It is estimated that half of all individuals who suffer a stroke are unable to walk immediately afterwards.[i] Stroke survivors often face challenges in regaining their mobility and independence, with impaired strength, sensation and balance often being a common consequence of stroke.

In this blog we will discuss how treadmill training is an effective treatment technique for improving walking ability after a stroke and the most effective parameters for gait training on a treadmill for stroke survivors. We also look into the existing research to explore the value of treadmill training and identify the optimal parameters for maximizing its benefits.

Table of Contents

What is Treadmill Training?

Treadmill training is walking or running on a stationary exercise machine as part of a rehabilitation program. A physiotherapist might incorporate treadmill training into a client’s program to improve endurance and cardiovascular health, as well as to train the nervous system.

A stroke occurs when there is a blockage in the brain or when a blood vessel bursts causing parts of the brain to become damaged or die.[ii] Approximately 15 million people worldwide suffer a stroke each year and 5 million are left with a permanent disability.

Numerous studies have investigated the impact of treadmill training on the walking ability of stroke survivors, and the consensus is promising.

You may also enjoy reading: Chronic Stroke Rehabilitation

Evidence for the Effectiveness of Treadmill Training in Stroke

Treadmill training has emerged as a potential treatment technique to improve walking and independence.

A scientific review article has demonstrated that treadmill training is effective in enhancing gait speed and endurance. Overall, gait speed increased by 0.06 m/s and endurance increased by 14 meters following treadmill training with or without body weight support.

Treadmill training benefits were greater for those who could walk independently at the start of training compared those who required assistance. For those who could walk independently initially, walking speed increased by 0.09 m/s and endurance increased by 20 meters.[iii]

Step length is an indicator of walking stability and commonly decreases with age and the occurrence of a stroke. Shorter step length can be one factor that leads to slower walking speeds.[iv] [v]

Fortunately, there is evidence demonstrating that treadmill training increases step length in adults with stroke.[vi]

Increased step length would therefore contribute to faster walking speeds following treadmill training. This would translate to an improved ability to cross streets and intersections leading to an increased independence in walking outdoors.

The rhythmic and repetitive nature of treadmill walking aids in promoting neuroplasticity, facilitating the reorganization of neural pathways that may have been damaged during the stroke.

One key aspect of treadmill training’s effectiveness lies in its ability to provide a controlled and structured environment for rehabilitation. The adjustable speed and safety features allow therapists to tailor the training to the individual’s capabilities, gradually increasing the challenge as the patient progresses.

Moreover, the incorporation of body-weight support systems in some cases further promotes early mobility and confidence in stroke survivors.

You may also enjoy reading: PoNS Therapy for Stroke Walking Impairments

Treadmill Parameters for Gait Training Post-Stroke

While the efficacy of treadmill training is established, determining the most effective parameters is crucial for optimizing its benefits. Here are key parameters to consider:

  1. Intensity: Research has shown that high intensity speed-based treadmill training (HITT) can be effective at increasing gait speed and endurance following stroke. This training method involves short bursts of maximal effort with longer breaks in between. After 4 weeks of HISTT, participants were able to walk 0.11 m/s faster and their endurance increased by 27.36 m. These results are clinically significant meaning that they can have a practical impact on client’s lives.[vii]
  2. Speed: Gradual progression in speed is vital. Initial sessions may involve slower speeds and lower inclines, with adjustments made based on the client’s response. This personalized approach ensures safety and effectiveness. Speed-dependent treadmill training (SDTT) involves repetitive, intensive treadmill training where speed is increased or decreased incrementally by 10% based on the performance of the client. Research has shown that SDTT is more effective in increasing step length and walking speed in stroke clients than pure treadmill training.[v]
  3. Sensory feedback: Sensory feedback consists of any combination of auditory, visual and rhythmic cues while performing an activity such as treadmill training. In adults with stroke, visual cues were the most effective in improving cadence (steps/minute) and step length.[v]
  4. Body weight support: Utilizing body-weight support systems, especially in the early stages of rehabilitation, can aid individuals with severe gait impairments. This allows for supported and controlled movements, reducing the fear of falling. Body weight support is facilitated during treadmill training using an overhead harness, pelvic belt and thigh straps. Research has demonstrated that body weight support treadmill training (BWSTT) can increase both walking speed and step length for adults with stroke.[v]
  5. Exoskeleton support: Body weight support harnesses can be combined with an exoskeleton to further augment stroke clients’ walking during treadmill training. Exoskeletons are devices worn on the legs and use motors to control movement and apply force to the joints and lower limbs making it easier to walk. A research review found that body weight support training alone may not be as effective as the combination of body weight and exoskeleton support. Propel Physiotherapy is one of the only clinics in Ontario with clinicians trained to use the Keeogo exoskeleton, which can be combined with our body-weight support system for treadmill training. However, physiotherapists can also support the movement of the legs and feet in place of the exoskeleton and this can also be effective.[ii]

You may also enjoy reading: Massage Therapy for Stroke

Conclusion

Treadmill training emerges as a valuable tool in the rehabilitation for stroke survivors, offering a structured and adaptable approach to improving gait. The effectiveness is evident in the enhancement of gait speed, endurance, and walking patterns.

By considering key parameters such as intensity, speed, sensory feedback, body weight support and exoskeleton support, therapists can tailor treadmill training to the unique needs of each individual, maximizing the potential for recovery and improved quality of life post-stroke.

References

[i] Sahraei, F., Rahemi, Z., Sadat, Z., Zamani, B., Ajorpaz, N. M., Afshar, M., & Mianehsaz, E. (2022). The effect of Swedish massage on pain in rheumatoid arthritis patients: A randomized controlled trial. Complementary Therapies in Clinical Practice, 46, 101524.

[ii] Centers for Disease Control and Prevention. (2023, May 4). About stroke. Centers for Disease Control and Prevention.

[iii] Mehrholz, J., Thomas, S., & Elsner, B. (2017). Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews, 2017(8). https://doi.org/10.1002/14651858.cd002840.pub4

[iv] Morio, Y., Izawa, K., Omori, Y., Katata, H., Ishiyama, D., Koyama, S., & Yamano, Y. (2019). The relationship between walking speed and step length in older aged patients. Diseases, 7(1), 17. https://doi.org/10.3390/diseases7010017

[v]Nascimento, L. R., de Oliveira, C. Q., Ada, L., Michaelsen, S. M., & Teixeira-Salmela, L. F. (2015). Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: A systematic review. Journal of Physiotherapy, 61(1), 10–15. https://doi.org/10.1016/j.jphys.2014.11.015

[vi] Bishnoi, A., Lee, R., Hu, Y., Mahoney, J. R., & Hernandez, M. E. (2022). Effect of treadmill training interventions on spatiotemporal gait parameters in older adults with neurological disorders: Systematic review and meta-analysis of randomized controlled trials. International Journal of Environmental Research and Public Health, 19(5), 2824. https://doi.org/10.3390/ijerph19052824

[vii] Madhavan, S., Lim, H., Sivaramakrishnan, A., & Iyer, P. (2019). Effects of high intensity speed-based treadmill training on ambulatory function in people with chronic stroke: A preliminary study with long-term follow-up. Scientific Reports, 9(1). https://doi.org/10.1038/s41598-018-37982-w

Written by

Propel Physiotherapy
Propel PhysiotherapyIntegrated Healthcare Team
A special thanks to our coop student Alexander Georgiou from McMaster University’s Health Sciences program for helping us put together this blog post as part of his placement.

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