COMPARITIVE STUDY OF TREADMILL GAIT TRAINING AND PLANE GROUND GAIT TRAINING TO IMPROVE MOBILITY AND GAIT SPEED

IN MILD TO MODERATE HEMIPLEGIC PATIENTS

DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTERS DEGREE IN PHYSIOTHERAPY WITH SPECIALISATION IN NEUROLOGIC PHYSIOTHERAPY

SUBMITTED BY BENSON BABY REG. NO: ASAH MPT 004

UNDER THE GUIDANCE OF Mr. BHUVANESH BABU. M. G, MPT

INTERNALEXAMINER

EXTERNAL EXAMINER

DEPARTMENT OF PHYSIOTHERAPY A W H SPECIAL COLLEGE (AFFILIATED TO UNIVERSITY OF CALICUT) KALLAI, CALICUT -673003, KERALA. 2007-2009

DECLARATION BY THE STUDENT

I hereby declare that this dissertation entitled COMPARITIVE STUDY OF TREADMILL GAIT TRAINING AND PLANE GROUND GAIT TRAINING TO IMPROVE MOBILITY AND GAIT SPEED IN MILD TO MODERATE HEMIPLEGIC PATIENTS is a bonafide and genuine research work carried out by me under the guidance of Mr. BHUVANESH BABU. M. G

Place: Date:

BENSON BABY

CERTIFICATE

This is to certify that Mr. Benson Baby is a bonafide student of Master of Physiotherapy Course with specialization in Neurologic physiotherapy at AWH Special College, Calicut. This dissertation entitled COMPARITIVE STUDY OF TREADMILL GAIT TRAINING AND PLANE GROUND GAIT TRAINING TO IMPROVE MOBILITY AND GAIT SPEED IN MILD TO MODERATE HEMIPLEGIC PATIENTS is submitted in partial fulfillment of the requirements for the degree of Master of Physiotherapy from University of Calicut. This bonafide work has been carried out under my guidance and supervision.

Place: Date:

Mr. BHUVANESH BABU. M. G MPT (Paediatric Neurology) Assistant professor PG Co-ordinator Department of Physiotherapy AWH Special College Calicut.

CERTIFICATE

This is to certify that Mr. BENSON BABY is a bonafide student of Master of Physiotherapy Course with specialization in Neurologic Physiotherapy at AWH Special College, Calicut. This dissertation entitled COMPARITIVE STUDY OF TREADMILL GAIT TRAINING AND PLANE GROUND GAIT TRAINING TO IMPROVE MOBILITY AND GAIT SPEED IN MILD TO MODERATE HEMIPLEGIC PATIENTS is submitted in partial fulfillment of the requirements for the degree of Master of Physiotherapy from University of Calicut.

Date: Place:

Mr. RASHIJ. M MPT (Neurology and Psychosomatic disorder) Assistant professor Head of the Department Dept of Physiotherapy AWH Special College Calicut.

CERTIFICATE

This is to certify that Mr. BENSON BABY is a bonafide student of Master of Physiotherapy course with specialization in neurologic Physiotherapy at AWH Special College, Calicut. This dissertation is submitted in partial fulfillment of the requirements for the degree of Master of Physiotherapy from university of Calicut.

Place:
Date:

Dr. P. K. ABDUL KADER Principal AWH Special College, Calicut

ADVISORS OF THE STUDY

Mr. ROSHITH. C MPT (Rehabilitation) Lecturer Department of Physiotherapy AWH Special College Calicut.

Mr. DEEPAK. T. V MPT (Neurology and Psychosomatic disorder) Lecturer Department of Physiotherapy AWH Special College Calicut.

Mr. RASHIJ. M MPT (Neurology and Psychosomatic disorder) Assistant professor Head of the Department Dept of Physiotherapy AWH Special College Calicut.

ACKNOWLEDGEMENT

I thank the Almighty who laid the foundation for the knowledge and wisdom and has always been my source of strength and inspiration and who guides me throughout. I would like to acknowledge my guide Mr. Bhuvanesh Babu. M. G, MPT. He set such an extra ordinary example for me and I cannot thank him enough. His endless guidance and support have been pivotal for my academic and personal development. I would like to express my gratitude to Mr. Roshith. C, MPT, for the random distractions, making me take breaks to run or play sports; answering my endless questions and putting up with me in general. I am utmost thankful to Mr. Rashij. M, MPT, Head of the department, Department of Physiotherapy, for the scholarly guidance and support in the fulfilment of my task. My sincere thanks to Dr. P. K. Abdul Khader, Principal AWH Special College, Calicut for his constant encouragement and valuable advice. My hearty thanks to Mr. Suhas. K. P, MPT, Mr. Premkumar, MPT and Mr. Deepak. T. V, MPT, for their support they have provided me in carrying out my work. I express my sincere thanks to my classmates Abhishek, Akheel, David, Linto, Nidhin, Micky, Lija, and Sweety who not only helped me by providing valuable information but also were a source of inspiration to carry out my thesis work. I wish to express my sincere thanks to the management, library staff and office staff of AWH Special College, Calicut. I am very much grateful to my beloved parents, loving brother for their keen interest in my academic excellence. I could not have attained my accomplishment without their patience and supports through all these years. I am making my dreams come true because of them. There are not enough words to describe all they have done for me. I love them. Last but certainly not least, I would like to thank all my participants for their extreme support during their break hours with great patience to complete my entire project within the stipulated time period with great success. I thank them all.

Dedicated to my loving parents

CONTENTS

CHAPTER 1. INTRODUCTION 1.1. Introduction 1.2. Need for the study 2. REVIEW OF LITERATURE

Page no 1

3.

METHODOLOGY 3.1. Aim of the study 3.2. Objectives of the study 3.3. Research Design 3.4. Hypotheses 3.5. Population 3.6. Study settings 3.7. Samples and Sampling Method 3.8. Selection Criteria 3.9. Variables of the study 3.10. Research Tool 3.11. Duration of the study 3.12. Data collection procedure

19

4.

DATA ANALYSIS

25

5.

RESULTS

27

CHAPTER 6. DISCUSSION 6.1. Discussion 6.2. Limitations and Suggestions

Page no 29

7.

CONCLUSION

39

8.

REFERENCES

41

APPENDICES 1. Assessment form 2. Data collection form 3. Graphs 4. Results tables 5. Protocols and Scales 5.1 Plane ground gait training protocol 5.2 Treadmill gait training protocol 5.3 Conventional therapy protocol 5.4 Stroke Rehabilitation Assessment of Movements (STREAM) 5.5 Timed Up and Go Test (TUG) 5.6 Orpingtons Prognostic Scale (OPS) 5.7 Dynamic Gait Index (DGI) 6. Informed consent form 7. Master chart

ABSTRACT Comparative study of Treadmill Gait Training and Plane Ground Gait Training to improve mobility and gait speed in mild to moderate hemiplegic patients
Objective: To compare the effectiveness of treadmill gait training and plane ground gait training in mild to moderate hemiplegic patients. Methods: 30 Subjects were selected on the basics of inclusion and exclusion criteria. All the subjects were divided equally into two groups, Group A and Group B based on Simple Random Sampling Technique. Before starting the training, pre-test scores are measured by using STREAM measure and Timed Up and Go test. Group A received treadmill gait training and Group B received plane ground gait training for 30 minutes, and both the groups received conventional therapy. At the end of fourth week, post-test scores of both groups were taken by used STREAM measure and Timed Up and Go test. Results: Treadmill gait training (TGT) group showed better improvements in mobility and gait speed, When compared to Plane ground gait training (PGT) group. Conclusion: Improvement of locomotor function including mobility and speed is seen in hemiplegic persons when intensively trained on a treadmill. Key words: Treadmill gait training, plane ground gait training, mobility, gait speed, hemiplegia

CHAPTER 1 INTRODUCTION

1.1 INTRODUCTION

Stroke is defined as rapidly developing clinical signs of focal/ global disturbances of cerebral blood function, with symptoms lasting 24 hours or longer or leading to death , with no apparent cause other than vascular origin(World Health Organization). The essential supply of oxygen and glucose to the central nervous tissue is subsequently interrupted causing cell necrosis (Sherwood 1997). Stroke is of high incidence, occurring between 250 350 per 100,000 / population per annum in India (Epidemiology of stroke in India, 2006) and as such represent a major economic burden to society as whole. The effects of stroke are variables and may include impairment in motor and sensory systems, emotion, language, perception, and cognitive function. Impairment of motor function involves paralysis or paresis of the muscle on the side of the body contra lateral to the side of the supra tentorial lesion. Damage to the descending neural pathways results in abnormal regulation of spinal motor neurons, causing alteration in postural and stretch reflexes and voluntary movement. Abnormality in the temporal and spatial recruitment of motor unit slow the ability of the muscle to generate tension, leading to prolonged agonist contraction. Common problems after stroke are impaired motor function including Gait and Balance, Sensory deficits, Perceptional deficits, Cognitive limitation, Visual deficits, Aphasia and Depression. Balance problem occurs due to muscle weakness, abnormal muscle tone, loss of Range of Motion (ROM), distorted proprioception and impairment of vestibular mechanism.

Independent walking is possible in the majority of the patients following stroke, but the patients rarely return to the pre-stroke status. The gait of the people following stroke is characterized by problems with initiation, timing, grading of muscle activity, hyper tonicity and influenced by mechanical changes in soft tissue. Gait speed, stride length, and cadence are reduced relative to normal values. Common kinematic deviation during the stance phase of gait cycle are; decreased pelvic force angles, decreased lateral pelvic tilt displacement, changed knee extension, and decreased plantar flexion angles with the swing phase being characterized by decreased hip flexion, knee extension and dorsi flexion angles. In physiotherapy a variety of movement therapy approaches are available for retraining motor skills in adult patients with hemiplegia. Certain approaches like Proprioceptive Neuromuscular Facilitation, Rood, Brunnstrom, and Bobath relay on reflex and hierarchical theories of motor control, while others like Motor Relearning Program (MRP) and System theory approaches derive clinical implications from more recent theories of motor control and learning as well as from the principles of neural plasticity. Conventional physiotherapy for gait training is generally recognized as beneficial in patients with stroke (Ernst E A Review of stroke rehabilitation and physiotherapy - Stroke 1990). One approach introduced for a gait training of patients with stroke involves the uses of gait training on a motorized treadmill. This approach facilitates walking movements on the treadmill by the activation of spinal locomotion centers. Centrally located sets of neurons (central pattern generators or neural oscillators), which can be modulated by descending control from supraspinal brain structures produce a rhythmic

output. This strategy provides a dynamic and task- specific approach that integrates three essential components of gait while the patient is walking on the treadmill namely; weight bearing, stepping and balance (Graham Brown 1911). Gait training based on the Bobath concept uses techniques aimed at; normalization of muscle tone, facilitation of more normal movement pattern in the trunk, pelvis and limbs; and facilitation of walking ( Adult Hemiplegia: Evaluation and Treatment) . This study was designed to evaluate the effectiveness of a training program involving both treadmill and plane ground walking as a means of reducing the disability and handicap associated with poor walking performance, thereby aiming at improving basic mobility and gait speed in persons after stroke. Although physical therapy for patients with mobility problems after stroke has been shown to be effective, the improvements gained are not maintained after cessation of treatment. Treadmill walking may be an useful intervention to improve both the speed and capacity of walking in such patients. In uncontrolled trials of chronic stroke patients, treadmill walking has been associated with increases in strength, decreases in energy expenditure, as well as increases in walking speed and quality. There is evidence to suggest that the content of a treadmill walking program is important in determining effectiveness. Pohl et al have shown the importance of manipulating the speed of the treadmill to achieve increases in over-ground walking speed. However, it has been shown that stroke patients generally achieve higher walking velocities by increasing their cadence rather than step length compared with normal. It was proposed that treadmill walking can be viewed as a form of forced use that may be used to improve the quality of walking as well as the quantity. The motion of the treadmill enforces the appropriate timing between the lower limbs and ensures that the

hips are extended during stance phase, both of which are critical biomechanical components of walking.

Gait training during actual walking favors a better recovery of walking abilities than a more conventional approach that emphasizes control of isolated components of gait before ambulation is resumed. The treadmill stimulates repetitive and rhythmic stepping with the patient in upright position and bearing weight on the lower limbs. The assessments of stroke patients with mobility problems can be carried out by a variety of outcome measures. This study used Stroke Rehabilitation Assessment of Movement (STREAM), an outcome measure which was designed to use in physiotherapy department to provide a comprehensive, objective, and quantitative evaluation of motor function of individual with stroke. The STREAM measure consists of 30 items of movement that are equally distributed among 3 subscales; upper limb movements, lower limb movements and basic mobility items. The assessment of gait speed of stroke patients is carried out by using a scale, Timed Up and Go test (TUG), a basic test which demonstrates subjects balance, functional ability and gait speed. In contrast to the studies which used Body Weight Support (BWS) during treadmill training, this study is designed to compare the effectiveness of plane ground training and treadmill training to improve mobility and gait speed in mild to moderate hemiplegic patients.

1.2 NEED FOR THE STUDY

Recent studies reported comparisons between conventional gait training and BWS treadmill training, in hemiplegic patients. Although the results suggested that treadmill training enhances locomotor recovery, further investigation was needed to determine whether loading contributes to the improvement in gait. There are very few researches which studied the effects of treadmill gait training (TGT) with 0% BWS and plane ground gait training (PGT). Also, as studies which compare the effects of different methods of gait training are least, further studies are needed to put forward better results to incorporate the findings in the rehabilitation of hemiplegic patients. The present study is designed to compare the effects of Plane Ground Gait Training (PGT) and Treadmill Gait Training (TGT) in mild to moderate hemiplegic patients.

CHAPTER 2 REVIEW OF LITERATURE

REVIEW OF LITERATURE
Chu- Ling Yen et al, 2008 Gait Training Induced Changes in Corticomotor Excitability in Patients with Chronic Stroke, The American Society of Neurorehabilitation Fourteen patients were randomly assigned in to experimental and control group. In the 4 week study, all the subjects received baseline and post treatment assessment. The outcome measures included Berg Balance scale and gait parameters. Focal transcranial magnetic stimulation was used to measure the motor threshold. After general physiotherapy, it was noted that the patients showed an improvement only in walking speed and cadence and there were no significant change in corticomotor excitability. After additional gait training, subjects improved significantly on BBS score, and motor performance, which may be related to change in corticomotor excitability. Gregory F Marchetti et al, 2008 Temporal and Spatial Characteristics of Gait Index in People with and without Balance, American Physical Therapy Association, conducted study on forty-seven subjects with balance or vestibular

dysfunctions which measured mean gait parameter differences between control group and experimental group. The reliability of most gait parameters during Dynamic Gait Index (DGI) performance was fair to excellent between trials. DGI may be useful in identifying gait deviations and in evaluating gait improvements as a result of interventions. Karen J. McCain et al, 2008, Locomotor Treadmill Training With Partial Body-Weight Support Before Over-ground Gait in Adults With Acute Stroke: A Pilot Study, Archives of Physical Medicine and rehabilitation-studied on 14 subjects with first stroke, and divided into two groups, and received Locomotor treadmill training with partial BWS or traditional gait training methods. Gait kinematics, symmetry,

velocity, and endurance were the variables, and this study concluded that application of locomotor treadmill training with partial BWS before over-ground gait training may be more effective than traditional gait training methods in acute rehabilitation. T George Hompy et al 2008 Enhanced Gait-Related Improvements After Therapist Versus Robotic Assisted Locomotor Training in Subject With Chronic Stroke, American Heart Association journals Forty-eight ambulatory chronic stroke survivors stratified by severity of locomotor deficits completed a randomized controlled study on the effect of robotic versus therapist assisted Locomotor Training (LT), where both groups received 12 LT sessions for 30 minutes at similar speed. Outcome measures included gait speed and symmetry, and clinical measures of activity and participation. Greater improvements in speed and single limb stance time on the impaired leg were observed in subjects who received therapist-assisted LT. The study concluded that therapist-assisted locomotor training facilitates greater improvements in walking ability in ambulatory stroke survivors as compared to a similar dosage of robotic-assisted locomotor training.

Cecily Partridge, 2007, Recent Advances in Physiotherapy, has shown the importance of manipulating the speed of the treadmill to achieve increases in overground walking speed and showed that stroke patients generally achieve higher walking velocities by increasing their cadence rather than step length (Wagenaar et al. 1992) and it has been concluded that treadmill training programs should include over-ground walking components where increases in walking speed and step length are encouraged. Cecily Partridge, 2007, Recent Advances in Physiotherapy, examined the effect of a four week treadmill and over-ground walking program, consisting of three 30

minute sessions a week, compared to a placebo of low intensity home exercises. The training sessions comprised 30 minutes of walking, which took about 45 minutes to accomplish. Each session consisted of both treadmill and over ground walking, with the proportion of treadmill walking decreasing by 10 % each week, from 80% in Week 1 to 50% in Week 4. Subjects received individual training from a physical therapist. The program was carried out in a community setting and transport was provided if necessary. The results proved that treadmill walking component was structured to increase step length, speed, balance, fitness, and automaticity. Cecily Partridge, 2007, Recent Advances in Physiotherapy, carried out a randomized trial comparing three treadmill speeds during training with BWS for patients who could walk but walked slowly and found that the fastest treadmill speed increased final over ground walking speed by 0.13 m/s (p = 0.02) more than the two slower speeds. Jesse A Lieberman et al, 2007, Therapeutic Exercise, Therapeutic Exercise expert-Therapeutic exercise seeks to accomplish goals like enable ambulation, release contracted muscle, mobilize joints, reduce rigidity, improve balance, promote relaxation, improve muscle strength, and improve endurance. In stroke patients exercises are aimed for improving maximal voluntary controls, endurance, co-ordination, balance and mobility. Sridar Alla et al, 2007 Does Treadmill Training without Body Weight Support Improve Gait and Balance in Patients with Hemiplegia- The journal of Indian Association of Physiotherapists. Thirty patients with mild to moderate hemiplegia were randomly divided in to two groups. The conventional gait training (CGT) group was treated with over ground walking training while treadmill gait training (TGT) group treated with treadmill training. All the participants received 20 minutes of walking

training 3 days a week for 6 weeks. Variables are mobility and balance, and measured by MSTREAM and Berg Balance Scale (BBS) respectively. In results, TGT group scored significantly higher than CGT group on the MSTREAM and BBS. Retraining of gait in patients with mild to moderate hemiplegia using harness with 0% BWS on a treadmill resulted in significant improvement in standing, walking abilities, and balance. Yu-Wei Hsieh et al, 2007, Simplified Stroke Rehabilitation Assessment of Movement Instrument In Patients With Stroke, Journal of Rehabilitation Medicine388 patients after stroke participated in this study, to examine the discriminative property, the patients were divided into 3 groups according to their Barthel Index scores. A comprehensive measure of activities of daily living was administered at 6 months after hospital discharge as an external criterion to examine the predictive property. Changes in the S-STREAM scores from the time of admission for rehabilitation, to hospital discharge, were used to examine the evaluative property. All pair-wise comparisons of mean scores among the 3 groups on the 3 subscales of the S-STREAM were significant. The scores of the S-STREAM showed moderate to good correlations with the comprehensive activities of daily living scores. This study concluded that all 3 subscales of the S-STREAM demonstrate good discriminative, predictive and evaluative properties in patients after stroke and these findings provide strong evidence that the S-STREAM is useful in measuring motor and mobility function in patients after stroke. Delphine David et at, 2006 Oxygen Consumption During Machine-Assisted and Unassisted Walking: A Pilot Study in Hemiplegic and Healthy Humans, Archives of Physical Medicine and Rehabilitation - seven patients with stroke were assigned to Floor walking (FW) and gait trainer (GT) - assisted walking with and without 50% body-weight support (BWS). Walking time duration, oxygen consumption, minute

ventilation, and heart rate were studied and concluded that compared with FW, GT assistance increased walking time duration and reduced VO2 in patients with severe hemiplegia. Tapas Kumar Banerjee et al, 2006, Epidemiology of stroke in India, Neurology Asia, Several population-based surveys on stroke were conducted from different parts of India. During last decade, the age-adjusted prevalence rate of stroke was 250-350/ 100,000. Stroke represented 1.2% of total death in India. Dr Uma Pandiyan, et al, 2005, Risk Factors and Stroke Outcome An Indian Study, Indian Journal of Physical Medicine and Rehabilitation - total of 402 definite stroke patients were evaluated and also the risk factors of stroke (such as age, hypertension, diabetes, ischemic heart disease, dyslipidemias and nicotine.) and stroke outcome were evaluated, found that hypertension was the commonest risk factor. The study concluded that the recovery depended essentially on the type, sub-type of stroke and its severity. The morbidity and mortality increased with a combination of risk factors. Mary Rieck et al, 2005, The Orpingtons Prognostic Scale (OPS) for Patients with Stroke, Disability and Rehabilitation - 94 patients with stroke were included, pairs of physiotherapist and occupational therapist assessed patients using OPS on 7th day and 14th day of post stroke. This study showed that interclass coefficient correlation of Orpingtons Prognostic Scale is 0.99 (95%). Laura Lennihan et al, 2005, Treadmill With Partial Body-Weight Support Versus Conventional Gait Training After Stroke, Archives of Physical Medicine and Rehabilitation-conducted study on 83 subjects who were randomly assigned to treadmill and conventional treatments and concluded that both treatment groups made

improvements in walking velocity and clinical measures during rehabilitation, but treadmill training with partial body-weight support conferred no additional benefit compared with conventional training. Age may be a contributing factor to the results. Shamay S. Ng et al, 2005, Timed Up & Go Test: Its Reliability and Association With Lower-Limb Impairments and Locomotor Capacities in People With Chronic Stroke, Archives of Physical Medicine and Rehabilitation-conducted study on ten healthy elderly subjects and 11 subjects with chronic stroke. Time taken to complete TUG test was recorded, gait parameters and endurance were measured respectively by walkway system and 6-minute walk test. The TUG test showed excellent reliability (ICC>.95) and TUG scores were reliable, were able to differentiate the patients from the healthy elderly subjects, and correlated well with plantar flexor strength, gait performance, and walking endurance in subjects with chronic stroke. Sinikka H. Peurala 2005, Rehabilitation of Gait in Chronic Stroke Patients, -The main purpose of the study was to evaluate the gait rehabilitation in patients over six months post stroke of 59 healthy subjects. Postural control, the spatio-temporal gait characteristics and effect of gait oriented rehabilitation were analyzed. The gait oriented rehabilitation was compared with conventional rehabilitation. Additionally, BWS with FES, the BWS without FES and active walking strategies were compared. As all gait oriented strategies were good choices for ambulatory stroke patients, it was concluded that intensive training improved gait in patients with chronic stroke and may lead to increased option for daily activities. Anouk Lamontage et al, 2004, Faster Is Better, Implication for SpeedIntensive Gait Training After Stroke, American Heart Association-Twelve subjects with a unilateral stroke were evaluated while walking over ground full weight or with

body weight support at a preferred or past speed. The study showed that stroke subjects can increase substantially their walking speed without deleterious effects and concluded that fast walking induces marked speed related improvements in body and limb kinematics and muscle activation patterns. C Lynne Dobrovoln yet al, 2003, Reliability of treadmill exercise testing in older patients with chronic hemiparetic stroke, Archives of Physical Medicine and Rehabilitation-Fifty-three subjects who had mild to moderate chronic hemiparetic gait deficits, making handrail support necessary during treadmill walking were studied. Reliability coefficients (r) were calculated for heart rate, systolic blood pressure, oxygen consumption, respiratory exchange ratio, rate-pressure product, and oxygen pulse during peak effort testing. This study provided the evidence that peak effort treadmill testing provides highly reliable oxygen consumption measures in chronic hemiparetic stroke patients using minimal handrail support. The sub-maximal tests were at or near the threshold level of reliability (r=.89, r=.84, respectively). Louisa Ada et al, 2003 A Treadmill and Over ground Walking Program Improves Walking in Persons Residing in the Community after Stroke: A PlaceboControlled, Randomized Trial, selected 29 post stroke patients (6-12 months) who were living in community. The experimental group participated in a 30-minute treadmill and over ground walking program, 3 times a week for 4 weeks. Outcome was measured by walking speed, walking capacity, and sickness impact profile for handicap. The treadmill and over ground walking was effective in improving walking speed and capacity in persons residing in the community after stroke. Sara Ahmed et al, 2003, The Stroke Rehabilitation Assessment of Movement (STREAM): A Comparison With other Measures Used to Evaluate Effect of Stroke

and rehabilitation, physical therapy, studied 83 patients with acute stroke on the STREAM and other measures of impairment and disability during 1st week, 4th week and 3 months later. Scores on the STREAM were associated with scores of Box and Block test, Balance scale, Barthel Index and Timed Up and Go test. The results obtained with the STREAM, as compared with other measures of impairment and disability in the people with stroke; suggest that it may be useful in clinical practice and research. C. Werner MA et al, 2002, Treadmill Training With Partial Body Weight Support and Electromechanical Gait Trainer for Restoration of Gait in Sub-acute Stroke Patients, American Heart association journals-studied 30 non-ambulatory hemiparetic patients, 4 to 12 weeks after stroke, who received locomotor therapy every workday for 15-20 minutes for 6 weeks. Weekly gait ability, gait velocity and motor functions were the outcome measures. It was concluded that, the newly developed gait trainer was at least as effective as treadmill therapy with partial body weight support while requiring less input from the therapist. Inacio Teixera da Cunha et al, 2002 Gait Outcome After Acute Stroke Rehabilitation With Supported Treadmill Ambulation Training (STAT): A Randomized Controlled Pilot Study, Archives of Physical Medicine and Rehabilitation, pilot studied on 7 acute stroke patients for regular intervention group and 6 patients are assigned to STAT intervention. Regular intervention consisted of 3 hours daily physical therapy, kinesiology, and occupational therapy. Participants were treated for average of 3 weeks. The main outcome measures were functional ambulation category scale, gait speed and walking distance. This pilot study concluded that STAT is a safe, feasible, and promising intervention for acute stroke survivors.

Katherine J. Sullivan, et al, 2002, Step Training With Body Weight Support: Effect of Treadmill Speed and Practice Paradigms on Post-stroke Locomotor Recovery, American Congress of Rehabilitation Medicine-studied on 24 individuals with hemiparetic gait deficits whose walking speeds were at least 50% below normal, participants were stratified by locomotor severity based on initial walking velocity and randomly assigned to treadmill training at slow (0.5mph), fast (2.0mph), or variable (0.5, 1.0, 1.5, 2.0mph) speeds. Participants received 20 minutes of training per session for 12 sessions over 4 weeks, self-selected over-ground walking velocity (SSV) was assessed at the onset, middle, and end of training, and 1 and 3 months later, concluded that training at speeds comparable with normal walking velocity was more effective in improving SSV than training at speeds at or below the patients typical over-ground walking velocity. Marc C. Kosak et al, 2002, Comparison of Partial Body Weight-Support Treadmill Gait Training (PBWSTGT) Versus Aggressive Bracing Assisted Walking (ABAW) Post Stroke,-56 Patients participating in an inpatient rehabilitation program with significant leg weakness and need moderate assistance for walking , without hypertension, dyspnea or angina pectoris were randomized to receive PBWSTGT vs. ABAW. Treatment sessions up to 45 minutes per day, five days per week were given. PBWSTGT and ABAW were equally effective gait training technique except for a subset of patients with major hemispheric stroke who were difficult to mobilize using ABAW alone. Richard Liston et al, 2000, Conventional Physiotherapy and Treadmill retraining for Higherlevel Gait Disorder in Cerebro-vascular Disease, British Geriatric Society - A schedule of treadmill re-training and specific schedule of

physiotherapy containing 31 interventions for 4 weeks, 18 subjects from elderly population were recruited and received 4 weeks treadmill retraining and conventional therapy was given. Spatial and temporal gait measures and activity of daily living assessments were the variables of the study. There was no difference between the effects of conventional physiotherapy and treadmill re-training on the gait of the patient with higher-level gait disorders associated with cerebral multi- infracts sites. Dr Mayo et al, 1999, Reliability of Scores on the Stroke Rehabilitation Assessment of Movement measure, The Free Library, Physical Therapy-The study was carried out at Jewish Rehabilitation Hospital, Canada. A convenient sample taken from 20 cooperative subjects. The reliability of scores obtained with the STREAM measure as determined under conditions of this study has excellent, both within and between raters, with of 0.99 for total scores and from 0.96 to 0.99 for subscale scores. The internal consistency of the STREAM scores was also excellent. SueMin Lai et al, 1998, Prediction of functional outcome after stroke, American Heart Association - studied on 184 individuals who sustained an eligible stroke and were recruited for the Kansas City Stroke Study. All patients were prospectively evaluated using standardized assessments at enrollment (within 14 days of stroke onset) and followed at 1, 3, and 6 months after stroke. Coefficient of determination (R2) was used to assess the ability of the 2 stroke scales are Orpingtons Prognostic Scale and National Institutes of Health (NIH) Stroke Scale to prognosticate outcomes. This study concluded that total score is ranging from 1.6 to 6.8; less than 3.2 is mild, in between 3.2 to 5.2 is moderate and above 5.2 is considered as severe stroke. Eric Hassid et al, 1997, Improved Gait Symmetry in Hemiparetic Stroke Patients Induced During Body Weight-Supported Treadmill (BWST) Stepping,

Neuro rehabilitation and Neural repair-evaluated the effects of varying two types of sensory inputs, limb load and treadmill belt speed of 45 post stroke patients, during BWST and assessed the effects of three levels of BWS and three treadmill speeds on the single limb stance time ratio (SLSR) and the single limb loading ratio (SLLR) and also studied the effects on SLSR of changing only the level of BWS at the one treadmill speed equal to best overground speed, and concluded that during BWSTT, the moving treadmill belt entrains greater symmetry of single limb stance time in hemiparetic subjects who otherwise step asymmetrically. S. Hesse et al, 1995 Treadmill Training With Partial Body Weight Support Compared With Physiotherapy in Non-ambulatory Hemi paretic Patients, American Heart Association - An A-B-A singlecase study design compared with treadmill training plus partial body weight support (A) with physiotherapy based on the Bobath concept (B) in seven non-ambulatory hemiparetic patients. Variables were gait ability assessed by functional ambulation category, other motor functions were tested by Rivermead Motor Assessment, muscle assessed by the Motricity Index, muscle tone rated by the Modified Ashworth Spasticity scale and gait cycle parameters. The study concluded that treadmill training was more effective with regard to restoration of gait ability and walking velocity and treadmill training offered the advantage of task-oriented training with numerous repetitions of a supervised gait pattern.

CHAPTER 3 METHODOLOGY

3.1 AIM OF THE STUDY

To compare the effectiveness of treadmill gait training and plane ground gait training. 3.2 OBJECTIVES OF THE STUDY To find out the effectiveness of treadmill gait training in mild to moderate hemiplegic patients. To find out the effectiveness of plane ground gait training in mild to moderate hemiplegic patients. To compare the effects of treadmill gait training and plane ground gait training in mild to moderate hemiplegic patients.

3.3 RESEARCH DESIGN

Randomized pre-test and post-test experimental design.

3.4 HYPOTHESES
Null hypothesis There is no significant difference of gait in hemiplegic patients with treadmill gait training when compared with plane ground gait training. Alternate hypothesis There is significant difference of gait in hemiplegic patients with treadmill gait training when compared with plane ground gait training.

3.5 POPULATION
Patients who are diagnosed as hemiplegics, referred by neurologist were taken as population of the study.

3.6 STUDY SETTINGS

1. Department of physiotherapy, AWH Special College, Kallai. 2. Department of physiotherapy, Christian Mission Hospital, Pandalam.

3.7 SAMPLES AND SAMPLING METHOD

30 Patients who are diagnosed as hemiplegics, referred by neurologist were selected as samples for the study from the population using consecutive sampling.

3.8 SELECTION CRITERIA

Inclusion criteria 1. Age between 50 years 70 years 2. Both male and female are included 3. Post stroke patients have duration 2 months to 12 months 4. Patient who had gait disturbances with score above 19 in Dynamic Gait Index 5. Confirmed to first stroke and unilateral involvement 6. Patients with mild to moderate- (3.2 - 5.2) score on the Orpingtons prognostic scale, with ability to stand without assistance.

7. Stable medical condition. 8. Subjects who signed Informed consent form. Exclusion Criteria 1. Non co-operative subjects 2. Past history of seizures 3. Severe multi infract sites 4. Traumatic brain injuries 5. Severe cardiovascular problems 6. Visual perceptual problems 7. Demyelinating disease 8. Degenerative changes in lower extremity joints

3.9 VARIABLES OF THE STUDY

Independent variables Plane Ground Gait Training Treadmill Gait Training Dependent variables STREAM Measure Timed Up and Go test

3.10 RESEARCH TOOLS

1. Orpingtons prognostic scale 2. Dynamic gait index 3. STREAM Measure 4. Timed Up and Go test 5. Motorized treadmill 6. Sphygmomanometer

3.11 DURATION OF THE STUDY

Total duration of study was 4 weeks.

3.12 DATA COLLECTION PROCEDURE

30 Subjects were selected on the basics of inclusion and exclusion criteria. All the subjects were divided equally into two groups, Group A and Group B. Each group consisted of 15 subjects, the study procedures were explained to the subjects and informed consent was obtained prior to study. Before starting the training, pre-test scores were measured by using STREAM measure and Timed Up and Go test.

Group A- Subjects in Group A (n=15) received Treadmill gait training and Conventional Therapy as per the appendix 5.2 and 5.3. Group B- Subjects in Group B (n=15) received Plane Ground gait training and treatments as per the appendix 5.1 and 5.3. At the end of fourth week post test scores of both groups were taken by using STREAM measure and Timed Up and Go test.

CHAPER 4 DATA ANALYSIS

DATA ANALYSIS

Data were analyzed using 22 ANOVA with between - subjects factor, being group and within subjects, being time. The significance level was set as 0.05. All data were analyzed using SPSS version 12.

CHAPTER 5 RESULTS

RESULTS

Voluntary movements and basic mobility measured by STREAM Graph 1, Appendix - 9, shows that voluntary movements and basic mobility of the treadmill gait training group improved to a greater extent when compared to plane ground gait training group. There was a mean effect for time F (1, 28; 0.05) = 184.073, P<0.000 and group time was also qualified F (1, 28; 0.05) = 10.7, P<0.003. Main effect for group also achieved significant levels F (1, 28; 0.05) = 40.8, P<0.000.

Gait speed measured by TUG test Graph 2, Appendix - 9, shows that gait speed improved of the treadmill gait training group to a greater extent when compared to plane ground gait training group. There was a mean effect of time F (1, 28; 0.05) = 213.09, P<0.000 and group time was qualified F (1, 28; 0.05) =16.7, P<0.000. Main effect for group also achieved significant levels F (1, 28; 0.05) = 11.4, P<0.002.

CHAPTER 6 DISCUSSION

6.1 DISCUSSION
The purpose of this study was to compare the effects of treadmill gait training (TGT) in relation to plane ground gait training (PGT) in patients with mild to moderate hemiplegia who were undergoing outpatient physical therapy. The patients in TGT group demonstrated significant improvement in mobility and gait speed measured with STREAM and TUG respectively than PGT group. The reduction of impairments caused by spontaneous natural recovery of neurological function is the preliminary factor contributing to the reduction of disabilities that occurs during rehabilitation. These improvements may be largely due to the learning and practice effects associated with rehabilitation. These results extend the findings of previous studies evaluating the effectiveness of treadmill training for retraining gait in stroke patients. Treadmill training has been found to be useful for improving walking in individuals with stroke. Hesse et al, showed that walking training with treadmill in the relatively later stages was superior to the Bobath method in regaining walking ability in shorter time period. This study in contrast to the previous studies on effectiveness of treadmill training with BWS, has shown that treadmill gait training with 0% BWS is valuable for patients with mild to moderate hemiplegia as demonstrated by significant improvements in basic mobility and gait speed following a 4-weeks training period. This clearly indicated that TGT is more advantageous in rehabilitating patients with hemiplegia for gait and mobility. In India most of the clinics are equipped with treadmill and combining the treadmill gait training with conventional therapy will likely give better results for patients with hemiplegia. The advantages of TGT were found include: increased

confidence level for the patients to walk independently and less manpower of physical therapists that may be cost beneficial than plane-ground gait training. It has also been reported that stroke patients in rehabilitation spend many hours a day alone and inactive if no special effort is made to keep them active (Ada et al. 2003). In this study, the patients were encouraged to practice by themselves with exercises and they were helped with transfers if needed by physiotherapists. Motor learning and developing walking skills require practice with concrete goals and the patients must have the opportunity to practice actively and to understand the importance of frequent repetitions (Rosebaum 1991). During treadmill walking the belt moves the stance leg backward resulting in beneficial changes such as increased hip extension and inter-limb symmetry as well as increased paretic and non-paretic limb step length. In contrast, the unchanging environment during treadmill walking provides conflicting proprioceptive, visual and vestibular information while the greater balance and attention demands result in undesirable changes such as the need to hold the handrail, slower walking speeds, smaller stride length and faster cadence. Change in the angular kinematics of the walking pattern while walking on a treadmill following stroke has received little investigation with only one study reporting greater hip flexion during swing phase at faster treadmill speeds. The improvement seen during this 4 week study in the PGT group can be attributed to this principle of re-education of basic movement patterns. Bobath considered abnormal coordination of movement patterns and abnormal tone to be main problems of people with hemiplegia. Normalizing tone is seen as a necessary preparation for practicing functional activities such as walking, facilitating of selective control of

movement, achieved by re-education of basic movement patterns of the trunk, the pelvis, and the limbs, is a key features of the approach. Therapists use handling techniques to correct alignment, to assist movement that the patient struggles to perform independently, and to block the atypical movements. The principle underlying the treatment is the capacity of the central nervous system to recover function following damage. It is important, therefore, to work at regaining normal movement of the affected side, thus achieving functional independence of the patient. Findings for gait speed and basic mobility in the present study supported the treadmill intervention. The speed of the participants in the treadmill gait training group was significantly faster than that of the plane ground gait training group with significance level for tests within-subjects contrasts, P<0.000 and significance level for tests between subjects effects, P<0.002. The mean pretest scores of gait speed based on the TUG in the treadmill gait training group and plane ground gait training group were 15.6s and 15.4s respectively. The mean scores of gait speed after the gait training intervention for both groups, on the TUG scale showed 8.2s and 11.2s respectively. The mean improvement in the gait speed was 7.4s and 4.2s for TGT and PGT groups respectively. This shows that the TGT group walked significantly faster than the PGT group in the TUG. In the results of the present study, basic mobility also significantly improved in TGT group when compared with PGT group with significance level for tests withinsubjects contrasts, P<0.000 and significance level for tests between subjects effects, P<0.000. The initial findings of basic mobility using STREAM measures before the intervention showed 47.2 and 44.7 respectively. After the 4 weeks intervention the scores of STREAM measures in TGT and PGT groups were 63.8 and 54 respectively. This

showed that both the groups had increments of 16.6 and 10.1 respectively with the gait training intervention. In this study, the treadmill environment provided optimum learning conditions at a critical time in the recovery of participants in the treadmill gait training group. This is in accordance with the results of recent researches in neuroscience which have provided new insight into neural plasticity and neural recovery after neurologic injury, with evidence of functional reorganization of the motor cortex resulting from behavioral experience. Fisher and Sullivan et al highlighted some of the essential components of training that must be addressed for learning after neurologic injury, including task complexity, task intensity, and task specificity. Locomotor treadmill training has been identified as an intervention that maximizes many of these key variables, and its application with people post stroke may have the most impact when applied as a part of intervention. The results of the present study support and extend findings related to the use of treadmill gait training to improve mobility and gait speed in individuals with mild to moderate hemiplegic stroke subjects. The treadmill training protocol which was used was of short-duration and from 12 sessions, treadmill training showed increases in the mobility and gait speed of subjects with gait training intervention. This suggests that gait training on a treadmill could be most effective when the subjects are patients with mild to moderate hemiplegic stroke and the factors attributing to the improvements can be discussed in detail. Understanding how and automated movements, such as walking and running, are controlled, forms a main challenge for modern neuroscience. The central nervous system (CNS) is able to coordinate which joint has to be moved, how far and at what time. Such

movements can only be made properly if a set of biomechanical requirements are met using a pattern of electrical signals sent along the nerves to activate the appropriate set of muscles. Furthermore, the locomotor movements are continuously adapted when obstacles are encountered, thereby ensuring the smooth progression of the ongoing movement. Hence, out of a large flow of sensory input from the periphery, the system is able to select the most optimal context-specific information and to incorporate this information into the executed movements. This task is simplified by the remarkable organization of neural networks, specialized in repeating particular actions over and over again. For many species the cyclical patterns needed for walking, respiration, mastication or other rhythmical activities are generated by such neural networks. The neuronal networks capable of generating rhythmic motor activity in the absence of sensory feedback are termed central pattern generators (CPG) (Kandel et al. 2000). The term CPG refers to a functional network, which could consist of neurons located in different parts of the CNS. This network generates the rhythm and shapes the pattern of the motor bursts of motor neurons. It is generally thought that the commands for initiation and termination of these rhythm generators are coming from supraspinal levels. After gait initiation, afferents deliver movement-related information to spinal and supraspinal levels. Some of this feedback acts directly on the CPG to aid the phase transitions during the step cycle thus providing the possible induction of variations to meet the environmental demands. On the other hand, afferent feedback is more directly connected to motor neurons through various reflex pathways and these pathways themselves are largely under the control of the CPG. In this way, it is ensured that reflex activations of given muscles occurs only at the appropriate times in the step cycle (phase-dependent modulation).

Descending signals, drugs or afferent signals could modify the motor activity pattern by altering the functioning of inter-neurons in the patterning network. Three important types of sensory information are used to regulate stepping: somatosensory input from the receptors of muscle and skin, input from the vestibular apparatus, and visual input. Input from proprioceptors in muscles and joints are involved in automatic regulation of stepping. Exteroceptors are located in the skin and adjust stepping to external stimuli. Exteroceptors have a powerful influence on the CPG for walking. Current evidence indicates that the signals that activate locomotion and control its speed are transmitted to the spinal cord by glutaminergic neurons whose axons travel in the reticulospinal pathway. Although the basic motor pattern for stepping is generated in the spinal cord, fine control of walking involves numerous regions of the brain, including the motor cortex, cerebellum, and various sites within the brain stem (Dietz 1996, Kandel et al. 2000). Supraspinal regulation of stepping includes activations of the spinal locomotor system, controlling the overall speed of locomotion, refining the motor pattern in response to feedback from the limbs and guiding limb movement in response to visual input. The spinal locomotor system is activated by signals from the mesencephalic locomotor region relayed via neurons in the medial reticular formation. The cerebellum receives signals via spinocerebellar pathways from both peripheral receptors and the spinal CPG and this structure adjusts the locomotor pattern via brain stem nuclei. The brain stem nuclei influenced by the cerebellum during walking include the vestibular nuclei, red nucleus, and nuclei in the medullary reticular formation. Cerebellar output to the vestibular nuclei may be involved in integrating proprioceptive information from the legs with vestibular signal for the control of balance. Modification of stepping by the visual signal is mediated via the motor cortex.

During the course of such an intensive treadmill training a wide variety of effects was seen. Patients, who were not capable of full movement against gravity at the time of training, were gradually able to self-initiate the swing phase for stepping but still required continued manual ankle and knee stabilization. Others, however, reported the development of unassisted knee extension during stance phase. The development of unassisted stepping followed an initial period of passively assisted stepping movements over period ranging from days to weeks. Dietz et al. showed that the EMG amplitude of gastrocnemius medialis increased significantly at the appropriate phase of the step-cycle during the treadmill training. This difference may be due to a reduction or complete loss of input from descending noradrenergic pathways to the spinal locomotor centers which make it difficult to sufficiently excite the proportion of each of the motor-neuron pools, as compared to healthy subjects. In conclusion, improvement of locomotor function was seen in hemiplegic subjects, when trained on a treadmill. The most important features are a better modulation pattern of activity in muscles of the lower extremities and an increased ability to support body weight. This suggests that spinal locomotor centers can be activated in hemiplegic patients. Although a clear improvement of locomotor function can be obtained on the treadmill, the question arises whether the trained hemiplegic persons reveal better performance of locomotion on a static underground as well. Most patients profited from locomotor training and were functionally better locomotor performers than before training. These results clearly illustrate that the improved locomotor function, as seen on the treadmill, is also reflected in better locomotor capabilities during over ground walking for the hemiplegic persons. Even more important, better locomotor abilities are revealed as compared to patients who underwent the plane ground gait training.

When treadmill training was started in humans, it was suggested that locomotor related afferent input could be of importance for the enhancement of locomotor activity. Several studies mentioned, only at a qualitative level, the relationship between the locomotor related load and kinematic input and the observed locomotor output. In subjects with one completely paralyzed lower limb, a flexor-like stepping movement could be elicited in the paralyzed leg when the person shifted the body weight onto the fully extended leg during stance and onto the other leg shortly before swing. Another group reported that the induction of flexion to initiate swing could be improved if the hip joint moved a few degrees in extension at the end of the stance phase and again the importance of weight shifting of the leg at end stance was noticed. Furthermore, it appeared that barefoot walking and pinching of the limb could facilitate stepping in some cases. The possibility to influence locomotor functioning by way of afferent information raises the question whether the rhythmic output, as seen in muscles of the lower limb during treadmill training in hemiplegic persons, are related to the CPG or is due to reflexively induced activity. At first instance, the most obvious explanation during treadmill gait training is the increase of muscle strength due to the training effect. In general, the locomotor activity during plane ground gait training is always lower in the hemiplegic patients when compared to treadmill gait training subjects. This difference may be due to a reduction (or complete loss) of input from descending noradrenergic pathways to the spinal locomotor centers. Restoration of motor function depends to a certain extent upon reorganization of the CNS. Since the training effects persisted after spinalization, this indicated that some kind of learning is possible by the spinal cord, thereby indicating the presence of some primitive form of spinal intelligence.

6.2 LIMITATIONS AND SUGGESTIONS

There are certain limitations associated with this study. Even if certain gait deviations associated with hemiplegia were corrected during treadmill walking, the practice of improved gait pattern may not improve the individuals locomotor ability over plane ground. The training may not be relevant to the more severely impaired individuals with hemiplegia. The study has limited sample size and did not assess the functional outcome of subjects following gait training intervention. Another limitation of this study is that it did not use additional control over groups. Also, this study lacks follow-up data. Future studies with evaluation of functional outcome of ambulatory hemiplegic subjects, following gait training by reliable measures may provide a more significant data, towards the overall functional activity. Additionally, introducing a control group and more than one outcome measures to assess the findings of gait speed, voluntary movements and basic mobility in the methodology will contribute better results. Further studies can be extended to include subjects in chronic stage, with a longer duration of study and with larger sample size. A follow-up study to find out the long-term effects of gait training in the post stroke subjects, may be beneficial in promoting the restoration of mobility and independence of subjects. Although results with treadmill trained hemiplegics are quite impressive, it is suggested that further research and development of therapy with the application of specific afferent inputs to CPG may lead to even better methods for restoring gait in stroke patients.

CHAPTER 7 CONCLUSION

CONCLUSION
Improvement of locomotor function including mobility and speed is seen in hemiplegic persons when intensively trained on a treadmill. This suggests that spinal locomotor centers can be activated in hemiplegic patients. The most important features are a better modulation pattern of activity in muscles of the lower extremities and the increased ability to support body weight. On the assumption that a locomotor CPG exists in humans, it is of utmost importance to have a good insight in the specific afferent inputs to the CPG. Artificial application of these inputs may lead to improved methods for the activation of human locomotor pattern generators. After stroke, although most people are able to walk, many are only able to walk slowly and hesitantly. At the very least, this level of disability may mean that they are unable to walk fast or far enough to cross the road, while at worst they may be unable to even leave the house. This study found that after stroke, people who participated in a training program, involving treadmill and overground walking focusing on increasing speed, balance and gained and maintained improvements in walking speed, and basic mobility. The routine provision of accessible, long-term, community-based walking programs based on these strategies should result in better ambulation after stroke. Improvements in ambulation provide the individual with the opportunities to participate in the community and, in addition, may indirectly reduce the burden on caregivers. Because other exercise programs have also resulted in improvements in function in persons residing in the community after stroke, long-term exercise programs should become a priority. The challenge for health planners is to devise ways to implement ongoing programs that are accessible and affordable.

CHAPTER 8 REFERENCES

REFERENCES
1. Suzanne S Kuys, Sandra G Brauer, Immediate effect of treadmill walking practice versus over-ground walking practice on over ground walking

pattern in ambulatory stroke patients. Clinical rehabilitation 2008; 22; 931 2. Ada L, Dean CM, Hall JM, Bampton J and Crompton S. A treadmill and overground walking program improves walking in persons residing in the community after stroke: a placebo-controlled, randomized trial. Arch Phys Med Rehabil 2003;84:1486-1491 3. Adams RD, Maurice V. Principles of Neurology. NY: McGraw; 1993:12. 4. Bobath B (1978). Adult hemiplegia: Evaluation and Treatment. London: Heinemann 5. Medical Books.Bogataj U, Gros N, Kljajic M, Acimovic R and Malezic M. The rehabilitation of gait in patients with hemiplegia: a comparison between conventional therapy and multichannel functional electrical stimulation therapy. Phys Ther 1995;75: 490-502. 6. Brunnstrom S (1970). Movement Therapy in Hemiplegia: a Neurophysiological Approach. New York: Harper & Row. 7. Colombo G, Joerg M, Schreier R and Dietz V. Treadmill training of paraplegic patients using a robotic orthosis. J Rehabil Res Dev 2000; 37: 693-700. 8. Chu-Ling Yen, MS, PT, Ray-Yau Wang, PhD, PT, Kwong-Kum Lio, MD: Gait Training - induced change in corticomotor excitability in patients with chroni stroke. 9. Davies P (1985). Steps to follow. A guide to the Treatment of Adult Hemiplegia. Berlin: Springer-Verlag.

10. Davies P (1990). Right in the middle; Selective Trunk Activity in the Treatment of Adult Hemiplegia. Berlin: Springer-Verlag. 11. Davies P (2000). Step to follow. Berlin: Springer-Verlag. 12. Geriatric assessment tool kit MU PT 8390 13. Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M and Mauritz KH. Treadmill training with partial body weight support compared with physiotherapy in non-ambulatory hemiparetic patients. Stroke 1995a;26:976-981. 14. Pamela K. Levangie. Cynthia C. Norkin. Joint structure and function third edition 15. Kosak MC and Reding MJ. Comparison of partial body weight-supported treadmill gait training versus aggressive bracing assisted walking post stroke. Neurorehabilitation - Neural Repair 2000;14:13-19. 16. A K Agarwal , BC Bansal Recent concept in stroke Indian college of physicians. 17. Reliability of score on the stroke rehabilitation assessment of movement measure. The free library >health> physical therapy 1999 january 18. Sandra Meirelles De Castro1, Monica Rodrigues Perracini2, Fernando Freitas dynamic gait index Canadian version. Rev Bras Otorrinolaringol 2006;72(6):817. 19. Sara Ahmed, Nancy E Mayo, Johanne Higgins, Nancy M Salbach, Lois Finch and Sharon L Wood-Dauphinee. The stroke rehabilitation assessment of movement: a comparison with other measures used to evaluate effects of stroke and rehabilitation 20. Sinika H. Peurala : rehabilitation of gait in chronic stroke patients 21. Sridar Alla, Glady S R Nadararulmani, S John Sullivan: does treadmill training without body weight support improve gait and balance in patients with hemiplegia

22. The rehabilitation of gait in patients with hemiplegia: a comparison between Conventional therapy and multichannel functional electrical stimulation therapy 23. Jesse A Lieberman, MD, Resident Physician, Carolinas Medical Center, William L Bockenek, Gustawa Stendig, Therapeutic exercise: - Lindberg. 24. Voss D, Ionta MK, Proprioceptive Neuromuscular Facilitation. Meyers BJ (1985). 25. Werner C, Bardeleben A, Mauritz KH, Kirker S and Hesse S, Treadmill training with Partial body weight support and physiotherapy in stroke patients: a preliminary Comparison. Eur J Neurol 2002a;9:639-644. 26. Werner C, von Frankenberg S, Treig T, Konrad M, Hesse S, Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients. Stroke 2002b;33: 2895-2901. 27. J Clin Epidemiol 1988 WHO. The World Health Organization MONICA Project (Monitoring trends and determinants in cardiovascular disease): a major International collaboration. 28. Yu- Wei Hsieh, MS, Jau-Hong Lin, Chun-Hou Wang, BS, Ching-Fan Sheu, PhD, IPing Hsueh. Discriminative, predictive and evaluative properties of simplified strok rehabilitation assessment of movement instrument in patient with stroke. 29. Shumway-Cook A, Brauer S, Woollacot M. Predicting the probability for fall in community-dwelling older adult using the timed up and go test. Phys Ther2000. 30. Isles RC, Low Choy NL, Steer M, Nitz JC Normal value of balance test in aged women

31. Ada L, Dean CM, Hall JM, Bampton J, Crompton S (2003) A treadmill and overground walking program improves walking in individuals residing in the community after stroke: a placebo-controlled, randomized trial. Archives of Physical Medicine and Rehabilitation. 32. Cecily Partridge, Recent Advances in Physiotherapy 2007. 33. Hesse S, Malezic M, Schaffrin A, Mauritz KH, Restoration of gait by combined treadmill training and multichannel electrical stimulation in non-ambulatory hemiparetic patients. Scand J Rehabil Med 1995;27: 199-204. 34. Grillner S, Wallen P. Central pattern generators for locomotion, with special reference to vertebrates. Ann Rev Neurosci 1985;8: 23361. 35. Paci M. Physiotherapy based on the Bobath concept for adults with post-stroke hemiplegia: a review of effectiveness studies. J Rehabil Med 2003;35: 2-7. 36. Teasell RW, Foley NC, Bhogal SK, Speechley MR, An evidence-based review of stroke rehabilitation. Top Stroke Rehabil 2003; 10:29-58. 37. Sullivan KJ, Knowlton BJ, Dobkin BH. Step-training with body weight support: effect of treadmill speed and practice paradigms on post-stroke locomotor recovery. Arch Phys Med Rehabil 2002; 83:683-91. 38. Colombo G, Wirz M, Dietz V. Driven gait orthosis for improvement of locomotor training in paraplegic patients. Spinal Cord 2001;39: 252-5. 39. Lovely RG, Gregor RJ, Roy RR, Edgerton VR. Effects of training on the recovery of full weight-bearing stepping in the adult spinal cat. Exp Neurol 1986; 92: 421.

40. Abraham J, Rao PSS, Imbraj SG, Shetty G. An epidemiological study of hemiplegia due to stroke in South India. Stroke 1970; 1: 477-481. 41. World Health Organization. World Health Statistics Manual.1993. Geneva. Switzerland: World Health Organization, 1994. 42. World Health Organization. The World Health Report 2002: Reducing risks, promoting healthy life. World Health Organization, 2002. 43. Nilsson L, Carlsson J, Danielsson A, et al. Walking training of patients with hemiparesis at an early stage after stroke: a comparison of walking training on a treadmill with body weight support and walking training on the ground. Clin Rehabil 2001;15: 515-27. 44. Bogataj U, Gros N, Kljajic M, Acimovic R and Malezic M. The rehabilitation of gait in patients with hemiplegia: a comparison between conventional therapy and multichannel functional electrical stimulation therapy. Phys Ther 1995;75: 490502.

APPENDICES

APPENDIX 1 ASSESSMENT FORM

A. Demographic data Name Age Sex Occupation Marital status B. History (a) PAST MEDICAL HISTORY 1. a) CVA b) TIA c) RIND d) Complete stroke 2. Hyper tension yes/no Date of admission Date of assessment

Duration of detected now..year Medication yes/no.regular or irregular

Present status controlled/uncontrolled

3. Cardiac disease yes/no Congenital / valvular Congestive heart disease Duration 4. Peripheral vascular disease Duration Site Treatment 5. Diabetes mellitus yes/no Duration Treatment regular/irregular Present status controlled/uncontrolled 6. Any other relevant illness yes/no (b) PRESENT MEDICAL HISTORY Onset sudden /acute /gradual Duration Symptoms Head ache

Vomiting Convulsion Unconsciousness Sensory disturbances Language disturbances Gait disturbances Paralysis Partial/total Face Upper limb Lower limb yes/no yes/no yes/no

(c) FAMILY HISTORY History of ischemic heart disease Myocardial infraction Hyper tension Cerebrovascular accidents (d) PERSONAL HISTORY Physical activities Smoking Alcohol intake Personality type C. General examination 1. General physical examination yes/no calm/anxious active/inactive

Built Nutrition : good /fair /poor 2. Vital signs Heart rate Blood pressure Respiratory rate Temperature D. Neurological examination 1. Level of consciousness 2. Higher mental function: normal/impaired 3. Minimental status test (MMSE) Orientation Registration Attention & concentration Recall Language E. Sensory assessment 1. Superficial sensation 2. Deep sensation 3. Cortical sensation

F. Motor assessment 1. Power Upper limb Lower limb 2. Tone Upper limb Lower limb 3. Reflexes Superficial reflex Deep tendon reflex 4. Voluntary control 5. Modified ashworth scale proximal distal proximal distal

G. Gait assessment Type normal /spastic /ataxic /hemiplegic Cadence: normal/asymmetrical Arm swing Base: narrow/broad Stride length: short/asymmetrical

H. Cranial nerve examination I. Cerebellar sign- yes/no J. Bladder and bowel function K. Hand functions L. Investigations M. Diagnosis N. Treatment

APPENDIX 2

DATA COLLECTION FORM

NAME AGE SEX Orpintons Prognostic Scale Score Dynamic Gait Index Score Group : : : : : :

Serial number

Outcome Measures

Pre Test Score

Post Test Score

STREAM Measure

TUG Test

APPENDIX 3 Graph for STREAM

70 60 50 40 pre 30 20 10 0 group1 group 2 post

Graph for TUG

18 16 14 12 10 8 6 4 2 0 group1 group 2 pre post

APPENDIX 4

RESULTS TABLES

MEAN VALUES FOR STREAM

PRE TEST TREADMILL 47.2 {1.3} 44.73 {0.67} 45.9 {0.98}

POST TEST 63.8 {0.91} 54.8 {0.62} 59.3 {0.76}

TOTAL 55.5 {1.1} 49.7 {0.64}

GROUND

TOTAL

MEAN VALUES FOR TUG

PRE TEST TREADMILL 15.6 {0.48} 15.4 {0.44} 15.5 {0.46}

POST TEST 8.2 {0.17} 11.2 {0.42} 9.7 {0.29}

TOTAL 11.9 {0.32} 13.3 {0.43}

GROUND

TOTAL

ANOVA TABLES FOR STREAM

Descriptive Statistics ST group 1.00 2.00 Total 1.00 2.00 Total Mean 47.2000 44.7333 45.9667 63.8000 54.8667 59.3333 Std. Deviation 5.25357 2.63131 4.27086 3.54965 2.41622 5.43509 N 15 15 30 15 15 30

ST2

Tests of Within-Subjects Contrasts Measure: MEASURE_1 Source time time * group Error(time) time Linear Linear Linear Type III Sum of Squares 2680.017 156.817 407.667 df 1 1 28 Mean Square 2680.017 156.817 14.560 F 184.073 10.771 Sig. .000 .003

Tests of Between-Subjects Effects Measure: MEASURE_1 Transformed Variable: Average Source Intercept group Error Type III Sum of Squares 166321.350 487.350 333.800 df 1 1 28 Mean Square 166321.350 487.350 11.921 F 13951.461 40.880 Sig. .000 .000

ANOVA TABLES FOR TUG

Descriptive Statistics TUG group 1.00 2.00 Total 1.00 2.00 Total Mean 15.6667 15.4000 15.5333 8.2000 11.2000 9.7000 Std. Deviation 1.87718 1.72378 1.77596 .67612 1.65616 1.96784 N 15 15 30 15 15 30

TUG2

Tests of Within-Subjects Contrasts Measure: MEASURE_1 Source time time * group Error(time) time Linear Linear Linear Type III Sum of Squares 510.417 40.017 67.067 df 1 1 28 Mean Square 510.417 40.017 2.395 F 213.096 16.707 Sig. .000 .000

Tests of Between-Subjects Effects Measure: MEASURE_1 Transformed Variable: Average Source Intercept group Error Type III Sum of Squares 9550.817 28.017 68.667 df 1 1 28 Mean Square 9550.817 28.017 2.452 F 3894.508 11.424 Sig. .000 .002

APPENDIX 5 PROTOCOLS AND SCALES 5.1 PLANE GROUND TRAINING PROTOCOL

Plane ground gait training protocol for an individual includes walking training on a plane ground for a maximum of 30 minutes, 3 days a week, for a total 4 weeks. The major emphasis for gait training was on methods of training support and propulsion of lower limbs, balance of the body mass over one or both feet and control of the foot and knee path through swing. These were addressed by a combination of weight bearing and walking practice. The patient was fitted with a blood pressure cuff connected to the sphygmomanometer to record BP changes. The gait training consists of walking on a ground at a comfortable speed using walking aid and assistance. Patients were given rest periods of 2 minutes when they felt tired, light headed or the blood pressure exceeds >220 mm Hg for SBP and >110 mm Hg for DBP. A. Training support and propulsion of lower limbs 1. Hip and knee flexion over the side of the bed 2. Knee extension with dorsi flexion 3. Hip control with the hip in extension 4. Lifting one leg at a time in sitting 5. Sitting with affected leg crossed B. Training balance of the body mass over one or both feet 1. Standing on both feet close together

2. Standing on affected leg 3. Standing and weight transfers 4. Manual perturbation to sideways 5. Manual perturbation to forwards and backwards C. Training control of foot and knee path through swing 1. Releasing the hemiplegic leg in standing 2. Releasing the knee with hemiplegic leg behind 3. Taking small steps backwards with affected lg 4. Walking sideways behind a line D. Facilitation of gait Walking can be assisted providing the therapist is able to prevent abnormal patterns of movements and normal gait can be facilitated. Patients pelvis is held on either side from behind and the action is made as smooth and rhythmic as possible. It is important to keep the affected hip well forward during the stance phase on that side so that the knee does not snap back into extension. Downward pressure on the pelvis during the swing phase helps him to release the knee instead of hitching the hip to bring the leg forward. The arm may be held forward to help overcome any flexion and retraction on the affected side or remain at his side without any associated increase of tone. As walking improves less assistance is required and a normal reciprocal arm swing can be facilitated by lightly rotating the trunk from the pelvis or shoulder.

5.2 TREADMILL TRAINING PROTOCOL

Subjects receive gait training on a motorized treadmill. All the subjects in the group receive gait training for a maximum of 30 minutes, 3 times per week for a total 4 weeks. Before starting treadmill training protocol, 2 trial training is given to the subjects to make familiar with the training. All the participants will train in indoors only. The subject is fitted with a blood pressure cuff connected to the sphygmomanometer to record BP changes. The subject could also hold onto a horizontal bar attached to the front of the treadmill for stability. The treadmill permitted walking to be initiated from 0.2778m/sec and slowly advanced by 0.0554m/sec increments according to patients subjective tolerance. The physiotherapist assisted if the patient could not actively lift the paralytic leg. The speed is adjusted to the patients comfortable walking speed ranging between 0.38-0.49 m/sec. Subjects were given rest periods of 2 minutes when they felt tired, light headed or the blood pressure exceeds >220 mm Hg for SBP and >110 mm Hg for DBP.

5.3 CONVENTIONAL THERAPY PROTOCOL

A. Upper limb active ROM exercise 1. Shoulder girdle- elevation and protraction 2. Gleno humeral joint- abduction, forward flexion and extension 3. Elbow joint- flexion and extension 4. Radioulnar joint- pronation and supination 5. Wrist joint- flexion and extension 6. MCP joint- flexion and extension 7. CMC of thumb- flexion, extension, abduction, adduction and opposition 8. IP joint- flexion and extension B. Lower limb active ROM exercise 1. Hip joint- flexion and extension, abduction and adduction, Internal and external rotation 2. Knee joint- flexion and extension 3. Ankle joint- dorsi flexion and platar flexion 4. Subtalar joint- inversion and eversion

C. Functional mobility exercise 1. Bed mobility exercise Rolling to affected side Rolling to unaffected side Bridging on pelvis Prone on elbow Prone on hands Supine lying to sitting Isolated knee extension in lying Moving to sideways, forwards and backwards Weight transfers through the arm behind and sideways Lift both legs together and rotates in sitting Reaching sideways, forwards and downwards in sitting 2. Sitting to standing and standing to sitting with or without support 3. Walking on parallel bar D. Balance training 1. Wooble board with support 2. Forward stepping, backward stepping 3. Bridging Each subject in both Groups receives above treatment in 5 repetitions, once daily, 3 times a week for 4 weeks.

5.4 STROKE REHABILITATION ASSESSMENT OF MOVEMENT (STREAM)

Description: The Stroke Rehabilitation Assessment Of Movement (STREAM) instrument was to designed to provide comprehensive and qualitative evaluation of voluntary movements (impairment measurement) and basic mobility (disability measurement) in patients with stroke. Completion Time ------- 15 minutes require Scoring Voluntary movements of limbs are scored on a 3-point scale 0 Unable to perform test movements 1 Able to perform the test movements only partially 2 Able to complete the test movements Mobility items scored on a 4-point scale 0 Unable to perform the test movements 1 Able to perform the test movements only partially 2 Able to complete the test movements with mobility aid 3 Able to complete the test movements without an aid 10 items of each limb movements subscales are scored out of 20

10 items of mobility are scored out of 30mobility Subscales The STREAM consist three subscales 1. Upper limb movement 2. Lower limb movement 3. Mobility

Upper Limb Movement Protracts scapula in supine Extends elbow in supine Raising hand to touch top of head Shrugs shoulders Moving hand to sacrum while sitting Raising arm overhead to fullest elevation Supinates and pronates forearm Close the hand fully opened position Open the hand from fully closed position Oppose the thumb to index finger (tip to tip)

Lower Limb Movement Flexes the hip and knee in supine Hip flexion while sitting Knee extension in sitting Flexes knee in sitting Dorsiflexes ankle in sitting Plantar flexes in sitting Extends knee and dorsiflexes ankle in sitting Dorsiflexion while standing Abducts affected hip with knee extended Flexes affected knee with hip extended Basic Mobility Rolling Bridging (raising off the bed) Moving from supine to sitting Standing for 20 counts by the rater Moving from sitting to standing Placing affected foot onto first step 10 meter walk 3 steps to affected side Walking down 3 stairs 3 steps backwards

Total score: ----- / 70

5.5 TIMED UP AND GO TEST

Type of Measure: Basic test which demonstrated subjects balance, functional ability and gait speed Equipment Required: Stopwatch, standard height armchair, 3m marked coyrse. Methods: The subjects begin seated in a standard height armchair with their back against the backrest and the arm resting on the armrest. The subject is tested wearing their usual footwear. The subject as their walking aid (if required) within reach. A line is marked on the floor three meters from the chair. One practice trail is given to become familiar with the test. The instruction is given: On the word go, I want you to walk as you safely can to the line on the floor, turn, walk back to the chair and sit down again. The test is timed from the instruction go until the subject achieves sitting again. If the subject cannot complete the test without assistance, is n not valid.

Normative Data: (Isles et al) Age 20-29 30-39 40-49 50-59 60-69 70-79 Adjusted Mean (sec) 5.31 5.39 6.24 6.44 7.24 8.54

Scoring: Time for Up and Go test: _________sec.

5.6 ORPINGTONS PROGNOSTIC SCALE

Motor deficit in arm Lying supine, patient shoulder to 90 and is given resistance 0.0 = MRC Grade 5 (normal power) 0.4 = MRC Grade 4 (diminished power) 0.8 = MRC Grade 3 (movement against gravity) 1.2 = MRC Grade 1-2 (movement with gravity eliminated plane) 1.6 = MRC Grade 0 (no movement) Proprioception (eye closed) Located affected thumb 0.0 = Accurately 0.4 = Slight difficulty 0.8 = Finds thumbs via arm 1.2 = Unable to find arm

Balance 0.0 = Walks 10 feet without help 0.4 = Maintains standing positions (unsupported for 1 minutes) 0.8 = Maintains sitting balance 1.2 = No sitting balance.

Cognition 0.0 = Mental score 10 0.4 = Mental score 8-9 0.8 = Mental score 5-7 1.2 = Mental score 0-4

Total score = 1.6+ motor + proprioception + balance + cognition

Hodkinsons Mental Test Score One point for each correct answer 1 Age of the patient 2 Time (to the nearest hour) 3 Address of the patient 4 Name of the hospital 5 Year 6 Date of birth of patient 7 Month 8 Year of First World War 9 Name of Monarch 10 Count backwards from 20 to 1

5.7 DYNAMIC GAIT INDEX

Description: Developed to assess the likelihood of falling in older adults. This scale was designed to test eight facets of gait. Equipment needed: Box (Shoebox) Cones (2) Stairs Completion: Time: 15 minutes Scoring: A four - point ordinal scale, ranging from 0-3 0 indicates the lowest level of function and 3 the highest level of function. Total Score = 24 Interpretation: < 19/24 = predictive of falls > 22/24 = safe ambulators

Gait level surface Instructions: Walk at your normal speed from here to the next mark (20) Grading: Mark the lowest category that applies. (3) Normal: Walks 20, no assistive devices, good sped, no evidence for imbalance, normal gait pattern (2) Mild Impairment: Walks 20, uses assistive devices, slower speed, mild gait deviations. (1) Moderate Impairment: Walks 20, slow speed, abnormal gait pattern, evidence for imbalance. (0) Severe Impairment: Cannot walk 20 without assistance, severe gait deviations or imbalance. Change in gait speed Instructions: Begin walking at your normal pace (for 5), when I tell you go, walk as fast as you can (for 5). When I tell you slow, walk as slowly as you can (for 5). Grading: Mark the lowest category that applies. (3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast and slow speeds. (2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable to achieve a significant change in velocity, or uses an assistive device.

(1) Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to recover and continue walking. (0) Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught. Gait with horizontal head turns Instructions: Begin walking at your normal pace. When I tell you to look right, keep walking straight, but turn your head to the right. Keep looking to the right until I tell you, look left, then keep walking straight and turn your head to the left. Keep your head to the left until I tell you look straight, then keep walking straight, but return your head to the center. Grading: Mark the lowest category that applies. (3) Normal: Performs head turns smoothly with no change in gait. (2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. (1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk. (0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15 path, loses balance, stops, reaches for wall.

Gait with vertical head turns Instructions: Begin walking at your normal pace. When I tell you to look up, keep walking straight, but tip your head up. Keep looking up until I tell you, look down, then keep walking straight and tip your head down. Keep your head down until I tell you look straight, then keep walking straight, but return your head to the center. Grading: Mark the lowest category that applies. (3) Normal: Performs head turns smoothly with no change in gait. (2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. (1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk. (0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15 path, loses balance, stops, reaches for wall. Gait and pivot turn Instructions: Begin walking at your normal pace. When I tell you, turn and stop, turn as quickly as you can to face the opposite direction and stop. Grading: Mark the lowest category that applies. (3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance. (2) Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of balance.

(1) Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop. (0) Severe Impairment: Cannot turn safely, requires assistance to turn and stop. Step over obstacle Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking. Grading: Mark the lowest category that applies. (3) Normal: Is able to step over the box without changing gait speed, no evidence of imbalance. (2) Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely. (1) Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing. (0) Severe Impairment: Cannot perform without assistance. Step around obstacles Instructions: Begin walking at normal speed. When you come to the first cone (about 6 away), walk around the right side of it. When you come to the second cone (6 past first cone), walk around it to the left. Grading: Mark the lowest category that applies. (3) Normal: Is able to walk around cones safely without changing gait speed; no evidence of imbalance.

(2) Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones. (1) Moderate Impairment: Is able to clear cones but must significantly slow, speed to accomplish task, or requires verbal cueing. (0) Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance. Steps Instructions: Walk up these stairs as you would at home, i.e., using the railing if necessary. At the top, turn around and walk down. Grading: Mark the lowest category that applies. (3) Normal: Alternating feet, no rail. (2) Mild Impairment: Alternating feet, must use rail. (1) Moderate Impairment: Two feet to a stair, must use rail. (0) Severe Impairment: Cannot do safely.

TOTAL SCORE: ___ / 24

APPENDIX 6
INFORMED CONSENT FORM Institutes name & address :Department of physiotherapy A.W.H Special collage Kallai Calicut Name of the researcher : Title of the study : BENSON BABY Comparative Study of Treadmill Gait Training and Plane Ground Gait Training to improve mobility and gait speed in mild to moderate hemiplegic patients Phone number: 09847406979

I ---------------------------------------------- agree to participate in the research conducted by Mr. Benson Baby for the partial fulfillment of his Masters in Physiotherapy program of the Department of Physiotherapy of A.W.H Special Collage, Kallai, under Calicut university. The project is under supervision of Mr. Bhuvanesh Babu. The purpose is to find out the effectiveness of treadmill gait training and plane ground gait training in mild to moderate hemiplegic patients.

My participation will consist essentially of attending once daily 3 days in a week for 4 weeks and each session approximately 45 minutes. I will be either treated with a combined protocol of treadmill gait training with conventional therapy and protocol of plane ground gait training with conventional therapy. I understand that treadmill gait training and plane ground gait training has no any side effects or danger. I am free to withdrawn from the project at any time before or during the interventions, refuse to participate and refuse to answer questions. I have received assurance from the researcher that the informations, I share will remain strictly confidential. Anonymity will be assured not using name an any type of publications or Non participation will not affect on service that I or my family members may receive from the physiotherapy department of this institution. These are 2 copies of the consent form one of which I may keep. If I have any questions about the conduct of the research project I may contact the researcher.

Researcher name: Official address :

BENSON BABY Department of Physiotherapy A.W.H special collage Kallai.

Respondents signature

Date: signature

Researchers

APPEXDIX 7

MASTER CHART

SERIAL NO

GROUP

SEX

AGE

PRE-TEST STREAM

POST-TEST STREAM

PRE-TEST TUG

POST-TEST TUG

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

A A A A A A A A A A A A A A A B B B B B B B B B B B B B B B

F M M M M M F M F F M M M F F F M F F M M M F M M M M F F F

59 52 65 70 61 64 55 59 51 58 60 52 55 57 54 67 53 54 59 60 58 56 65 52 52 58 58 70 64 53

45 41 42 48 48 41 48 48 45 46 58 58 50 42 48 45 41 42 48 48 41 48 48 45 46 58 58 50 42 48

62 62 64 60 56 66 66 65 66 64 66 62 70 68 60 56 54 56 52 57 52 58 52 58 56 58 52 56 52 54

16 12 18 16 14 15 18 18 14 16 13 16 18 15 16 16 16 15 18 16 13 14 14 16 14 18 13 14 18 16

8 9 8 7 9 8 8 8 8 9 8 8 7 9 9 13 12 10 11 12 10 8 12 10 10 13 12 14 12 9