinson disease patients - A preliminary study

INTRODUCTION

Balance and gait disorders are relevant symptoms in the quality of life of Parkinson's patients. Currently, there is no therapy to reverse or treat this condition. Acupuncture treatment is believed to improve motor ability through the cortico-basal-thalamus-cortical-ganglia.

AIM

To investigate qualitatively the acute effect of acupuncture on balance and gait in Parkinson's disease in 7 patients.

METHODS

This is a randomized and controlled crossover study. The same individual patient was part of both, experimental (real acupuncture) and control group (false acupuncture/sham), and the sequence was randomized. Balance and gait parameters were measured at two different moments, before and after treatment, using four force platforms as well as the collection of 3D markers positions taken by 11 cameras. Images were analyzed using Qualisys Track Manager software that let us extract data related to the quality of gait and balance.

RESULTS

Statistically significant differences were found in gait speed (p = 0.016), gait cadence (p = 0.006), support base width (p = 0.0001), medio-lateral oscillation (p = 0.017), left-right step length (p = 0.0002), and stride length: right-right (p = 0.0000) and left-left (p = 0.0018), time of left support phase (p = 0.029), right support phase (p = 0.025) and double support phase (p = 0.015), between the initial and final moments for the experimental group. Differences in right-left stride length were found for both groups.

CONCLUSION

Our results suggest that the acupuncture protocol used objectively could improve gait in Parkinson disease patients. A deep research involving a statistical evaluation supported on a larger number of voluntaries should be accomplished to confirming these promising preliminary results.

Effects of a Perturbation-Based Balance Training on Compensatory Postural Responses to Backward Loss of Balance in Patients with Cerebellar Disease: A Case Study

OBJECTIVES The damage to the cerebellum primarily results in balance-related abnormalities that may affect performance of locomotion and postural adjustments, eventually contributing to an increased risk of fall and fear of falling in patients with cerebellar disease. The purpose of the present study was to investigate the effect of a perturbation-based training that induced backward loss of balance on compensatory postural responses in patients with cerebellar disease.METHODS The participant was a 51-year-old female diagnosed with spinocerebellar ataxia and had the disease for 19 years. The perturbation-based backward balance training was performed over 8 weeks (a total of 24 training sessions) in order to facilitate the perception of postural perturbation onset and execution of rapid compensatory responses.RESULTS The patient demonstrated a noticeable reduction in the number of steps required to recover body balance after postural disturbances. The reduction of multi-step reactions in recovering balance could be attributed to improvements in the body center-of-mass displacement and trunk control during the landing of step. Besides, there were also improvements in subjective measures of functional mobility and psychological well-being after the balance training.CONCLUSION Although current research evidence of balance rehabilitation for cerebellar patients is lacking, this study offers the feasibility of adaptive training to improve postural stability through task-specific training intervention.

Rostrocaudal Distribution of the C-Fos-Immunopositive Spinal Network Defined by Muscle Activity during Locomotion

The optimization of multisystem neurorehabilitation protocols including electrical spinal cord stimulation and multi-directional tasks training require understanding of underlying circuits mechanisms and distribution of the neuronal network over the spinal cord. In this study we compared the locomotor activity during forward and backward stepping in eighteen adult decerebrated cats. Interneuronal spinal networks responsible for forward and backward stepping were visualized using the C-Fos technique. A bi-modal rostrocaudal distribution of C-Fos-immunopositive neurons over the lumbosacral spinal cord (peaks in the L4/L5 and L6/S1 segments) was revealed. These patterns were compared with motoneuronal pools using Vanderhorst and Holstege scheme; the location of the first peak was correspondent to the motoneurons of the hip flexors and knee extensors, an inter-peak drop was presumably attributed to the motoneurons controlling the adductor muscles. Both were better expressed in cats stepping forward and in parallel, electromyographic (EMG) activity of the hip flexor and knee extensors was higher, while EMG activity of the adductor was lower, during this locomotor mode. On the basis of the present data, which showed greater activity of the adductor muscles and the attributed interneuronal spinal network during backward stepping and according with data about greater demands on postural control systems during backward locomotion, we suppose that the locomotor networks for movements in opposite directions are at least partially different.

Current Perspectives on the Assessment and Management of Gait Disorders in Parkinson's Disease

Gait dysfunction is a key defining feature of Parkinson's disease (PD), and is associated with symptoms of freezing and an increased risk of falls. In this narrative review, we cover the putative mechanisms of gait dysfunction in PD, the assessment of gait abnormalities, and the management of symptoms caused by the inherent difficulty in walking. Our understanding of the causes of gait problems in PD has progressed in recent times, moving from neurocognitive theory to correlates of affected neuronal pathways. In particular, this can be shown to correspond with abnormalities in responses to dual-task paradigms and dysfunction in cholinergic signaling. Great progress has been made in the sophistication and precision of gait assessment; however, it has firmly remained in the research domain. There is significant momentum behind wearable technologies that can be used by patients in their own environment, acting as digital biomarkers that can not only reflect progression but also independently discriminate PD from non-PD individuals. The treatment of gait dysfunction has historically relied on physical therapies and training combined with a view to mitigating the impact of such consequences as falls. Pharmacological therapies that are the mainstay of treatment in PD have tended to address symptoms like bradykinesia; however, optimization of dopaminergic therapies likely has a positive effect on quality of gait. Other targets have been assessed with the goal of improving gait, of which medications that improve cholinergic signaling appear most promising. Neuromodulation techniques are increasingly used in the form of deep-brain stimulation; however, standard targets, such as the globus pallidus interna, have a modest effect on gait. Considerable benefit has been seen through targeting the pedunculopontine nucleus, and a dual-target approach may be warranted. Stimulation of the spinal cord and brain through direct or magnetic approaches has been assessed, but requires further evidence.

Effectiveness of backward walking for people affected by stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Backward walking (BW) training is increasingly used in rehabilitation for stroke, but relevant evidence remains unclear.

OBJECTIVE

To determine the effect of BW training on patients with stroke.

METHODS

A keyword search was conducted in PubMed, EMBASE, CINAHL, and China National Knowledge Infrastructure database for articles published until November, 2019. Two investigators screened the articles and extract data from each included study. Meta-analysis was performed to estimate the effect of BW on stroke. In addition, the quality of evidence was evaluated by GRADE (grading of recommendations, assessment, development, and evaluation; version:3.6) approach.

RESULTS

A total of ten studies were included according to the inclusion and exclusion criteria in the review. All included studies described some positive influences of BW on stroke relative to the control group (forward walking or conventional treatment). Compared to control group, there is a statistically significant improvement for BW group in gait velocity (mean difference [MD] = 6.87, 95%CI: [1.40, 12.33], P = .01, I = 3%), Berg balance score (MD =3.82, 95%CI: [2.12, 5.52], P < .0001, I = 0%), and walk test (MD =0.11, 95%CI: [0.02, 0.20], P = .02, I = 36%).

CONCLUSIONS

For patients with stroke, BW training, as an adjunct an adjunct to conventional treatment, can improve Berg balance score (moderate evidence), walk test performance (very low evidence), gait velocity (very low evidence). More large-scale and high-quality studies are warranted.

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

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.

Transcutaneous spinal direct current stimulation improves locomotor learning in healthy humans

BACKGROUND

Ambulation is an essential aspect of daily living and is often impaired after brain and spinal cord injuries. Despite the implementation of standard neurorehabilitative care, locomotor recovery is often incomplete.

OBJECTIVE

In this randomized, sham-controlled, double-blind, parallel design study, we aimed to determine if anodal transcutaneous spinal direct current stimulation (anodal tsDCS) could improve training effects on locomotion compared to sham (sham tsDCS) in healthy subjects.

METHODS

43 participants underwent a single backwards locomotion training (BLT) session on a reverse treadmill with concurrent anodal (n = 22) or sham (n = 21) tsDCS. The primary outcome measure was speed gain measured 24 h post-training. We hypothesized that anodal tsDCS + BLT would improve training effects on backward locomotor speed compared to sham tsDCS + BLT. A subset of participants (n = 31) returned for two additional training days of either anodal (n = 16) or sham (n = 15) tsDCS and underwent (n = 29) H-reflex testing immediately before, immediately after, and 30 min post-training over three consecutive days.

RESULTS

A single session of anodal tsDCS + BLT elicited greater speed gain at 24 h relative to sham tsDCS + BLT (p = 0.008, two-sample t-test, adjusted for one interim analysis after the initial 12 subjects). Anodal tsDCS + BLT resulted in higher retention of the acquired skill at day 30 relative to sham tsDCS + BLT (p = 0.002) in the absence of significant group differences in online or offline learning over the three training days (p = 0.467 and p = 0.131). BLT resulted in transient down-regulation of H-reflex amplitude (Hmax/Mmax) in both test groups (p < 0.0001). However, the concurrent application of anodal-tsDCS with BLT elicited a longer lasting effect than sham-tsDCS + BLT (p = 0.050).

CONCLUSION

tsDCS improved locomotor skill acquisition and retention in healthy subjects and prolonged the physiological exercise-mediated downregulation of excitability of the alpha motoneuron pool. These results suggest that this strategy is worth exploring in neurorehabilitation of locomotor function.

Motor Learning Deficits in Parkinson's Disease (PD) and Their Effect on Training Response in Gait and Balance: A Narrative Review

Parkinson's disease (PD) is a neurological disorder traditionally associated with degeneration of the dopaminergic neurons within the substantia nigra, which results in bradykinesia, rigidity, tremor, and postural instability and gait disability (PIGD). The disorder has also been implicated in degradation of motor learning. While individuals with PD are able to learn, certain aspects of learning, especially automatic responses to feedback, are faulty, resulting in a reliance on feedforward systems of movement learning and control. Because of this, patients with PD may require more training to achieve and retain motor learning and may require additional sensory information or motor guidance in order to facilitate this learning. Furthermore, they may be unable to maintain these gains in environments and situations in which conscious effort is divided (such as dual-tasking). These shortcomings in motor learning could play a large part in degenerative gait and balance symptoms often seen in the disease, as patients are unable to adapt to gradual sensory and motor degradation. Research has shown that physical and exercise therapy can help patients with PD to adapt new feedforward strategies to partially counteract these symptoms. In particular, balance, treadmill, resistance, and repeated perturbation training therapies have been shown to improve motor patterns in PD. However, much research is still needed to determine which of these therapies best alleviates which symptoms of PIGD, the needed dose and intensity of these therapies, and long-term retention effects. The benefits of such technologies as augmented feedback, motorized perturbations, virtual reality, and weight-bearing assistance are also of interest. This narrative review will evaluate the effect of PD on motor learning and the effect of motor learning deficits on response to physical therapy and training programs, focusing specifically on features related to PIGD. Potential methods to strengthen therapeutic effects will be discussed.

Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis

BACKGROUND

Backward walking (BW) training is thought to impact balance performance through improving motor system proprioception and gait characteristic, but relevant evidence remains sparse and inconclusive.

OBJECTIVE

This study systematically reviewed and quantified the scientific evidence regarding the effectiveness of BW training on balance performance.

METHODS

Keyword and reference search on BW training interventions was conducted in six electronic databases (PubMed, Web of science, SPORTDiscus, CINAHL, Cochrane Library, and CNKI) for peer-reviewed articles published till November 2017. A standardized form was used to extract data from each selected article that met the pre-specified eligibility criteria. Meta-analysis was conducted to estimate the pooled effects of BW training on balance performance measures.

RESULTS

Eleven studies (nine randomized controlled trials and two pre-post studies) met the eligibility criteria and were included in the review. All studies reported some beneficial effects of BW training on balance performance. Compared to control, BW training was associated with a reduction in overall stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model), medial-lateral stability index score by 0.95 (95% CI = 0.34, 1.57; I² = 0.0%; fixed-effect model), and anterior-posterior stability index score by 0.99 (95% CI = 0.37, 1.61; I² = 0.0%; fixed-effect model). Meanwhile, BW training was associated with an increase in open-eyes single leg standing duration by 0.91 s (95% CI = 0.29, 1.53; I² = 75.9%; random-effect model) in comparison to control.

CONCLUSIONS

BW training could serve as a potentially useful tool to improve balance performance among those with a high risk of fall. However, current evidence remains preliminary due to the small cohort of studies and possible learning effect in pre-post studies. Future work with larger scale and randomized experimental design is warranted to evaluate the effectiveness of BW training on balance performance across diverse population and disease subgroups, and elucidate the underlying biomechanical and neurological pathways.

The effectiveness of backward walking as a treatment for people with gait impairments: a systematic review and meta-analysis

OBJECTIVE:

To investigate the effectiveness of backward walking in the treatment of people with gait impairments related to neurological and musculoskeletal disorders.

DESIGN:

Systematic review and meta-analysis of randomized and quasi-randomized control studies.

DATA SOURCES:

Searched from the date of inception to March 2018, and included PubMed, Scopus, Cochrane Library, PEDro, CINAHL, and the MEDLINE databases.

METHODS:

Investigating the effects of backward walking on pain, functional disability, muscle strength, gait parameters, balance, stability, and plantar pressure in people with gait impairments. The PEDro scale was used to assess the quality. Similar outcomes were pooled by calculating the standardized mean difference.

RESULTS:

Of the 21 studies (neurological 11 and musculoskeletal 10), 635 participants were included. The average PEDro score was 5.4/10. The meta-analysis demonstrated significant standardized mean difference values in favour of backward walking, with conventional physiotherapy treatment for two to four weeks to reduce pain (-0.87) and functional disability (-1.19) and to improve quadriceps strength (1.22) in patients suffering from knee osteoarthritis. The balance and stability in cases of juvenile rheumatoid arthritis, and gait parameters and muscle strength in anterior cruciate ligament injury improved significantly when backward walking was included as an exercise. There was no significant evidence in favour of backward walking in any of the other conditions.

CONCLUSION:

The systematic review and meta-analysis suggests that backward walking with conventional physiotherapy treatment is effective and clinically worthwhile in patients with knee osteoarthritis. Insufficient evidence was available for the remaining gait impairment conditions and no conclusions could be drawn.