INTRODUCTION

Stroke is a leading cause of serious, long-term disability throughout the

world. As many as two-thirds of individuals are unable to walk or require physical
assistance to walk immediately after their stroke and a third of individuals still
require assistance or are unable to walk 3 months post stroke. These chronic
limitations in mobility can lead to a decrease in endurance and fitness reserve that
can also negatively impact function. Since walking ability and endurance have
been shown to be important predictors of independence and community
mobility,4,5 it is essential that clinicians find effective and affordable interventions
for improving walking ability and fitness in persons with stroke.
Recent studies have emphasized the use of intensive task-specific forms of
activity such as treadmill-based locomotor training that can provide both gait and
endurance training in a controlled and systematic fashion. However, one of the
recognized limitations of treadmill training is the physical demands it can place on
both the therapist and the participant during the intervention. This is especially true
when training more severely impaired individuals who may require the use of
body-weight support and additional staff to provide appropriate cueing and manual
facilitation of the lower extremities and trunk. In such cases, treatment time and
intensity may be limited by therapist/participant fatigue and may be cost
prohibitive in cases where reimbursement rates do not adequately account for the

increased time and staffing associated with this type of training. Another limitation
of treadmill-based locomotor training is that it may be difficult to perform safely
and independently in home and community settings.
To address the limitations of using a treadmill for locomotor training, some
researchers have investigated alternatives such as robotic-assisted locomotor
training and electromechanical gait training; the latter is a motorized elliptical
machine that adjusts the amount of assistance based on the user's effort level.
These interventions rely on the use of motorized equipment to move the lower
extremities to reduce the work of both the therapist and the patient and allow for
increased practice opportunities. To date, the few studies evaluating the
effectiveness of these interventions have demonstrated mixed results.
The primary purpose of this case series was to assess the feasibility of using
a commercially available non motorized elliptical machine to improve cadence in
individuals with chronic stroke. If this type of training is safe and effective,
elliptical training could offer an alternative to treadmill or robotic-assisted gait
training. More important, elliptical training might provide an affordable form of
training that could be used safely in home and community settings on a long-term
basis.

STATEMENT OF THE STUDY

Effectiveness of elliptical exercise training to improve cadence in stroke
patients.

REVIEW OF LITERATURE
Macko rf, et al., (1997)
Suggested that task oriented aerobic exercise may improve
functional mobility and the cardiovascular fitness profile in this population.
Salbach. et al.,(1998)
Suggested that the newly developed elliptical trainer was at least
as effective as treadmill therapy with partial body weight support while
requiring less input from the therapist.
Silver KH, et al.,(2000)
Found that treadmill exercise improves functional over ground
mobility in individuals with chronic, stable hemi paresis.
Laufer Y, et al., (2001)
Suggested that elliptical training may be more effective than
conventional gait training for improving some gait parameters such as
functional ambulation, stride length, percentage of paretic single stance
period, and gastrocnemius muscular activity.

 Jackson ML, et al., (2001)

Suggested that a higher training frequency and/or training speed
are required to influence walking performance in individuals who are
ambulatory. Equipment design, principles of exercise prescription, and
participant characteristics should be considered when selecting elliptical
training as an intervention.
Nilsson L, et al., (2001)
Stated that the elliptical training with BWS at an early stage of
rehabilitation after stoke is a comparable choice to walking training on the
ground.
Sullivin KJ, et al., (2002)
Found that training at speeds comparable with normal walking
velocity was more effective in improving self detected over- ground
walking velocity.
Tong RK, et al.,(2006)
Stated that participants who trained on the electromechanical
gait trainer with body-weight support, with or without FES, had a faster
gait, better mobility, and improvement in functional ambulation

DESIGN AND METHODOLOGY

RESEARCH DESIGN
The study is quasi experimental in nature.
1 st day

6 th week
Elliptical training

Pre - test

post test

Twenty samples were taken for this study. All subjects underwent Pretest
measurements for cadence by using stopwatch. After the pre test, the subjects
received elliptical training for 15 sessions over 6 weeks. Post test measurements
were taken on the 6th week in a similar fashion as that of pre test measurements.

CRITERIA FOR SELECTION

INCLUSION CRITERIA
Subjects age group more than 65 years
Both sex were included

 Subjects who were diagnosis of chronic first-time supratentorial stroke,

Subjects who were impaired walking function but able to walk at least 10 m
with no more than contact guard assistance.
All participants had a minimum score of 24/30 on the Modified Mini-Mental
Status Exam.
Participants were free of significant comorbidities such as recent myocardial
infarction, acute inflammation, recent surgery, painful orthopedic conditions,
and the presence of other neurological conditions.

EXCLUSION CRITERIA
Subjects those inability to give informed consent
Subjects inability to walk 25 feet,
pregnancy, breast-feeding were excluded
within 3 months postpartum at the initiation of the study,
any other neurological or vestibular disorder,
any other comorbid conditions that would make participation in exercise
unsafe.

POPULATION

All the patients who fulfilled the selection criteria were taken as the
Population of the study.

SAMPLE SIZE AND METHOD OF SELECTION

Twenty samples were selected from the population using simple Random
sampling method.

VARIABLES
Independent variable
Elliptical training
Dependent Variable
cadence

TOOLS USED
Stop watch used to measure the cadence

VALIDITY AND RELIABILITY OF THE TOOLS USED

The tool of stopwatch is used to measure the cadence is a valid one and
has high inter rater reliability.

SETTING
This study was conducted in the out patient department of physiotherapy,
Vinayaka Missions Medical College Hospital. Salem.
METHODOLOGY
A pilot study was conducted prior to the main study with subjects to
observe the feasibility of the study.
After this, samples of subjects were selected using simple random
sampling method from the population.
All the participants were explained about the purpose and procedure of
study and written consent was obtained from them before being included in the
study.
All subjects were assessed with a pre test Performa, which had provisions
to record the subjects basic demographic data and the details of the pre test and
post test.
PRE TEST
All the subjects were subjected to a pretest to assess the cadence using
stopwatch and it was calculated by using the formula of
Cadence = number of steps/minute.
Before starting the training session all the subjects went for screening test to
evaluate the cardio vascular tolerance.

Training was performed using a commercially available elliptical machine.

During training sessions, a harness apparatus was used to minimize the risk of
falling and to reduce anxiety. This harness system was mounted to the ceiling,
using a single eye-bolt attachment. Body-weight support could be adjusted if
needed using a simple rope-and-pulley system. This system provided a 3-to-1
mechanical advantage when lifting the participant and used a cam cleat to lock or
release the rope so the amount of body-weight support could be easily adjusted
during training.
Intervention
Prior to each training session, the participants sat quietly for 5 minutes and
resting blood pressure (BP) and Heart rate were recorded. Participants were also
fitted with a Heart rate monitor and safety harness. Participants who wore anklefoot orthoses for walking were asked to remove them during training.
The duration of the training sessions was progressively increased with the
goal of achieving a target training duration of 20 minutes of uninterrupted elliptical
training. An additional goal was to maintain a stepping cadence of 100 to 110 steps
per minute (50-55 rpm) to simulate normal over ground walking cadence. If a
participant was unable to complete 20 minutes of training initially, attempts were
made on each subsequent session to increase the total training time while giving as
many rest breaks as needed. If a participant was able to achieve 20 minutes of

uninterrupted training while maintaining the predetermined exercise parameters,

then the resistance level of the elliptical machine was increased. All participants
trained for 8 weeks.

If they exceeded either the Heart rate or perceived exertion threshold, then
they were asked to reduce their effort or stop and rest in either a standing or sitting
position until Heart rate and perceived exertion returned to acceptable levels.
During the first several sessions, BP was also assessed during the rest breaks to
ensure a normal exercise response. During and immediately following the training
session, systolic pressure less than 200 mm Hg and diastolic pressure less than 110
mm Hg were considered the safe limits. If a participant were to exceed any of these
values, he would be discontinued from the training program and his physician
would be contacted.
As mentioned previously, participants wore a harness during all training.
Initially we intended only to use the harness for safety purposes. However, as
training progressed, we found it beneficial to provide some body-weight support to
maintain proper form and postural control especially as the participants fatigued
during the course of a training session. While we did not have an accurate method
for measuring the amount of body-weight support provided, on the basis of

previous clinical experience, we estimate that the amount of support was less than
20% of body weight.
OBSERVATION AND ANALYSIS
The collected data were analyzed using paired t test.
Table 1.1
Elliptical training
Variables
cadence

cal

value

value

18.26

2.093

table

The data was subjected to statistical analysis and the following results were
obtained t calculated value > t table value. So this study was significant at 5%
level

RESULTS AND DISCUSSIONS

RESULTS
The data was subjected to statistical analysis and the following results were
obtained
There is a statistically significant improvement in cadence for the stroke
patients trained with elliptical training.

DISCUSSION
The result of the study shows in favor of elliptical training for improving the
cadence for the hemi paretic patients. The mechanism which is behind this are
Six weeks of elliptical training may have allowed for improved axonal
conduction and therefore improved supraspinal contribution to motor
control. While this idea is only speculative, inclusion of a gait-simulating
exercise may have helped to improve muscle firing patterns and increase
supraspinal input. To verify this idea, researchers could measure
somatosensory-evoked potentials to investigate whether spinal conduction
speeds improved. In animal models of spinal cord injury, exercise has been

shown to increase the release of brain-derived neurotrophic factor, which

promotes reflex normalization, and to increase action of microRNAs, which
help regulate apoptosis after injury.
A study an University of Missouri measured oxygen utilization, lactic acid
formation, heart rate, and rating of perceived exertion on an elliptical trainer
compared to a treadmill, and found that the elliptical exercise was nearly
identical to the treadmill exercise in every respect but the elliptical trainer
creates far less joint impact.
The elliptical trainer produced significantly great quadriceps utilization and
greater quadriceps/hamstring coordination than any of the other modes of
exercise
Greater muscle activation during the elliptical training for the gluteus
maximus (butt) and vastus lateralis (external hip muscles), with a slightly
lower activation of the hamstrings.
On an elliptical trainer that includes arm motion, a shoulder, chest, biceps
and triceps workout can be incorporated simultaneous. In addition, the
upright posture on an elliptical trainer will utilize more of your core muscles,
and if you go hand-free without using the railing on an indoor elliptical
trainer, you can increase the balance and postural training effect.

 Speed training in elliptical training induces marked speed related

improvements in body and limb kinematics and muscle activation patterns.
Speed training facilities the movement co ordination and intra limb and inter
limb energy transfers.
Speed training, which facilitates relevant weight bearing muscles gait
effectively.
Fisher et al. showed that when neurologically damaged rats were exposed to
treadmill training, their walking performance returned to the level of nondisabled
control subjects within 30 days. These results speak to the widespread effects that
exercise may have in patients with neurological disease.

RECOMMENTATIONS FOR THE FURTHER STUDY

Similar study can be done to find the effectiveness of body weight
supported gait training and floor walking in patients with stroke.
Similar study can be done to find the effectiveness of partial body weight
supported elliptical training versus aggressive bracing walking for post
stroke.

CONCLUSIONS
The results of this study make us to conclude that elliptical training is
effective in improving cadence on patients with stroke. These findings indicate that
regular elliptical exercise could be a part of inpatient and outpatient stroke
rehabilitation programs.

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