790053

research-article2018
CRE0010.1177/0269215518790053Clinical RehabilitationElnahhas et al.

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effects of backward gait training 2019, Vol. 33(1) 3­–12

© The Author(s) 2018
Article reuse guidelines:
on balance, gross motor function, sagepub.com/journals-permissions
DOI: 10.1177/0269215518790053
https://doi.org/10.1177/0269215518790053

and gait in children with cerebral journals.sagepub.com/home/cre

palsy: a systematic review

Ahmed M Elnahhas, Shorouk Elshennawy

and Maya G Aly

Abstract
Objective: To investigate the effects of backward gait training on balance, gross motor function, and gait
parameters in children with cerebral palsy.
Data sources: PubMed, Cochrane Library, Web of Science, Science Direct, Physiotherapy Evidence
Database (PEDro), and Google Scholar were searched up to May 2018.
Review methods: Randomized controlled trials were included if they involved any form of backward
gait training for children with cerebral palsy. Two authors independently screened articles, extracted data
and assessed the methodological quality using PEDro scale, with any confliction resolved by the third
author. Modified Sackett Scale was used to determine the level of evidence for each outcome.
Results: Out of 1492 papers screened, 7 studies with 172 participants met the inclusion criteria. The
duration of treatment ranged from 15 to 25 minutes, three times a week and for 6–12 weeks. The quality
of studies ranged from good (two studies) to fair (four studies) and poor (one study), with a mean PEDro
score of 4.7 out of 10. All included studies showed positive effects in the measured outcomes. The
results showed level 1b evidence for balance when compared to no intervention, and for gross motor
function, step length and walking speed when compared to same dose of forward gait training. The clinical
heterogeneity of studies makes meta-analysis inappropriate.
Conclusion: In children with cerebral palsy, there is moderate evidence that backward gait training improves
balance, gross motor function, step length and walking velocity. More high-quality studies are needed.

Keywords
Backward walking, gait training, children, cerebral palsy, balance, systematic review

Received: 26 February 2018; accepted: 25 June 2018

Introduction Department of Pediatric Physical Therapy, Faculty of Physical

Balance deficits and gait limitations are common
in children with cerebral palsy;1 gait training is
an important part of their rehabilitation as it
plays a major role in children’s quality of life
and social participation. As cerebral palsy
Therapy, Cairo University, Giza, Egypt
Corresponding author:
Shorouk Elshennawy, Department of Pediatric Physical
Therapy, Faculty of Physical Therapy, Cairo University, Giza
12613, Egypt.
Email: shoroukelshennawy@cu.edu.eg
4 Clinical Rehabilitation 33(1)

Table 1.  Inclusion criteria.

Design •• Randomized controlled trial (RCT), published in any language and at any year till May 2018.
Participants •• Children (i.e. <18 years old)
•• Cerebral palsy
Intervention •• Any form of backward gait training (e.g. over ground, on treadmill, and with or without body
weight support)
Outcome •• Measure of balance
measures •• Gross Motor Function Measure (GMFM)
•• Temporal and spatial gait parameters
Comparisons •• Backward gait training plus other therapy versus other therapy (i.e. backward gait training
versus no backward gait training)
•• Backward gait training versus forward gait training

cannot be cured; its treatment is increasingly Method

focusing on improving activities, such as ambu-
lation and self-care activities.2 The ultimate goal
of rehabilitation in cerebral palsy is to enable the
child to gain maximal functional independence
by achieving the optimal developmental poten-
tial of the child.3
For several decades, backward gait training
has been used in sports to improve cardiovascu-
lar fitness and for prevention and rehabilitation
of musculoskeletal injuries.4,5 It has been used
not only with athletes but also with different
populations as healthy non-athlete adults,
elderly, and children.6–9
Backward gait training was suggested to
enhance stability and static balance for healthy
adults and young women,10,11 also it found its place
in the rehabilitation of patients with neurological
disorders; it has been implemented in the gait train-
ing program to increase the motor control and
improve the gait pattern of patients with stroke.12
A narrative review of the literature was done in
2015 by Joshi et al.13 about the role of retro-walk-
ing or backward gait training in physiotherapy
and rehabilitation; it showed the limited evidence
of retro-walking effect on balance and gait in chil-
dren with cerebral palsy. Afterward, several stud-
ies14–20 suggested that backward gait training
could be used in children with cerebral palsy.
This review aimed to investigate and summarize
the most updated evidence on the effectiveness of
backward gait training on balance, gross motor
function and gait parameters in children with cere-
bral palsy.
This review was registered on PROSPERO register
with a registration number CRD42017055559.
The databases PubMed, Cochrane Library, Web
of Science, Science Direct, Physiotherapy Evidence
Database (PEDro), and Google Scholar were
searched without restrictions regarding language or
year of publication. Relevant studies were also
searched by the trial register ClinicalTrials.gov.
The following keywords were used: “Backward,”
“Rearward,” “Rear,” “Reverse,” “Gait,” “Walking,”
“Locomotion,” and “Ambulation.” All databases
were searched from the inception till May 2018.
Two independent reviewers (A.M.E. and S.E.)
assessed titles and abstracts of the trials identified by
the search against the eligibility criteria (Table 1).
All articles that were considered potentially eligible
were obtained in full text, and additional screening
of reference lists of the eligible studies was also per-
formed. A copy of the complete search strategy is
included in Supplementary Appendix 1.
The quality of included studies was assessed
using PEDro scale.21 Two authors (A.M.E. and
M.G.A.) rated the included studied using PEDro
scale, with any confliction resolved by the third
author (S.E.).
The data extracted includes the participants’
age, gender, type and severity of cerebral palsy.
Also, the intervention data include the device
used, the training duration and frequency. The
control intervention was no backward gait train-
ing while comparison intervention was forward
gait training.
Elnahhas et al. 5

Figure 1.  PRISMA flow diagram of studies through the review.25

One reviewer (M.G.A.) extracted data from the Results

included studies and a second reviewer (A.M.E.)
cross-checked it. Continuous variables data were
extracted and expressed as a mean difference with
95% confidence interval.22
The following classification was used for rating
the methodological quality: a PEDro score of <4
indicated poor quality; score of 4–5 indicated fair
quality; score of 6–8 indicated good quality; and
score of 9–10 indicated excellent quality.23
For interpretation of results, Modified Sackett
Scale was used to determine the level of evidence
for each outcome.24
The search strategy identified 1492 studies till May
2018. After screening titles and abstracts and
removing duplicates, 38 full papers were retrieved.
After assessing articles against the eligibility crite-
ria, seven papers14–20 were included in the review
(Figure 125; see Supplementary Appendix 1 for
search strategy and the list of excluded studies).
Table 2 presented the summary of the included
studies.26 The PEDro scores are presented in Table 3.
From Table 2, we can summarize that there is clinical
heterogeneity between the participants, interventions,

Table 2.  Summary of included studies.
Study Participants
Abdou et al.14 n = 30
Mean age (range) = 6.1 years
(5–7 years)
Gender = not stated
Classification = spastic
hemiparesis, DDST
12–17 months
El-Basatiny n = 30
and Abdel- Mean age (range) = 12 years
aziem15 (10–14 years)
Gender = 16 M, 14 F
Classification = spastic
hemiparesis, GMFCS I–II
Ayoub16 n = 20
Mean age (range) = 7.9 years
(7–10 years)
Gender = 7 M, 13 F
Classification = spastic
diplegia, GMFCS II–III
Ayoub17 n = 20
Mean age (range) = 7.9 years
(8–11 years)
Gender = 7 M,13 F
Classification = spastic
diplegia, GMFCS II–III
Intervention
Exp = backward gait training
on treadmill 20 minutes, 3/
week × 6 weeks
Con = no intervention
Both = regular PT program
Exp = backward gait training on
ground based on methods as
described by Davies and Klein-
Vogelbach,26 25 minutes, 3/
week × 12 weeks
Con = no intervention
Both = traditional PT program
Exp = backward treadmill gait training
with partial body weight support
(30% relief of total body weight)
using Biodex® unweighing equipment,
15 minutes, 3/week × 12 weeks
Con = no intervention
Both = regular PT program
Exp = Partial body weight supported
backward treadmill training
15 minutes, 3/week × 12 weeks
Con = Partial body weight supported
forward treadmill training
Both = regular exercise program
6
Outcome measures
Dynamic balance = mediolateral
stability index via Biodex®
balance system (°)
Follow-up = 0, 3, 6 weeks
Dynamic balance = overall,
anteroposterior & mediolateral
stability indices via Biodex®
balance system (°)
Follow-up = 0, 12 weeks
Walking velocity using Biodex®
gait trainer II (m/s)
Follow-up = 0, 12 weeks
Step symmetry presented by
time spent on each foot (% of
gait cycle) using Biodex Gait
Trainer 2™
Follow-up = 0
Clinical Rehabilitation 33(1)
 Elnahhas et al.

Table 2. (Continued)
Study Participants Intervention Outcome measures
Abdel-aziem n = 30 Exp = backward gait training on Spatiotemporal gait
and El- Mean age (range) = 12 years ground based on methods as parameters via 3D gait analysis
Basatiny18 (10–14 years) described by Davies and Klein- system = step length (m),
Gender = 10 M, 20 F Vogelbach,26 25 minutes, 3/ walking velocity (m/s), cadence
Classification = spastic week × 12 weeks (steps/minutes), percentage of
hemiparesis, GMFCS I–II Con = forward gait training the stance & swing phases of
on ground 25 minutes, 3/ the affected LL in relation to
week × 12 weeks gait cycle (%)
Both = conventional PT program Activity = Dimensions D & E of
GMFM-88 (%)
Follow-up = 0, 12, 16 weeks
Abdou19 n = 30 Exp = backward gait training Dynamic balance = overall
Mean age (range) = not on Treadmill, 20 minutes, 3/ stability index via Biodex®
stated (5–7 years) week × 6 weeks balance system (°)
Gender = not stated Con = no intervention Follow-up = 0, 6 weeks
Classification = spastic Both = regular PT program
diplegia, DDST 12–
17 months
Sanad20 n = 12 Exp = Backward treadmill gait training Walking speed using Biodex
Mean age (range) = not 20 minutes, 3/week × 12 weeks Gait Trainer 2TM
stated (5–9 years) Con = no intervention Follow-up = 0
Gender = 8 M, 4 F Both = traditional PT program
Classification = spastic
diplegia, GMFCS I–III

Exp: experimental group; Con: control group; RCT: randomized controlled trial; DDST: Denver Developmental Screening Test; GMFCS: Gross Motor Function Classification
System; M: male; F: female; PT: physiotherapy; GMFM: Gross Motor Function Measure; LL: lower limb.
7
8 Clinical Rehabilitation 33(1)

or outcome measures of the included studies.

estimate and (0–10)

Total
Therefore, meta-analysis was not applicable.
The quality of studies ranged from good (two

4
7

4
4
7

4
3
studies15–18) to fair (four studies14,16,17,19) and poor
(one study20), with a mean PEDro score of 4.7 out
variability
reported
of 10 (range 3–7) (Table 3). Regarding the method
Point

Y of randomization and allocation, the lack of clarity

Y

Y
Y
Y

Y
Y
was the main methodological limitation as whether
difference
Between-

randomization was achieved through software,

reported

random numbers or other methods, constituting

group

high risk of bias. All the papers were randomized,

Y
Y

Y
Y
Y

Y
Y
analyzed the between-group difference, reported
Intention-

point estimates and variability. Most stud-

dropouts to-treat
analysis

ies14,16,17,19,20 (71%) did not report < 15% loss to

follow-up, conceal the allocation list nor had
N
N

N
N
N

N
N

blinded assessors. None of the studies carry out an

intention-to-treat analysis, nor blind participants
<15%

or therapists.
N

N
N

N
N
Y

Participants were 172 children and adolescents

who were classified as having either hemiparetic or
Therapist Assessor
blinding

diplegic cerebral palsy, including both genders and

their ages ranged from 5 to 14 years.
N

N
N

N
N
Y

Backward gait training was provided by tread-

blinding

mill without body weight support,14,19,20 by tread-

mill with body weight support16,17 or over
N
N

N
N
N

N
N

ground,15,18 with a duration ranged from 15 to

25 minutes, three times a week and lasted from 6
Participant

to 12 weeks. The control group received either no

blinding

backward gait training (five studies14–16,19,20) or

the same dose of forward gait training (two
N
N

N
N
N

N
N

studies17,18).
similar at

Measures of balance were reported in three

baseline
Groups

studies,14,15,19 using the stability indices of Biodex®

N
Y
Y

Y
Y
Y

balance system. The levels of difficulty of stability

Table 3.  PEDro scores of included studies.

testing was reported in only one study,15 but not

Random Concealed
allocation allocation

mentioned in the other two studies.14,19

Measure of gross motor function was reported
in one study.18 The measure chosen for the assess-
N

N
N

N
N
Y

ment of gross motor function was the Gross Motor

Function Measure (GMFM-88).
Gait analysis was reported in four studies.16–18,20
Y
Y

Y
Y
Y

Y
Y

The measures chosen for the analysis of gait were

walking velocity,16,18,20 step length,18 cadence,18
Abdel-aziem and
El-Basatiny and
Abdel-aziem15
Abdou et al.14

and percentage of the stance phase in relation to

El-Basatiny18

gait cycle.17,18
Abdou19
Ayoub16
Ayoub17

Sanad20

The findings of the included studies are pre-

Study

sented in Table 4. All the included studies showed

Elnahhas et al. 9

Table 4.  Mean (SD) of the post-treatment outcomes for each group and mean (95% CI) difference between
groups of included studies.

Study Groups Difference between groups

Experimental Control group Experimental group minus

group control group
Overall stability index (°)
  El-Basatiny and Abdel-aziem15 1.4 (0.44) 1.8 (0.44) −0.37 (−0.71 to −0.03), –21%
 Abdou19 1.5 (0.28) 2.2 (1.3) −0.76 (−1.37 to −0.15), –34%
AP stability index (°)
  El-Basatiny and Abdel-aziem15 1.1 (0.34) 1.4 (0.44) −0.33 (–0.93 to 0.27), –23%
ML stability index (°)
  Abdou et al.14 1.1 (0.23) 1.6 (0.42) −0.52 (−1 to −0.02), –32%
  El-Basatiny and Abdel-aziem15 1.9 (0.51) 2.4 (0.65) −0.46 (−0.91 to −0.01), –19%
GMFM (dimension D) (%)
  Abdel-aziem and El-Basatiny18* 90 (6.4) 82 (7.1) 7.7 (13 to 2.5), 9 %
GMFM (dimension E) (%)
  Abdel-aziem and El-Basatiny18* 82 (13) 80 (13) 2 (–7.8 to 11.8), 3 %
Walking velocity (m/s)
 Ayoub16 0.6 (0.12) 0.31 (0.14) 0.29 (0.2 to 0.38), 94%
  Abdel-aziem and El-Basatiny18* 0.53 (0.19) 0.46 (0.2) 0.07 (–0.08 to 0.22), 15%
 Sanad20 0.52 (0.16) 0.31 (0.14) 0.21 (0.03 to 0.39), 68 %
Cadence (steps/min)
  Abdel-aziem and El-Basatiny18* 122 (2.9) 126 (2.7) −4.1 (−6.3 to −1.8), –3%
Step length (m)
  Abdel-aziem and El-Basatiny18* 0.55 (0.16) 0.39 (0.13) 0.16 (0.05 to 0.27), 41%
Stance phase percentage (%)
  Abdel-aziem and El-Basatiny18* 55 (1.7) 50 (1.6) 4.5 (3.2 to 5.8), 9%
 Ayoub17(Left LL)* 46.7 (3.1) 43.7 (4.7) 3 (–0.7 to 6.7), 7%
Swing phase percentage (%)
  Abdel-aziem and El-Basatiny18* 44 (1.4) 49 (1.6) −5.1 (−6.2 to −3.7), –10%

SD: standard deviation; CI: confidence interval; GMFM: Gross Motor Function Measure; LL: lower limb.
*Backward gait training compared to same dose of forward gait training.

significant improvement in the measured out-
comes. The clinical heterogeneity restricted the
pooling of data from individual trials to determine
a weighted estimate.
One high-quality study15 and two low-quality
studies14,19 reported the effect of backward gait
training on dynamic balance in children with cere-
bral palsy. Consequently, there is moderate-quality
evidence (level 1b) to support using backward gait
training to improve balance in children with cere-
bral palsy when compared to no intervention.
Two studies16,20 with low quality reported the
effect of backward gait training on walking
velocity in children with cerebral palsy when
compared to control (no intervention).
Consequently, there is limited evidence (level 2a)
to support using backward gait training to
improve walking velocity in children with cere-
bral palsy when compared to no intervention.
One high-quality study18 reported the effect of
backward gait training on GMFM in children with
cerebral palsy. Consequently, there is moderate-
quality evidence (level 1b) to support using back-
ward gait training to improve gross motor function
in children with cerebral palsy when compared to
same dose of forward gait training.
10 Clinical Rehabilitation 33(1)
One high-quality study18 and one low-quality
study17 reported the effect of backward gait train-
ing on gait parameters in children with cerebral
palsy when compared to the same dose of forward
gait training. Backward gait training improved
walking velocity by 15%, cadence by 3%, step
length by 41%, and stance phase percentage by
7%–9%. Consequently, there is moderate-quality
evidence (level 1b) to support using backward gait
training to improve gait parameters in children
with cerebral palsy when compared to same dose
of forward gait training.
Discussion
Results of all randomized controlled trials included
in this review were consistent and agreed that
backward gait training improve balance, gross
motor functions, and gait parameters in children
with cerebral palsy. The current review found mod-
erate-quality evidence supporting the use of back-
ward gait training for children with cerebral palsy.
Moderate evidence was reported from three
studies14,15,19 that backward gait training improves
balance. Several mechanisms have been suggested
to explain the benefits of backward gait training for
children with cerebral palsy; one of them was the
reorganization of muscle synergies or neuromotor
control in the lower extremities during backward
gait training.9,27
Backward gait training emphasizes on foot posi-
tioning behind the body that facilitates hip extension
while the knee is going into flexion, instead of per-
forming the crouched pattern of gait in which hip
and knee are both in flexed position and the ankle is
in dorsiflexion. It was stated that the neural and
mechanical responses that based on the reduction in
hip movement probably increases stability by mini-
mizing the anterior–posterior displacement of the
center of gravity, and shorter absolute swing/stance
duration. The reversal of triple-flexion posture of the
lower limbs and the improvement in postural bal-
ance were suggested as reasons for the improvement
in the spatiotemporal gait parameters after backward
gait training for children with cerebral palsy.6
Another reported explanation was the greater
muscle strength gain in the lower limbs during
backward gait training that was attributed to the
longer period of muscle activity when compared
with forward gait training, also the sufficient prac-
tice opportunities was stated as an explanation for
stability improvement in children with cerebral
palsy who practiced backward gait training.18,28
Findings of this review revealed limited evi-
dence from two low-quality studies16,20 that back-
ward gait training increases gait speed when
compared to no intervention, while moderate evi-
dence from one high-quality study18 was found
that backward gait training improves gait param-
eters including walking velocity when compared
to the same dose of forward gait training.
Although results of the three studies16,18,20 were
consistent that backward gait training improves
gait speed, the present evidence is limited and not
clear by considering also the heterogeneity
between the inclusion criteria of the high-quality
study18 with the other two studies16,20 and the
method of training.
Studies in this review included children with
cerebral palsy of hemiparetic type (Gross Motor
Function Classification System (GMFCS) levels I
and II)14,15,18 and diplegic type (GMFCS levels I to
III).16,17,19,20
Moderate evidence from one high-quality
study18 was found that backward gait training
improves gross motor function and gait parame-
ters when compared to the same dose of forward
gait training. Improvement in gross motor skills as
standing and walking that involve upright posture
was attributed to the improved neuromuscular
control after backward gait training that over-
comes the lower limbs extensor synergy pattern by
repeated practicing of knee flexion combined with
hip extension.12,18
Various methods of backward gait training were
used in the included studies, either training on the
ground or using treadmill with or without body
weight support. Both gait training on a stable or
moving surface resulted in improved functional
and static balance. However, gait training using
treadmill resulted in a greater improvement of the
functional balance in children with cerebral palsy.29
Backward treadmill training with partial weight
support enhances walking abilities in children with
Elnahhas et al. 11
cerebral palsy due to double impact of proper posi-
tioning of different body segments achieved by
suspension along with improved balance and lower
limb muscles strength gained by backward gait
training.16 Backward gait training of any form is an
intervention that does not allow blinding of the
patients or the therapists; therefore, none of the
included studies in this review blind the partici-
pated children or the therapists.
The main limitation of this systematic review
is the low quality of included studies (mean
PEDro score 4.7) which limit the strength of con-
clusion. In this review, the included studies
lacked standardization in the method of back-
ward gait training (technique and duration of
walking), outcome measures, and follow-up. The
duration of treatment varied between 15 and
25  minutes for a period of 6–12  weeks.
Reassessment after the intervention also lack
consistency; this clinical heterogeneity limits the
degree of comparison between the results of these
studies and makes meta-analysis inappropriate in
the current review.
This review has provided a synthesis of rand-
omized controlled trials that involved any form of
backward gait training for children with cerebral
palsy. There is moderate-quality evidence to rec-
ommend the use of backward gait training in the
rehabilitation of children with cerebral palsy to
improve balance, gait parameters, and gross motor
functions. More well-designed studies on the effec-
tiveness of backward gait training for children with
cerebral palsy with larger sample sizes on different
types of cerebral palsy and better methodology are
still needed. Future high-quality research may con-
firm the present evidence about the benefit of back-
ward gait training for children with cerebral palsy.
Clinical messages
•• There is moderate evidence but no more
that backward gait training improves
mobility in children with cerebral palsy.
•• There is some evidence that backward
gait training may also improve balance
and gross motor function in children with
cerebral palsy.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iDs
Shorouk Elshennawy https://orcid.org/0000-0001-
8007-8059
Maya G Aly https://orcid.org/0000-0002-3640-7799
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