TITLE: Effect of gait training with constrained-induced movement therapy (CIMT) on
the balance of stroke patients

  ABSTRACT:
[Purpose] The purpose of the present study was to examine the effect of intensive gait
training using a constrained induced movement therapy (CIMT) technique applied to the
non-paretic upper extremity on the balance ability of stroke patients. [Subjects and
Methods] Twenty stroke patients were randomly assigned to an experimental group or a
control group. The experimental group received gait training with CIMT for 30 minutes per
session, three sessions per week for four weeks, and the control group received gait
training alone. [Results] The experimental group showed improvements in dynamic balance
and the degree of improvement in this group was greater than that observed in the control
group. Furthermore, the experimental group showed improvements in movement distances to
the paretic side. On the other hand, the control group showed no significant improvements
in balance indices after the intervention. [Conclusion] Gait training of stroke patients
using CIMT techniques should be regarded as a treatment that can improve the balance of
stroke patients.

BODY.INTRODUCTION:
Arm swing during walking plays a role in maintaining body balance by inducing rotation of
the upper extremity in the opposite direction to the direction of pelvic rotation1). Stroke patients show arm swing asymmetry
which is considered to be due to their low walking velocity and the asymmetric movements of
the paretic and non-paretic sides due to an incorrect stance2, 3). Reduction or limitation of
arm swing due to paralysis excessively increases non-paretic side arm swing leading to
reductions in paretic side stride length, stride frequency, and walking velocity. It also
limits thoracic rotation and alters normal movements of the extremities and the trunk,
thereby adversely affecting balance control while walking4,5,6).  Constrained-induced movement therapy (CIMT) is a training method that encourages the use of
the paretic upper extremity by suppressing excessive use of the non-paretic upper extremity,
and has been reported to be effective at not only enhancing the paretic upper extremity
functions of hemiplegia patients, but also at enhancing coordination between the upper and
lower extremities7,8,9).  The majority of training courses that utilize CIMT techniques are based on functional
training in sitting positions rather than walking, and the major dependent variables used to
determine the training effects of CIMT have been associated with movements of the upper
extremity during gait6, 9, 10). In fact, no study has
investigated whether gait training that directly induces paretic side arm swing by fixing
the non-paretic upper extremity during walking improves the balance ability of stroke
patients. Therefore, the present study was conducted to examine the effects of intensive
gait training combined with CIMT techniques, to induce paretic side arm swing, on the
balance abilities of hemiplegia patients.

BODY.SUBJECTS AND METHODS:
Subjects inclusion criteria were: stroke onset of at least three months before the study
commencement, a Korean Mini-Mental State Examination (MMSE-K) score of ≥ 24 points, and the
ability to walk independently outdoors for at least 30 minutes without an ambulatory aid.
The study exclusion criteria were: a limitation in movement of the non-paretic upper
extremity, a visual field defect, problems with the vestibular organ, or an orthopedic
medical history of the upper or lower extremity. From among a total of 151 subjects
considered, 20 subjects were selected following the above-mentioned inclusion and exclusion
criteria. Before participating in the experiment, all subjects were provided with a
comprehensive explanation of the study purpose and method and they voluntarily agreed to
participate. The experiment was approved by the Institutional Bioethics Committee of Daejeon
University.  The experimental group received ground gait training, after fixing the non-paretic upper
extremity so that it could not move, for 30 minutes per session, three sessions per week for
4 weeks in addition to central nervous system developmental treatment for 60 minutes per
session, five times per week, over the same 4 weeks. The control group received general
ground gait training, without fixation of the non-paretic upper extremity, as well as
central nervous system developmental treatment for the same number of sessions and duration
as those received by the experimental group.  To fix the non-paretic upper extremity, the midpoint between the shoulder joint, and the
elbow joint, and the midpoint between the elbow joint and the wrist were fixed to the trunk
using Velcro straps to prevent the non-paretic upper extremity from moving. All subjects in
the two groups performed gait training by walking back and forth on a 10 m straight indoor
walking path on an even floor a set number of times at speeds which were determined based on
subject comfort. Subjects were instructed to swing the paretic upper extremity to the
greatest extent they could. Rest time was allowed whenever a subject complained of fatigue
after which gait training was re-started. Therapists assisted subjects as required.  To measure balance ability, dynamic balance was measured using a Biorescue (RM INGENIERIE,
Rodez, France). Subjects were instructed to spread their feet to approximately 30° and keep
their eyes looking forward in an upright standing position. Before taking measurements,
subjects were shown a video of the measuring method and were given a demonstration. The
Trunk Impairment Scale (TIS) is used to measure the degree of damage to the trunk and to
assess trunk coordination and balance in the sitting position. The TIS is subdivided into
static sitting balance, dynamic sitting balance, and coordination. Higher scores indicate
less trunk damage11). The maximum limit of
stability (LOS) is defined as the distance moved by the center of gravity in the standing
position when body weight is moved maximally to the paretic and non-paretic sides using
ankle strategies without losing balance. Measurements were taken three times and the results
were averaged12).  The χ2 and independent t tests were used to verify group homogeneity. Wilcoxon's
signed rank test was used to compare results before and after the intervention, and the
Mann-Whitney U test was used to compare the experimental and control groups with respect to
differences in values before and after intervention. Statistical significance was accepted
for p values < 0.05.

BODY.RESULTS:
The general characteristics of the subjects in the experimental and control groups are
shown in Table 1Table 1.Baseline characteristics of the subjects (n = 20)CharacteristicsExperimental groupControl groupSex (male/female)6/47/3Affected side (right/left)3/76/4Age (years)*57.6±3.751.9±6.1Height (cm)164.8±8.2166.2±8.0Weight (kg)64.6±12.469.21±16.5Onset (month)24.1±10.730.8±11.0Values are expressed as frequency or mean (SD). *Significant difference
between two groups, p<0.05. Group homogeneity testing failed to reveal any significant differences
between the groups' general characteristics other than age. Out of the 20 subjects, one
subject in the experimental group and one in the control group dropped out before
post-testing due to a deteriorating condition or discharge from hospital. Accordingly, the
analysis was conducted using the data of the 9 subjects remaining in each group. Table 2Table 2.Comparison of balance changes in the experimental and control groupsExperimental group (n=9)Control group (n=9)Pre-testPost-testPre-testPost-testTISStatic7.0 (6.0–7.0)7.0 (7.0–7.0)6.0 (4.0–6.5)6.0 (6.0–7.0)Dynamica7.0 (5.0–8.0)9.0 (8.0–9.5)*7.0 (5.5–9.0)8.0 (5.5–8.5)Coordination4.0 (2.0–4.0)4.0 (3.0–4.5)4.0 (2.5–4.5)3.0 (2.0–4.5)LOSTAS (cm)3.2 (1.6–5.6)4.3 (3.7–7.3)*3.6 (2.7–4.5)4.0 (3.3–4.9)TUS (cm)2.9 (1.3–5.9)5.2 (3.0–7.5)3.7 (2.5–6.4)4.3 (3.5–5.8)Values are expressed as median (25–75% percentile). TIS: trunk impairment scale; LOS:
limit of stability, TAS: to affected side; TUS: to unaffected side. *Significant
difference from pre-test, p<0.05. aSignificant difference in changes
between the two groups, p<0.05 summarizes the balance abilities of the two groups before and after
intervention. The experimental group showed an improvement of 28.6% in dynamic balance as
determined by the TIS, and of 34.3% in movement distances of the paretic side as determined
by the LOS, and the changes in dynamic balance were significantly larger in the experimental
group than in the control group, which showed no significant improvements in balance ability
after gait training.

BODY.DISCUSSION:
The present study was undertaken to examine the effect of intensive gait training using a
constrained induced movement therapy (CIMT) technique for the non-paretic upper extremity on
the balance ability of stroke patients.  According to our results, gait training conducted with CIMT improved the dynamic balance of
hemiplegic stroke patients by 28.6% after training, indicating improved trunk stability, and
movement distances to the paretic side in the standing position increased by 34.3%.
Furthermore, the improvements were larger in the experimental group than in the control
group. Stephenson et al.13) reported that
gait training of stroke patients with the non-paretic upper extremity fixed to treadmill
handrails was effective at inducing paretic side arm swing and that training improved upper
trunk stabilization, results which are in agreement with our findings.  In the present study, the experimental group showed increases in movement distance to the
paretic side. We consider this was due to fixation of the non-paretic upper extremity, which
would have increased the pendulum movement of the paretic upper extremity and conscious
attempts to swing the paretic side arm9).  Homogeneity testing of the two groups revealed significant differences in the groups' ages.
However, our results indicate that the experimental group achieved greater benefits from
gait training with CIMT despite having a higher average age. Therefore, we consider the age
difference was not a confounding factor for the results.  The major limitation of the present study was the small number of study subjects, which
makes it difficult to generalize our results in the context of proposing an intervention for
improving the balance of stroke patients. However, the results of the present study are
meaningful, because it is the first study to investigate the effects of upper extremity CIMT
techniques combined with gait training on the balance ability of stroke patients. Therefore,
we suggest that additional studies should be conducted to investigate the levels of upper
extremity function and training effects according to movements of the paretic upper
extremity to confirm our findings. Despite the limitations of our study, in our opinion, the
method presented in the present study could be applied as a gait training method to improve
the balance of stroke patients.

Question: Compared to Gait training alone what was the result of Gait training with constrained induced movement therapy on Baseline characteristics (except age)?
Evidence: The experimental group showed an improvement of 28.6% in dynamic balance as
determined by the TIS, and of 34.3% in movement distances of the paretic side as determined
by the LOS, and the changes in dynamic balance were significantly larger in the experimental
group than in the control group, which showed no significant improvements in balance ability
after gait training.
Answer: no significant difference