Effect of backward walking training on postural balance in children with hemiparetic cerebral palsy: a randomized controlled study

Enhancing physical attributes and performance in badminton players: efficacy of backward walking training on treadmill

BACKGROUND

Badminton, a dynamic sport, demands players to display exceptional physical attributes such as agility, core stability, and reaction time. Backward walking training on a treadmill has garnered attention for its potential to enhance physical attributes and optimize performance in athletes while minimizing the risk of injuries.

OBJECTIVE

By investigating the efficacy of this novel approach, we aim to provide valuable insights to optimize training regimens and contribute to the advancement of sports science in badminton.

METHODOLOGY

Sixty-four participants were randomized into a control group (n = 32) and an experimental group (n = 32). The control group received routine exercise training, while the experimental group received routine exercise training along with additional backward walking training on the treadmill. Pre- and post-intervention measurements were taken for core stability using the Plank test, balance using the Star Excursion Balance test, reaction time using the 6-point footwork test, and agility using the Illinois Agility test.

RESULTS

The results showed that the experimental group demonstrated significant improvements in core stability (p < 0.001), balance (p < 0.001), reaction time (p < 0.05), and agility (p < 0.001) compared to the control group. The backward walking training proved to be effective in enhancing these physical attributes in badminton players.

CONCLUSION

Incorporating backward walking exercises into the training regimen of badminton players may contribute to their overall performance.

Effects of exercise intervention on balance function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effectiveness of exercise intervention on postural balance, gait parameters, and muscle strength in children with cerebral palsy by quantifying the information from randomized controlled trials (RCTs).

METHODS

We conducted a systematical search for RCTs from the databases, including PubMed, ISI Web of Science, and Scopus using a between-group design involving children with cerebral palsy and assessing the effect of exercise intervention on postural balance, gait parameters, and muscle strength. The specified inclusion criteria were determined by the PICOS tool. The outcomes of included studies were evaluated by meta-analysis, and subgroup and sensitivity analyses were conducted to analyze the observed heterogeneities using Review Manager 5.4 and Stata version 18.0. The revised Cochrane risk of bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias and quality of the included studies.

RESULTS

Twenty-four studies were included in this meta-analysis, with 579 children with cerebral palsy. Exercise intervention showed a statistically significant favorable effect on gross motor function (SMD = 0.32; 95%CI [0.03 to 0.61]; I2 = 16%), anteroposterior stability index (SMD = -0.93; 95%CI [-1.69 to -0.18]; I2 = 80%), and mediolateral stability index (SMD = -0.60; 95%CI [-1.16 to -0.03]; I2 = 73%) compared to control group among children with cerebral palsy. None of the above meta-analyses exhibited publication bias, as indicated by Egger's test with p-values greater than 0.05 for all.

CONCLUSIONS

Exercise is effective in improving gross motor function and balance in children with cerebral palsy. Due to the lack of studies examining the efficacy of each exercise type, we are unable to provide definitive training recommendations.

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.

Back geometry and mobility function changes in cerebral palsy children after backward walking training: arandomized controlled trial

AIM

To compare the effects of backward (BW) and forward (FW) walking training on back geometry and mobility function in children with hemiparetic cerebral palsy (CP).

METHODS

Fifty-five children with hemiparetic CP participated in this study. They were randomly assigned into two groups. For 12 weeks, both groups got a conventional physical therapy program three days/week. Groups A and B got a specifically developed FW walking training (25 minutes/session) and a specially designed BW walking training (25 minutes/session), respectively.

RESULTS

The trunk imbalance, lateral deviation, pelvic tilting, pelvic torsion, surface motion, and dynamic gait index of group B improved significantly more than group A (p < .05). Both groups showed significant improvements in all measured variables (p < .05).

CONCLUSION

BW walking training might be considered as an effective therapy modality for improving back geometry and mobility function in hemiparetic CP children compared with FW walking training combined with a typical program.

Addition of backward walking training to forward walking training improves walking speed in children with cerebral palsy: a systematic review with meta-analysis

The objective was to examine the effects of backward walking training for improving walking speed and balance in children with cerebral palsy. A systematic review of randomized trials was conducted. Trials had to include children with cerebral palsy, with a Gross Motor Function Classification System, between I and III, that delivered backward walking training as a solo intervention or in combination with forward walking training. The outcomes of interest were walking speed and balance. The methodological quality of included trials was assessed by the PEDro scale, and the quality of evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation. Eight papers, involving 156 participants, were included. Using random-effects meta-analysis, we estimated that backward walking training improved walking speed by 0.10 m/s [95% confidence interval (CI) 0.05-0.16] and by 2 points on the Pediatric Balance Scale (0-56) (95% CI 1.5-2.2) more than forward walking training. We also estimated that the addition of backward walking training increased walking speed by 0.20 m/s (95% CI 0.07-0.34) and reduced the angular excursion of the center of gravity by 0.5 degrees (95% CI -0.7 to -0.3). The quality of the evidence was classified as low to moderate. In conclusion, overall, backward walking training appears to be as effective or slightly superior to forward walking training for improving walking speed in children with CP. The addition of backward walking training statistically significantly and clinically important enhanced benefits on walking speed.

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.

Investigation of Motor Activity, Movement Kinematics and Forward-Backwards Gait in Children with Cerebral Palsy

Our aim in this study was to examine relationships between the motor activity ability, sensor-based kinematics and forward-backwards gait characteristics of children with cerebral palsy (CP). In this prospective cross-sectional study we studied 40 children with CP. We used the Pediatric Motor Activity Log Revised (PMAL-R) to assess motor activity, evaluated motion kinematics (acceleration and angular velocity) with a sensor-based application, applied the Edinburgh Visual Gait Score (EVGS) and the Timed Up and Go Test (TUG) to observe gait performance, and used the Three Meter Backward Walk Test (3MBWT) to assess backward gait. We found moderately positive significant correlations (r1 = 0.416, r2 = 0.418, p < 0.05) between the chilidren's minimum angular velocity on PMAL-R motor activity frequency (how often) and quality (how well) scores, respectively. We also found moderately negative significant correlations (r1 = -0.529, r2 = -0.521, p < 0.05) between PMAL-R frequency (how often) and quality (how well) scores with TUG, respectively. There were moderately high positive correlations (r1 = 0.415, r2 = 0.726, p < 0.05) between EVGS scores and 3MBWT and TUG scores, respectively. We concluded that angular velocity ability was moderately related to children's motor activity and showed that physical performance tests (TUG and 3MBWT) could monitor gait function and upper extremity motor activity level, including both forward and backward walking tasks, in children with CP.

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.

Effect of Whole-Body Vibration Exercise on Hamstrings-to-Quadriceps Ratio, Walking Performance, and Postural Control in Children With Hemiparetic Cerebral Palsy: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to investigate the effect of whole-body vibration (WBV) exercises combined with traditional physiotherapy on the hamstrings-to-quadriceps (H:Q) ratio, walking ability, and control of posture in children with hemiparetic cerebral palsy (CP).

METHODS

A total of 34 children with spastic hemiparetic CP (boys and girls) participated in this 2-arm, parallel, randomized controlled trial. The inclusion criteria were spasticity ranging from 1 to 1+, gross level skills (I and II), at least 1 meter tall, standing alone, and walking forward and backward. They were randomly allocated to the control group (traditional physiotherapy) and study group and were treated by the same physiotherapy program combined with WBV training (3 times per week for 2 successive months). Quadriceps and hamstring muscle strength, walking performance, and postural control were evaluated before and after intervention by a blinded assessor.

RESULTS

The post-intervention values of the hamstring and quadriceps muscle force, gross motor function, and stability indices of the 2 groups were higher than the pre-values (P < .05). In addition, the post-values of the study group were higher than those of the control group (P < .05). Regarding the H:Q ratio, there was no significant difference between pre-values or the post-values of both groups (P = .948 and P = .397, respectively). There were no significant differences between the pre- and post-values of each group (P = .500 and P = .195, respectively).

CONCLUSION

Eight weeks of WBV training combined with traditional physiotherapy was more effective than traditional physiotherapy alone in improving walking ability and postural control. Furthermore, the combined intervention strengthened the quadriceps and hamstring muscles, with no change in the H:Q ratio in children with hemiparetic CP.

Backward Locomotor Treadmill Training Differentially Improves Walking Performance across Stroke Walking Impairment Levels

Background: Post-stroke walking impairment is a significant cause of chronic disability worldwide and often leads to loss of life roles for survivors and their caregivers. Walking impairment is traditionally classified into mild (>0.8 m/s), moderate (0.41–0.8 m/s), and severe (≤0.4 m/s), and those categorized as “severe” are more likely to be homebound and at greater risk of falls, fractures, and rehospitalization. In addition, there are minimal effective walking rehabilitation strategies currently available for this subgroup. Backward locomotor treadmill training (BLTT) is a novel and promising training approach that has been demonstrated to be safe and feasible across all levels of impairment; however, its benefits across baseline walking impairment levels (severe (≤0.4 m/s) vs. mild–moderate (>0.4 m/s)) have not been examined. Methods: Thirty-nine adults (>6 months post-stroke) underwent 6 days of BLTT (3×/week) over 2 weeks. Baseline and PRE to POST changes were measured during treadmill training and overground walking. Results: Individuals with baseline severe walking impairment were at a more significant functional disadvantage across all spatiotemporal walking measures at baseline and demonstrated fewer overall gains post-training. However, contrary to our working hypothesis, both groups experienced comparable increases in cadence, bilateral percent single support times, and step lengths. Conclusion: BLTT is well tolerated and beneficial across all walking impairment levels, and baseline walking speed (≤0.4 m/s) should serve as a covariate in the design of future walking rehabilitation trials.

A 10-Week Program of Combined Hippotherapy and Scroth's Exercises Improves Balance and Postural Asymmetries in Adolescence Idiopathic Scoliosis: A Randomized Controlled Study

Introduction: The most frequent type of spine abnormality throughout adolescence was adolescent idiopathic scoliosis (AIS). Hippotherapy improved posture, balance and gait of different musculoskeletal conditions. Therefore, this study aims to see how hippotherapy combined with Schroth exercises affected postural asymmetry and dynamic balance in AIS compared to traditional physiotherapy (Schroth exercises) alone. Materials and methods: In this randomized controlled trial, fifty-two patients with AIS (10–18 years, 37 girls and 15 boys) participated. They were arbitrarily allocated into two groups: experimental (19 female/8 male; aged 14.74 ± 1.79 years; Cobb angle 18.59 ± 2.66 degrees) and control (18 female/7 male; aged 15.04 ± 1.81 years; Cobb angle 19.32 ± 2.69 degrees) groups. Both groups received Schroth exercises for 10 weeks, three days/week. The experimental group additionally received hippotherapy training. Pre-treatment and post-treatment assessment for the scoliotic, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the anteroposterior, mediolateral and overall stability indices were assessed using the formetric system 4D and Biodex Balance System, respectively. Results: After intervention, both groups illustrated significant improvements in all examined variables (p < 0.05). The experimental group illustrated significant improvements in scoliotic angle, kyphotic angle, pelvic obliquity, pelvic torsion and vertical spinal rotation and the stability indices compared to the control group (p < 0.05). Conclusion: In adolescence idiopathic scoliosis, hippotherapy training combined with Schroth exercises improves posture asymmetry and balancing ability more effectively than Schroth exercises alone.

Comparison of forward and backward gait in males with and without intellectual disabilities

BACKGROUND

Intellectual disabilities (ID) affect both cognitive and motor functions. The backward gait is a daily activity and its assessment is used for fall risk estimation and training in the general population. For proper use of backward gait as a rehabilitation tool and in fall prevention programmes for people with ID, it is necessary to determine the backward gait characteristics in the ID population. The aim of this study was to compare the differences between forward and backward gait in persons with nonsyndromic mild and moderate ID, persons with Down syndrome (DS) and a control group of healthy adults.

METHODS

Fifty males divided into four groups (mild ID: n = 15, moderate ID: n = 19, DS: n = 6, controls: n = 10) participated in this study. All participants were asked to walk both forward and backward, barefooted and at their natural velocity on a Zebris FDM platform. The Kruskal-Wallis H test was used to compare differences between the analysed groups in forward and backward gait. The Mann-Whitney U test was used to compare the differences between forward and backward gait within each group.

RESULTS

The velocity was significantly slower in moderate ID and DS compared to controls in forward and backward gait. When comparing forward and backward gait within each group, the gait velocity decreased in backward gait compared with forward gait by 21.80% in controls, by 33.89% in mild ID, by 34.45% in moderate ID, and by 40.32% in DS. In both moderate ID and DS, the mean backward velocity was slower than 2.16 km/h, the velocity used to identify elderly fallers in the general population.

CONCLUSIONS

Gait velocity was especially affected in DS and moderate ID compared with controls. In both mentioned groups, the backward gait velocity suggests an increased risk of falling. Future studies are necessary to examine the possibility of improving balance control and leg muscle strength by backward walking training in the ID population.

A Backward Walking Training Program to Improve Balance and Mobility in Children with Cerebral Palsy

Background: We studied the effects of motor tasks using backward walking training on balance and gait functions of children with cerebral palsy. This was a single-blinded, randomized controlled trial with a crossover design conducted at a single facility. Methods: Among 12 children with cerebral palsy, the forward (FWG) (n = 6) and backward walking groups (BWG) (n = 6) underwent training three times a week for 4 weeks, 40 min a day. After a 6-week break, the crossover training was conducted. Functional walking variables were measured. Time-Up-and-Go (TUG) test, Figure-8 Walk Test (FW8T), and Pediatric Balance Scale (PBS) were used for measuring balance. Results: Both groups showed significant improvement in walking speed, stride length, and step length. The BWG demonstrated significant improvement in walking speed (p < 0.05) compared with the FWG. The TUG test, FW8T, and PBS showed significant improvement. After the 4-week intervention, both groups displayed a remarkable decrease in TUG duration and FW8T. Both groups also exhibited improvement in the PBS; more so in the BWG. Conclusions: Backward walking training with motor dual tasks could be a more effective interventional approach than forward walking training to improve balance and walking functions of children with spastic hemiplegia.

Backward locomotor treadmill training combined with transcutaneous spinal direct current stimulation in stroke: a randomized pilot feasibility and safety study

Walking impairment impacts nearly 66% of stroke survivors and is a rising cause of morbidity worldwide. Despite conventional post-stroke rehabilitative care, the majority of stroke survivors experience continued limitations in their walking speed, temporospatial dynamics and walking capacity. Hence, novel and comprehensive approaches are needed to improve the trajectory of walking recovery in stroke survivors. Herein, we test the safety, feasibility and preliminary efficacy of two approaches for post-stroke walking recovery: backward locomotor treadmill training and transcutaneous spinal direct current stimulation. In this double-blinded study, 30 chronic stroke survivors (>6 months post-stroke) with mild-severe residual walking impairment underwent six 30-min sessions (three sessions/week) of backward locomotor treadmill training, with concurrent anodal (N = 19) or sham transcutaneous spinal direct current stimulation (N = 11) over the thoracolumbar spine, in a 2:1 stratified randomized fashion. The primary outcomes were: per cent participant completion, safety and tolerability of these two approaches. In addition, we collected data on training-related changes in overground walking speed, cadence, stride length (baseline, daily, 24-h post-intervention, 2 weeks post-intervention) and walking capacity (baseline, 24-h post-intervention, 2 weeks post-intervention), as secondary exploratory aims testing the preliminary efficacy of these interventions. Eighty-seven per cent (N = 26) of randomized participants completed the study protocol. The majority of the study attrition involved participants with severe baseline walking impairment. There were no serious adverse events in either the backward locomotor treadmill training or transcutaneous spinal direct current stimulation approaches. Also, both groups experienced a clinically meaningful improvement in walking speed immediately post-intervention that persisted at the 2-week follow-up. However, in contrast to our working hypothesis, anodal-transcutaneous spinal direct current stimulation did not enhance the degree of improvement in walking speed and capacity, relative to backward locomotor treadmill training + sham, in our sample. Backward locomotor treadmill training and transcutaneous spinal direct current stimulation are safe and feasible approaches for walking recovery in chronic stroke survivors. Definitive efficacy studies are needed to validate our findings on backward locomotor treadmill training-related changes in walking performance. The results raise interesting questions about mechanisms of locomotor learning in stroke, and well-powered transcutaneous spinal direct current stimulation dosing studies are needed to understand better its potential role as a neuromodulatory adjunct for walking rehabilitation.

Improvement in Overground Walking After Treadmill-Based Gait Training in a Child With Agenesis of the Corpus Callosum

BACKGROUND

Agenesis of the corpus callosum (ACC) is a rare congenital brain defect that produces a wide variety of cognitive and motor impairments. Literature regarding the response of pediatric populations with ACC to physical rehabilitation is scarce. Treadmill-based gait training (TT) has been shown to improve walking ability in some pediatric populations but has not been investigated in children with ACC.

OBJECTIVE

The purpose of this study was to investigate the effect of a novel treadmill intervention paradigm on the gait parameters of a child with ACC.

DESIGN

A single-participant design with 2 phases was used.

METHODS

The settings were the participant's home and the laboratory. The participant was a 13-year-old girl who had ACC and cortical visual impairment and who ambulated independently using a reverse walker for household and short community distances. A home-based TT intervention (2 phases of 3 months of training over 6 months) was implemented, and a laboratory-based gait analysis was conducted at 4 time points: baseline, after each of the 2 training phases, and 3 months after the cessation of training. The intervention consisted of weekly bouts of TT. Phase I incorporated forward, backward, and incline walking for 15 minutes each; in phase II, this protocol was continued, but short-burst interval training for 10 minutes was added. Data collected at each laboratory visit included spatiotemporal parameters and kinematics (joint angles) during overground and treadmill walking.

RESULTS

After both phases of training, increased step length, decreased step width, and foot progression angle and decreased variability of most spatiotemporal parameters were observed for the participant. Further, after phase II, increased peak extension at the hip, knee, and ankle, decreased crouched gait, and improved minimum foot clearance during overground walking were observed. Most gait improvements were retained for 3 months after the cessation of the intervention.

LIMITATIONS

The small sample size of this study and wide variety of presentations within individuals with ACC limit the generalizability of our findings.

CONCLUSIONS

TT may be a safe and effective treatment paradigm for children with ACC. Future research should investigate the effect of intervention dosage on gait improvements and generalization in individuals with ACC.

Effects of backward walking on knee proprioception after ACL reconstruction

Objective: The present study aimed to assess proprioception of the knee to evaluate the effectiveness of backward walking for rehabilitation after anterior cruciate ligament (ACL) reconstruction.Methods: Patients (n = 52) who underwent ACL reconstruction in a single knee divided randomly into four experimental groups (A-D) and a control group, who all practiced a systematic rehabilitation exercise program. The patients in the experimental groups underwent backward walking using different treadmill angles: group A (0°), B (5°), C (10°) and D (15°). The whole training period comprised 4 weeks. Outcomes for the joint were assessed using the Angle Reproduction Test (ART) and Passive Motion Perception Test (PMPT).Results: Compared with the pre-training recorded parameters, significant differences were found in the ART and PMPT scores among all training groups and between the control group and the training groups. When the four training groups were compared with each other, there was no difference in the ART results between groups A and B, but significant differences were found between group A and groups C and D.Conclusion: Backward walking as a rehabilitation technique improved knee proprioception after ACL reconstruction. Increasing the angle of the treadmill during exercise improved the efficacy of rehabilitation.

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.

Backward walking alters vastus medialis oblique/vastus lateralis muscle activity ratio in females with patellofemoral pain syndrome

Objectives

This study aims to examine the effect of backward walking (BW) and forward walking (FW) on the myoelectric activity ratio of the vastus medialis oblique (VMO)/vastus lateralis (VL) in females with patellofemoral pain syndrome (PFPS).

Patients and methods

Between September 2016 and December 2016, a total of 40 female participants (mean age 20.9±1.9 years; range, 19 to 26 years) were included in the study. The participants were divided into two groups as those with unilateral PFPS (PFPS group, n=20) and healthy controls (Control group, n=20). Surface electromyography (EMG) from VMO and VL muscles were collected during FW and BW at a speed of 3 km/h using the Myomonitor® IV EMG system.

Results

There was a significant increase in the EMG activities of the VMO and VL muscles during BW compared to FW in PFPS and healthy groups (p=0.001). During BW, the VMO activity of PFPS was significantly higher than the healthy controls (p=0.013) without any significant difference in the VL activity (p=0.916). During FW, there was no significant difference in the VMO and VL activities between the groups (p=0.348 and p=0.705), respectively. The VMO/VL ratio of the PFPS group during BW was significantly higher than the FW ratio (p=0.001) without any significant difference between BW and FW of the healthy group (p=0.841). During BW, the ratio of the PFPS group was significantly higher than compared to the healthy controls (p=0.016) without any significant difference between the groups during FW (p=0.100).

Conclusion

Our study results show that BW increases the VMO muscle activation and preserve the ideal VMO/VL ratio in PFPS patients. Therefore, clinicians should consider BW training when developing rehabilitation programs for females with PFPS.

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.

Four-week training involving ankle mobilization with movement versus static muscle stretching in patients with chronic stroke: a randomized controlled trial

BACKGROUND

Patients with stroke generally have diminished balance and gait. Mobilization with movement (MWM) can be used with manual force applied by a therapist to enhance talus gliding movement. Furthermore, the weight-bearing position during the lunge may enhance the stretch force.

OBJECTIVES

This study aimed to compare the effects of a 4-week program of MWM training with those of static muscle stretching (SMS). Ankle dorsiflexion passive range of motion (DF-PROM), static balance ability (SBA), the Berg balance scale (BBS), and gait parameters (gait speed and cadence) were measured in patients with chronic stroke.

METHODS

Twenty patients with chronic stroke participated in this study. Participants were randomized to either the MWM (n = 10) or the SMS (n = 10) group. Patients in both groups underwent standard rehabilitation therapy for 30 min per session. In addition, MWM and SMS techniques were performed three times per week for 4 weeks. Ankle DF-PROM, SBA, BBS score, and gait parameters were measured after 4 weeks of training.

RESULTS

After 4 weeks of training, the MWM group showed significant improvement in all outcome measures compared with baseline (p < 0.05). Furthermore, SBA, BBS, and cadence showed greater improvement in the MWM group compared to the SMS group (p < 0.05).

CONCLUSIONS

This study demonstrated that MWM training, combined with standard rehabilitation, improved ankle DF-PROM, SBA, BBS scores, and gait speed and cadence. Thus, MWM may be an effective treatment for patients with chronic stroke.

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.

Effects of backward gait training on balance, gross motor function, and gait in children with cerebral palsy: a systematic review

Objective:

To investigate the effects of backward gait training on balance, gross motor function, and gait parameters in children with cerebral palsy.

Data sources:

PubMed, Cochrane Library, Web of Science, Science Direct, Physiotherapy Evidence Database (PEDro), and Google Scholar were searched up to May 2018.

Review methods:

Randomized controlled trials were included if they involved any form of backward gait training for children with cerebral palsy. Two authors independently screened articles, extracted data and assessed the methodological quality using PEDro scale, with any confliction resolved by the third author. Modified Sackett Scale was used to determine the level of evidence for each outcome.

Results:

Out of 1492 papers screened, 7 studies with 172 participants met the inclusion criteria. The duration of treatment ranged from 15 to 25 minutes, three times a week and for 6–12 weeks. The quality of studies ranged from good (two studies) to fair (four studies) and poor (one study), with a mean PEDro score of 4.7 out of 10. All included studies showed positive effects in the measured outcomes. The results showed level 1b evidence for balance when compared to no intervention, and for gross motor function, step length and walking speed when compared to same dose of forward gait training. The clinical heterogeneity of studies makes meta-analysis inappropriate.

Conclusion:

In children with cerebral palsy, there is moderate evidence that backward gait training improves balance, gross motor function, step length and walking velocity. More high-quality studies are needed.

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

Over ground gait retraining in the reverse direction has shown to be beneficial for neurological rehabilitation, but has not yet been investigated in Parkinson's disease (PD). Backwards walking (BW) might be a useful training alternative to improve PD gait and possibly reduce fall risk during complex multi-directional daily activities. The primary aim was to compare the effect of an eight-week forward (FWG) and backwards (BWG) gait retraining program on gait parameters in PD individuals. Twenty-nine participants (aged 71.0±8.8years; UPDRS-III 38.1±12.3; H&Y 2.7±0.5) were randomly assigned to either the control (FWG; n=14) or experimental group (BWG; n=15). Baseline measures included disease severity (UPDRS III), global cognition (MoCA) and depression (PHQ-9). Outcome measures were selected gait variables on the 10m-instrumented-walk-test (i10mWT) assessed before and after the interventions. Both groups improved usual gait speed (FWG: p=0.03, d=0.35; BWG: p<0.01, d=0.35) and height-normalized gait speed (FWG: p=0.04, d=0.35; BWG: p<0.01, d=0.57). Additionally, the BWG demonstrated improved cadence (p<0.01, d=0.67) and stride length (SL; p=0.02, d=0.39). Both interventions were effective to improved gait speed sufficiently to independently navigate in the community.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

Effectiveness of backward walking training on walking ability in children with hemiparetic cerebral palsy: a randomized controlled trial

OBJECTIVE

To compare the effects of backward walking training and forward walking training on spatiotemporal gait parameters, and gross motor function measures in children with cerebral palsy.

DESIGN

Randomized controlled clinical trial.

SETTING

Physical therapy clinics.

SUBJECTS

A total of 30 children with hemiparetic cerebral palsy of both sexes (10 to 14 years of age, classified as I or II by gross motor function classification system) participated in this study. They were randomly assigned into two equal groups.

INTERVENTIONS

Both groups received a conventional physical therapy program for 12 successive weeks (three sessions per week). The experimental group additionally received (25 min) backward walking training. The control group additionally received (25 min) forward walking training.

OUTCOME MEASURES

Baseline, posttreatment, and follow-up assessment for spatiotemporal gait parameters and gross motor functions were evaluated by using three dimensional gait analysis system and gross motor function measures.

RESULTS

There was a significant improvement in step length, walking velocity, cadence, stance phase, and swing phase percentage and gross motor function measures (Dimensions D and E) of the experimental group (0.55 ±0.16, 0.53 ±0.19, 121.73 ±2.89, 54.73 ±1.67, 44.40 ±1.40, 90.20 ±6.44, 82.47 ±12.82), respectively, than the control group (0.39 ±0.13, 0.46 ±0.20, 125.80 ±2.96, 50.27 ±1.62, 49.47 ±1.55, 82.47 ±7.05, 80.47 ±12.61), respectively, ( p < 0.05). The significant improvement of all measured outcomes of the experimental group was maintained at 1 month follow-up assessment ( p < 0.05).

CONCLUSION

In addition to a conventional physical therapy program, backward walking training is more effective than forward walking training on spatiotemporal gait parameters, and gross motor function measures in children with hemiparetic cerebral palsy.

The effects of forward and backward walking according to treadmill inclination in children with cerebral palsy

[Purpose] This study investigated the effects of forward and backward walking using different treadmill incline positions on lower muscle activity in children with cerebral palsy, to provide baseline data for gait training intensity. [Subjects and Methods] Nineteen subjects with cerebral palsy walked forward and backward at a self-selected pace on a treadmill with inclines of 0%, 5%, 10%, and 15%. Activation of the rectus femoris, biceps femoris, tibialisanterior, and lateral gastrocnemius was measured using surface electromyography during the stance phase. [Results] As treadmill incline increased during forward walking, muscle activation of the paralyzed lower limbs did not significantly change. However, as treadmill incline increased during backward walking, rectus femoris activation significantly increased and a significant difference was found between treadmill inclines of 0% and 10%. A comparison of backward and forward walking showed a significant difference in rectus femoris activation at treadmill inclines of 0%, 5%, and 10%. Activation of the tibialis anterior was only significantly higher for backward walking at the 10% gradient. [Conclusion] Backward walking may strengthen the rectus femoris and tibialis anterior in walking training for cerebral palsy. Gradient adjustment of the treadmill can be used to select the intensity of walking training.