Mehrholz Jan, Thomas Simone, Elsner Bernhard
Department of Public Health, Dresden Medical School, Technical University Dresden, Fetscherstr. 74, Dresden, Germany, 01307.
Cochrane Database Syst Rev. 2017 Aug 17;8(8):CD002840. doi: 10.1002/14651858.CD002840.pub4.
Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.
To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.
We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists, and contacted trialists to identify further trials.
Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.
Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency.
We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.
AUTHORS' CONCLUSIONS: Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.
跑步机训练，无论是否使用吊带提供体重支持，都被用于康复治疗，可能有助于改善中风后的行走能力。这是对Cochrane系统评价的更新，该评价首次发表于2003年，并于2005年和2014年进行了更新。
与中风后其他物理治疗步态训练干预措施相比，确定跑步机训练和体重支持单独或联合使用是否能改善行走能力、生活质量、日常生活活动能力、依赖性或死亡率以及机构化或死亡率。次要目的是确定这种步态训练方法的安全性和可接受性。
我们检索了Cochrane中风组试验注册库（最后检索时间为2017年2月14日）、Cochrane对照试验中央注册库（CENTRAL）和效果评价数据库（DARE）（Cochrane图书馆2017年第2期）、MEDLINE（1966年至2017年2月14日）、Embase（1980年至2017年2月14日）、CINAHL（1982年至2017年2月14日）、AMED（1985年至2017年2月14日）和SPORTDiscus（1949年至2017年2月14日）。我们还手工检索了相关会议记录、正在进行的试验和研究注册库，筛选了参考文献列表，并联系试验人员以识别更多试验。
关于跑步机训练和体重支持单独或联合使用治疗中风后行走的随机或半随机对照及交叉试验。
两位综述作者独立选择试验、提取数据，并评估偏倚风险和方法学质量。研究的主要结局为步行速度、耐力和依赖性。
在本次更新的综述中，我们纳入了56项试验，共3105名参与者。参与者的平均年龄为60岁，研究在住院和门诊环境中均有开展。所有参与者至少存在一定程度的行走困难，许多人在无辅助的情况下无法行走。总体而言，与其他物理治疗干预措施相比，使用跑步机训练并未增加独立行走的可能性（风险差异（RD）-0.00，95%置信区间（CI）-0.02至0.02；18项试验，1210名参与者；P = 0.94；I² = 0%；低质量证据）。总体而言，在中风后人群的步行康复中使用跑步机训练显著提高了步行速度和步行耐力。步行速度的合并平均差（MD）（随机效应模型）为0.06 m/s（95% CI 0.03至0.09；47项试验，2323名参与者；P < 0.0001；I² = 44%；中等质量证据），步行耐力的合并MD为14.19米（95% CI 2.92至25.46；28项试验，1680名参与者；P = 0.01；I² = 27%；中等质量证据）。总体而言，在中风后人群的步行康复中，使用带体重支持的跑步机训练在预定随访结束时并未提高步行速度和步行耐力。步行速度的合并MD（随机效应模型）为0.03 m/s（95% CI -0.05至0.10；12项试验，954名参与者；P = 0.50；I² = 55%；低质量证据），步行耐力的合并MD为21.64米（95% CI -4.70至47.98；10项试验，882名参与者；P = 0.11；I² = 47%；低质量证据）。在38项共有1571名在研究开始时能够独立行走的参与者的研究中，使用跑步机训练显著提高了步行速度。步行速度的合并MD（随机效应模型）为0.08 m/s（95% CI 0.05至0.12；P < 0.00001；I = 49%）。没有足够的数据来评价对生活质量或日常生活活动的任何影响。接受跑步机训练的人群中不良事件和退出情况并未更频繁发生，且这些未被判定为临床严重事件。
总体而言，与未接受跑步机训练的中风后人群相比，接受跑步机训练（无论是否有体重支持）的中风后人群独立行走能力提高的可能性并不更大，但步行速度和步行耐力可能在短期内略有改善。具体而言，能够行走的中风患者（而非在治疗开始时依赖行走的患者）似乎在步行速度和步行耐力方面从这种干预类型中获益最大。然而，本综述未发现步行速度和耐力的改善可能具有持续的有益效果。进一步的研究应具体调查跑步机训练的不同频率、持续时间或强度（就速度增加和倾斜度而言）以及扶手的使用对能够行走的参与者（而非依赖行走者）的影响。
