Gait Performance and Lower-Limb Muscle Strength Improved in Both Upper-Limb and Lower-Limb Isokinetic Training Programs in Individuals with Chronic Stroke
Background. Limited improvement in gait performance has been noted after training despite a significant increase in strength of the affected lower-limb muscles after stroke. A mismatch between the training program and the requirements of gait could explain this finding. Objective. To compare the impact of a training program, matching the requirements of the muscle groups involved in the energy generation of gait, to a control intervention, on gait performance and strength. Methods. 30 individuals with chronic stroke were randomly assigned into two groups (n = 15), each training three times/week for six weeks. The experimental group trained the affected plantarflexors, hip flexors, and extensors, while the control group trained the upper-limb muscles. Baseline and posttraining values of gait speed, positive power (muscles’ concentric action during gait), and strength were retained and compared between groups. Results. After training, both groups showed a similar and significant increase in gait speed, positive power of the hip muscles, and plantarflexors strength. Conclusion. A training program targeting the lower-limb muscles involved in the energy generation of gait did not lead to a greater improvement in gait performance and strength than a training program of the upper-limb muscles. Attending the training sessions might have been a sufficient stimulus to generate gains in the control group. 1. Introduction It is well recognized that residual muscle strength on the affected side secondary to a stroke has a great impact on activities of daily living, especially on gait performance. The self-selected and maximal gait speeds of individuals with stroke have been positively related to the residual strength of the affected plantarflexors [1–3], hip flexors [1–3], knee extensors, and flexors [1, 2]. Gait asymmetry has also been negatively related to the residual strength of various muscle groups including the plantarflexors and the knee extensors [1]. Knowing that muscle weakness can jeopardize the fulfillment of a functional gait in individuals with stroke, muscle strengthening of the affected lower-limb has become a recognized therapy in the field of rehabilitation. Many studies have verified the impact of resistance-strengthening programs on the muscle strength of the affected lower extremity of chronic individuals who have had a stroke (>3 months after stroke). Static, dynamic or isokinetic training protocols applied for less than three months resulted in a mean strength increase ranging from 7% to 155% and, generally speaking, this increase was
References
[1]
A. L. Hsu, P. F. Tang, and M. H. Jan, “Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke,” Archives of Physical Medicine and Rehabilitation, vol. 84, no. 8, pp. 1185–1193, 2003.
[2]
C. Maria Kim and J. J. Eng, “The relationship of lower-extremity muscle torque to locomotor performance in people with stroke,” Physical Therapy, vol. 83, no. 1, pp. 49–57, 2003.
[3]
S. Nadeau, D. Gravel, A. B. Arsenault, and D. Bourbonnais, “Plantarflexor weakness as a limiting factor of gait speed in stroke subjects and the compensating role of hip flexors,” Clinical Biomechanics, vol. 14, no. 2, pp. 125–135, 1999.
[4]
U. B. Flansbjer, M. Miller, D. Downham, and J. Lexell, “Progressive resistance training after stroke: effects on muscle strength, muscle tone, gait performance and perceived participation,” Journal of Rehabilitation Medicine, vol. 40, no. 1, pp. 42–48, 2008.
[5]
T. R. Hill, T. I. Gjellesvik, P. M. Moen, et al., “Maximal strength training enhances strength and functional performance in chronic stroke survivors,” American Journal of Physical Medicine & Rehabilitation, vol. 91, no. 5, pp. 393–400, 2012.
[6]
M. J. Lee, S. L. Kilbreath, M. F. Singh, B. Zeman, and G. M. Davis, “Effect of progressive resistance training on muscle performance after chronic stroke,” Medicine and Science in Sports and Exercise, vol. 42, no. 1, pp. 23–34, 2010.
[7]
M. M. Ouellette, N. K. LeBrasseur, J. F. Bean et al., “High-intensity resistance training improves muscle strength, self-reported function, and disability in long-term stroke survivors,” Stroke, vol. 35, no. 6, pp. 1404–1409, 2004.
[8]
C. M. Kim, J. J. Eng, D. L. MacIntyre, and A. S. Dawson, “Effects of isokinetic strength training on walking in persons with stroke: a double-blind controlled pilot study,” Journal of Stroke and Cerebrovascular Diseases, vol. 10, no. 6, pp. 265–273, 2001.
[9]
S. L. Morris, K. J. Dodd, and M. E. Morris, “Outcomes of progressive resistance strenght training following stroke: a systematic review,” Clinical Rehabilitation, vol. 18, no. 1, pp. 27–39, 2004.
[10]
N. Hammami, F. O. Coroian, M. Julia, et al., “Isokinetic muscle strengthening after acquired cerebral damage: a literature review,” Annals of Physical and Rehabilitation Medicine, vol. 55, no. 4, pp. 279–291, 2012.
[11]
S. A. Sharp and B. J. Brouwer, “Isokinetic strength training of the hemiparetic knee: effects on function and spasticity,” Archives of Physical Medicine and Rehabilitation, vol. 78, no. 11, pp. 1231–1236, 1997.
[12]
J. Eng, “Strength training in individuals with stroke,” Physiotherapy Canada, vol. 56, pp. 189–201, 2004.
[13]
I. J. Hubbard, M. W. Parsons, C. Neilson, and L. M. Carey, “Task-specific training: evidence for and translation to clinical practice,” Occupational Therapy International, vol. 16, no. 3-4, pp. 175–189, 2009.
[14]
B. French, L. Thomas, M. Leathley et al., “Does repetitive task training improve functional activity after stroke? A Cochrane systematic review and meta-analysis,” Journal of Rehabilitation Medicine, vol. 42, no. 1, pp. 9–15, 2010.
[15]
C. Mercier, D. Bourbonnais, S. Bilodeau, J. F. Lemay, and P. Cross, “Description of a new motor re-education programme for the paretic lower limb aimed at improving the mobility of stroke patients,” Clinical Rehabilitation, vol. 13, no. 3, pp. 199–206, 1999.
[16]
C. M. Dean, C. L. Richards, and F. Malouin, “Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial,” Archives of Physical Medicine and Rehabilitation, vol. 81, no. 4, pp. 409–417, 2000.
[17]
L. F. Teixeira-Salmela, S. Nadeau, I. Mcbride, and S. J. Olney, “Effects of muscle strengthening and physical conditioning training on temporal, kinematic and kinetic variables during gait in chronic stroke survivors,” Journal of Rehabilitation Medicine, vol. 33, no. 2, pp. 53–60, 2001.
[18]
D. A. Winter, The Biomechanics and Motor Control of Human Gait: Normal, Elderly and Pathological, University of Waterloo Press, Waterloo, Canada, 2nd edition, 1991.
[19]
C. Gowland, P. Stratford, M. Ward et al., “Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment,” Stroke, vol. 24, no. 1, pp. 58–63, 1993.
[20]
M. H. Rabadi and F. M. Rabadi, “Comparison of the action research arm test and the Fugl-Meyer assessment as measures of upper-extremity motor weakness after stroke,” Archives of Physical Medicine and Rehabilitation, vol. 87, no. 7, pp. 962–966, 2006.
[21]
M. F. Levin and C. Hui-Chan, “Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity?” Journal of Neurology, vol. 240, no. 2, pp. 63–71, 1993.
[22]
K. Berg, S. Wood-Dauphinee, and J. I. Williams, “The balance scale: reliability assessment with elderly residents and patients with an acute stroke,” Scandinavian Journal of Rehabilitation Medicine, vol. 27, no. 1, pp. 27–36, 1995.
[23]
N. M. Salbach, N. E. Mayo, J. Higgins, S. Ahmed, L. E. Finch, and C. L. Richards, “Responsiveness and predictability of gait speed and other disability measures in acute stroke,” Archives of Physical Medicine and Rehabilitation, vol. 82, no. 9, pp. 1204–1212, 2001.
[24]
J. Fix and D. Daughton, Human Activity Profile: Professional Manual, Psychological Assessment Resources, Odessa, Fla, USA, 1988.
[25]
J. E. Ware Jr., K. K. Snow, M. Kosinski, and B. Gandek, SF-36 Health Survey: Manual and Interpretation Guide, The Health Institute, New England Medical Center, Boston, Mass, USA, 1993.
[26]
M. H. Milot, S. Nadeau, and D. Gravel, “Muscular utilization of the plantarflexors, hip flexors and extensors in persons with hemiparesis walking at self-selected and maximal speeds,” Journal of Electromyography and Kinesiology, vol. 17, no. 2, pp. 184–193, 2007.
[27]
J. Perry, M. Garrett, J. K. Gronley, and S. J. Mulroy, “Classification of walking handicap in the stroke population,” Stroke, vol. 26, no. 6, pp. 982–989, 1995.
[28]
H. Van der Lee, Forced Use of the Upper Extremity in Chronic Stroke Patients, Vrije Universiteit, Amsterdam, The Netherlands, 2001.
[29]
W. J. Kraemer, K. Adams, E. Cafarelli, et al., “American College of Sports Medicine position stand; progression models in resistance training for healthy adults,” Medicine & Science in Sports & Exercise, vol. 34, no. 2, pp. 364–380, 2002.
[30]
M. C. Cirstea and M. F. Levin, “Compensatory strategies for reaching in stroke,” Brain, vol. 123, no. 5, pp. 940–953, 2000.
[31]
A. M. Bertrand, C. Mercier, P. L. W. Shun, D. Bourbonnais, and J. Desrosiers, “Effects of weakness on symmetrical bilateral grip force exertion in subjects with hemiparesis,” Journal of Neurophysiology, vol. 91, no. 4, pp. 1579–1585, 2004.
[32]
L. F. Requi？o, S. Nadeau, M. H. Milot, D. Gravel, D. Bourbonnais, and D. Gagnon, “Quantification of level of effort at the plantarflexors and hip extensors and flexor muscles in healthy subjects walking at different cadences,” Journal of Electromyography and Kinesiology, vol. 15, no. 4, pp. 393–405, 2005.
[33]
S. A. Moore, K. Hallsworth, T. Plotz, et al., “Physical activity, sedentary behaviour and metabolic control following stroke: a cross-sectional and longitudinal study,” PloS One, vol. 8, no. 1, Article ID e55263, 2013.
[34]
I. G. L. Van de Port, S. Wood-Dauphinee, E. Lindeman, and G. Kwakkel, “Effects of exercise training programs on walking competency after stroke: a systematic review,” American Journal of Physical Medicine and Rehabilitation, vol. 86, no. 11, pp. 935–951, 2007.
[35]
R. Dickstein, “Rehabilitation of gait speed after stroke: a critical review of intervention approaches,” Neurorehabilitation and Neural Repair, vol. 22, no. 6, pp. 649–660, 2008.
[36]
M. H. Milot, S. Nadeau, D. Gravel, and L. F. Requi？o, “Bilateral level of effort of the plantar flexors, hip flexors, and extensors during gait in hemiparetic and healthy individuals,” Stroke, vol. 37, no. 8, pp. 2070–2075, 2006.
[37]
S. J. Mulroy, T. Klassen, J. K. Gronley, V. J. Eberly, D. A. Brown, and K. J. Sullivan, “Gait parameters associated with responsiveness to treadmill training with body-weight support after stroke: an exploratory study,” Physical Therapy, vol. 90, no. 2, pp. 209–223, 2010.
[38]
K. Hakkinen, “Factors influencing trainability of muscular strength during short term and prolonged training,” NSCA Journal, vol. 7, no. 2, pp. 32–37, 1985.
[39]
H. J. Hislop, “Quantitative changes in human muscular strength during isometric exercise,” Journal of the American Physical Therapy Association, vol. 43, no. 1, pp. 21–38, 1963.
[40]
M. Lindh, “Increase of muscle strength from isometric quadriceps exercises at different knee angles,” Scandinavian Journal of Rehabilitation Medicine, vol. 11, no. 1, pp. 33–36, 1979.
[41]
M. I. R. Pereira and P. S. C. Gomes, “Movement velocity in resistance training,” Sports Medicine, vol. 33, no. 6, pp. 427–438, 2003.
[42]
M. H. Milot, S. Nadeau, D. Gravel, and D. Bourbonnais, “Effect of increases in plantarflexor and hip flexor muscle strength on the levels of effort during gait in individuals with hemiparesis,” Clinical Biomechanics, vol. 23, no. 4, pp. 415–423, 2008.
[43]
S. J. Garland, V. L. Gray, and S. Knorr, “Muscle activation patterns and postural control following stroke,” Motor Control, vol. 13, no. 4, pp. 387–411, 2009.
