1. 病人 需要恢復到什 麽樣的程度才 能使用跑步機 作訓練呢？ 1

2. Instructor ：簡毓瑾 物理治療師 （大林慈濟） Presenter ： 李勇霆 8 實習生（義守大學） 2

3. Outline Introduction Method ◦ Design ◦ Participants ◦ Intervention ◦ Outcome measure ◦ Data analysis Results ◦ Flow of participants through the study ◦ Effect of intervention between subgroups Discussion ◦ Conclusion 3

4. Introduction Losing the ability to walk independently is one of the most disabling consequences of stroke (Pound P, Gompertz P, Ebrahim S) Despite some stroke survivors regaining the ability to walk, their walking speed and distance may remain significantly reduced 4

5. Introduction Treadmill training is increasingly being used as a method for increasing walking speed and distance in stroke survivors, both for ambulatory and non-ambulatory (Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF) (Ada L, Dean CM, Vargas J, Ennis S) Meta-analysis shows that the size of the effect is moderate (Polese JC, Ada L, Dean CM, Nascimento LR, Teixeira-Salmela LF) 5

6. Introduction A greater effect of intervention on walking speed and distance for those able to walk faster than 0.8m/s at baseline (Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al) Gait speed > 0.8 m/s are able to ambulate fully around their community (Perry J, Garrett M, Gronley JAK, Mulroy SJ) 6

7. Introduction Walk very slowly (gait speed 0.4 m/s) ◦ Rarely venture outside their homes Walk faster (gait speed > 0.4 m/s) ◦ Some ability to ambulate around their community Walking speed has been shown to be associated with community ambulation and participation following stroke 7

8. Introduction Question for this study ◦ After stroke, does treadmill training to improve walking speed and distance have a greater effect on community-dwelling people who walk faster than 0.4 m/s than those who walk more slowly? 8

9. Method-Design Data collected ◦ Randomized trial of treadmill training to improve walking in community-dwelling people after stroke: the AMBULATE trial (Ada L, Dean CM, Lindley R) Three-arm randomized trial ◦ Experimental group ( > 0.4 m/s and < 0.4 m/s ) ◦ Control group Concealed allocation Assessor blinding 9

10. Method-Design Pretest Analysis baseline data Intervention Four months Posttest After four months Follow up After eight months Outcome data analysis 10

11. Method-Participants Inclusion Criteria ◦ Were within five years of their first stroke ◦ Were adults capable of providing consent (MMSE > 23) ◦ Discharged from formal rehabilitation ◦ Were community dwellers ◦ Walked slowly (able to walk 10m in more than 9 seconds across flat ground in bare feet without any aids) 11

12. Method-Participants Exclusion criteria ◦ Unstable cardiac status precluding ◦ Severe cognitive and/or language deficits  (Aphasia)  (Unable to follow two-step commands) 12

13. Method-Intervention Experimental group ◦ Treadmill walking program 30 minutes 3 times/week 4 months >0.4m/s (EXP 2 months <0.4 ) Without any body weight support Increase step length, speed, workload, and automaticity ◦ Over ground walking program Initially comprised 20% of the intervention time Progressively increased each week to 50% of the 30 minute Propulsion forwards, backwards, sideways or up and down stairs (whole-task practice) 13

14. Method-Intervention Control group ◦ The control group received no intervention 14

15. Method-Outcome measure six-minute walk test ◦ Walk as continuously as possible, but they could slow down or stop if necessary ◦ Three minutes and one minute remaining ◦ Participants wore shoes and used aids if necessary Three min One min Start Six min 15

16. Method-Outcome measure 10-m walk test ◦ Measuring speed ◦ Comfortable and fast speeds over the middle 10-m of a 15-m track ◦ Allow for acceleration and deceleration 16

17. Method-Outcome measure EuroQol EQ-5D-3L ◦ Records self-rated health on a vertical, 100- mm visual analogue scale where the endpoints are labelled ‘best imaginable health state’ and ‘worst imaginable health state ’ 17

18. Method-Outcome measure 18

19. Method-Data analysis Intention-to-treat analysis ◦ Missing data were interpolated from the nearest measure taken to maintain all outcome measures from each participant The mean for change (SD) ◦ 4 and 12 months for the experimental and control groups of the two subgroups The mean difference (95% CI) ◦ Experimental and control groups between subgroups for outcomes in the 4 months and the 12 months 19

20. Results 10-m walk test 68 participants 20

21. Results 21

22. Discussion Categories of two type walkers ◦ Slow walkers < 0.4 m/s Physiological walker Limited household walker Unlimited household walker Most-limited community walker ◦ Moderate-to-faster walkers > 0.4 m/s Least-limited community walker Community walker (Perry J, Garrett M, Gronley JAK, Mulroy SJ) 22

23. Discussion Moderate-to-fast walkers ◦ Comfortable walking speeds ↑ 0.16 m/s ◦ Fast walking speeds ↑ 0.175 m/s Indicate that these benefits are clinically meaningful (Fulk GD, Ludwig M, Dunning K, Golden S, Boyne P, West T) (Tilson JK, Sullivan KJ, Cen SY, Rose DK, Koradia CH, Azen SP, et al.) 23

24. Discussion Treadmill and over ground walking training ◦ Performing: faster walkers > slower walkers Community stroke trial of exercise classes and a home program ◦ Larger improvements in walking speed and six- minute walking distance were found for faster walkers > slower walkers (Dean CM, Rissel C, Sherrington C, Sharkey M, Cumming RG, Lord SR, et al) 24

25. Discussion Suggestion ◦ Treadmill and over ground walking intervention Walking speeds of greater than 0.4 m/s ◦ Poor walkers Additional and/or different interventions ◦ For more disabled stroke survivors Scooters or wheelchairs 25

26. Discussion Future research ◦ How stroke survivors with walking speeds > 0.4 m/s can become life-long exercisers and maintain a reasonable level of physical activity ◦ Develop appropriate, accessible, low-cost, community exercise programs ◦ Ways of overcoming the barriers to life-long exercise after stroke and testing strategies for promoting life-long exercise 26

27. Discussion-Conclusion The benefit of the treadmill and over ground walking intervention in walking distance and speed was greater for those who walked faster at the start of therapy. The additional benefit declined over time. 27

28. What this study adds Treadmill training greater benefits ◦ walking speed and distance ◦ comfortable walking speed > 0.4 m/s. (before training) Use comfortable walking speed to predict the potential for improvement. 28

29. THE END 29

30. Q&A?! 30

31. Nottingham Sensory Assessment 31

32. Line Bisection Test 32

33. Tardieu Scale 33