Original Paper Biomedical Human Kinetics, 10, 76–80, 2018

DOI: 10.1515/bhk-2018-0012

Alterations in gait velocity and grip strength of stroke survivors following

a 12-week structured therapeutic exercise programme
Hammed I. Adebisi1, Adodo S. Monikhe2, Agwubike E. Okey2
1Department of Physiotherapy, University of Benin Teaching Hospital, Benin City, Nigeria; 2 Department of Human
Kinetics and Sports Science, University of Benin, Benin City, Nigeria

Summary
Study aim: This study investigated the alterations in gait velocity and grip strength of stroke survivors following a structured
therapeutic exercise programme (STEP).
Material and methods: This was a pre-test, post-test experimental study of the effectiveness of a 12-week STEP on gait veloc-
ity and grip strength of stroke survivors. A total of 30 hemiparetic stroke survivors participated in the study. The instrument
for this study was an adaptation of a training protocol for the training and assessment of gait velocity and grip strength. The
participants underwent a 12-week STEP of a frequency of 3 times per week and the training programme focused on exercises
aimed at improving the gait velocity and grip strength of the participants. The gait velocity and grip strength were measured
before and after the training. Data generated were analysed using descriptive statistics of mean and standard deviation to sum-
marize the profile of the participants. The analysis of variance for repeated measures (ANOVA) was used to test the hypotheses.
Statistical significance was accepted for a p value of <0.05.
Results: The outcome of this study showed that the STEP had significant (p < 0.05) effects on the gait velocity and grip strength
of stroke survivors. Meanwhile, there was no significant (p > 0.05) effect of haemorrhagic and ischaemic groups of stroke sur-
vivors on gait velocity and grip strength.
Conclusion: It was therefore concluded that the use of the STEP can substantially improve the gait velocity and grip strength
of stroke survivors.

Keywords: Exercise therapy – Gait velocity – Grip strength – Stroke survivors

Introduction of uncertainty. These are dependent on several variables

such as age, gender, severity of neurological involvement
and the like.
Stroke, as defined by Sims, et al. [14], is a rapidly de- Moreover, walking ability is one of the most impor-
veloping loss of brain function(s) due to disturbance in tant functions because independent ambulation is essen-
the blood supply to the brain. According to the authors, it tial for community reintegration and social participation.
could be due to ischaemia, which is a lack of blood flow, Thus, gait training accounts for a large proportion of time
caused by blockage (thrombosis or arterial embolism) or spent in stroke rehabilitation. So, restoration of normal
haemorrhage, which is leakage of blood into the brain. movements of the trunk, pelvis, and lower extremity while
The physical manifestation is paresis or paralysis (partial walking, improving symmetry and weight bearing on the
or complete weakness) of the muscles of the limbs of the paretic side, and to establish an energy-efficient walk, are
contralateral side, otherwise known as the hemiparetic or the most important goals of gait training in stroke patients
hemiplegic side. It is important to note that patients af- [23]. Gait speed among stroke survivors has enjoyed a lot
flicted with stroke are faced with a lot of challenges. Ac- of research over the years with stimulating results. Several
cording to Gordon [2], such challenges include reduced authors have reported varying results ranging from sig-
functional capacity, motor activity intolerance, muscle nificant findings to non-significant findings. However, the
atrophy, partial paralysis, residual gait deviation, anxiety, baseline is that the gait rehabilitation exercise programme
job/economic stress and, for some, an overwhelming sense has been reported to have brought about improvement in

Author’s address Adebisi I. Hammed, Department of Physiotherapy, University of Benin Teaching Hospital, Benin City, Nigeria
[email protected]

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Alteration in gait velocity and grip strength of stroke survivors 77

the gait speed of stroke survivors [7, 20, 27]. In fact, de- with moderate and mild upper-limb impairment among
pendence in mobility is one of the primary reasons for ad- stroke survivors. It is particularly important to remember
mission for inpatient rehabilitation after stroke [4]. In ad- that exercise therapy has the capacity to increase strength
dition, many factors can influence the level of limitation in and develop muscle [8]. Substantial evidence has pointed
walking activity, and these include learning ability, coping to the obvious effects of therapeutic exercise programmes
skills, motivation, medical co-morbidities, physical endur- on gait velocity and grip strength of stroke survivors [5, 11,
ance levels, family support, housing and the amount and 16, 17, 19]. However, it is worth noting that gradients or
type of rehabilitation training [13]. Consequently, hemi- clinical characteristics of stroke morbidity and other clini-
paretic gait is characterized by slow and asymmetric steps cal factors which are said to affect the outcome of exer-
with poor selective motor control delayed and disrupted cise therapy are never the same across communities in the
equilibrium reactions and reduced weight bearing on the same country, and nor are they the same across countries.
paretic limb [13, 21]. Likewise, smooth and symmetric For this reason, the effects of exercise therapy on gait ve-
forward progression of the body is impaired, with a large locity and grip strength of stroke survivors in this locality
variation in gait patterns related to the degree of recovery. may not be the same as found elsewhere. This study was
Well-controlled intra-limb and inter-limb coordination is therefore conducted to establish the efficacy of a structured
replaced by mass limb movement patterns (synergies) on therapeutic exercise programme (STEP) on gait velocity
the paretic side requiring compensatory adjustments of the and grip strength among Nigerian stroke survivors.
pelvis and non-paretic side. Compensatory movements
necessary for ambulation produce abnormal displacement Research hypotheses
of the centre of gravity, resulting in increased energy ex- The following hypotheses were formulated and tested
penditure [6]. at the 0.05 significance level.
On the other hand, reliable and valid evaluation of 1. There is no significant difference in the gait velocity
hand strength can provide an objective index of general of stroke survivors prior to and following a  12-week
upper body strength. Grip strength is the result of force- STEP.
ful flexion of the finger joints with the maximal voluntary 2. There is no significant difference in the grip strength
force that a  person is able to exert under normal bioki- of stroke survivors prior to and following a  12-week
netic conditions. Therefore, grip strength is an important STEP.
component in performing precise and refined fine motor 3. There is no significant difference between haemorrha-
activities. It is one of the commonest measurements used gic and ischaemic stroke survivors in their gait velocity
as a part of physical assessment of various diseases affect- prior to and following a 12-week STEP.
ing musculoskeletal, neuromuscular and cardiorespira- 4. There is no significant difference between haemorrha-
tory systems in children and the elderly population. It also gic and ischaemic stroke survivors in their grip strength
provides selective information to estimate the nutritional prior to and following a 12-week STEP.
status and overall muscle strength of an individual [10].
However, a decrease in grip strength can cause significant Material and Methods
functional limitations which could lead to decreased basic
and instrumental activities of daily living, thereby dimin-
ishing the quality of life of an individual. This is because Research design
hand functionality is considered to be vital in most of the This study was a  pre-test, post-test experimental de-
activities involving the upper limb, be it writing, eating, sign concerning the alterations in gait velocity and grip
carrying loads, lifting objects, or opening and closing strength of stroke survivors following a 12-week STEP.
doors, to name a few. Grip strength is often used in medi-
cine as a specific test for upper limb strength. The purpose Population
of this testing is diverse, including to diagnose diseases, The population for this study included 65 hemiparetic
to evaluate and compare treatments, to document progres- stroke survivors between the biological ages of 45 and
sion of muscle strength, and to provide feedback during 75, who were receiving treatment at the Physiotherapy
the rehabilitation process as a  measure of indicating the Department of the University of Benin Teaching Hospital
level of hand function and fatigue. from 1st June to 31st December, 2015.
Moreover, strength training is one intervention with the
potential to improve function among stroke survivors. Var- Sample size and sampling technique
ious studies have demonstrated improvement of varying The sample for this study comprised 30 hemiparetic
degrees of the muscular strength of stroke survivors. ����Har- stroke survivors receiving treatment at the Physiotherapy
ris,�����������������������������������������������������������
et al [3] reported a significant effect of strength train- Department of the University of Benin Teaching Hospi-
ing on upper-limb function in studies including subjects tal. The purposive sampling technique was used to select

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78 Hammed I. Adebisi et al.

the 30 hemiparetic stroke survivors comprising 15 hemor- she could without running, to the end point. The process
rhagic and 15 ischaemic stroke patients based on the fol- was repeated three times with three minutes rest between
lowing criteria: the sets. Time taken to cover each 10 m distance was re-
Inclusion criteria: corded in seconds.
• The participant must be ambulant without a  walking Scoring: The total distance covered (30 m) by each
aid. participant was divided by the total time taken. The result
• The participant’s grip strength must be good enough to was, however, recorded as the gait velocity.
compress the handgrip exerciser.
Exclusion criteria: Grip strength training
• Participants with communication deficits and cognitive Aim: To improve the grip strength of the affected
impairment. hand.
• Participants with an upper-limb fracture in the past Equipment: Hand grip exerciser.
6 months. Procedure: Participants were made to compress the
hand grip exerciser 50 times as hard as they could with the
Data collection instruments affected hand.
The instrument for this study was a STEP for training Instruction: Each participant was instructed to compress
and assessment of gait and muscular strength in the Physi- or grip the test equipment 50 times as hard as he/she could
otherapy Department of the University of Benin Teaching continuously with the affected hand. The process was re-
Hospital. peated three times with three minutes rest between the sets.
Scoring: Grip strength was measured using a  Camry
Validity and reliability of data collection instrument Electronic Hand Dynamometer (Model: EH101). This de-
The test instrument was validated for the training and vice comes with dual scale readout of forces in kilograms
assessment of upper and lower limb strength by experts in and pounds. However, all readings were recorded in kilo-
physiotherapy and exercise physiology, and its reliability grams in the present study. To standardize the test, the fol-
was calculated to be 0.81 to 0.88 (r = 0.81–0.88) using the lowing guidelines were established: the arm positioning
split-half method. followed the American Society of Hand Therapists guide-
lines [1], with the participant comfortably seated and the
Data collection procedure shoulder slightly forward with the elbow flexed at a  90°
The study received ethical approval to conduct this angle. The forearm and wrist were in a  neutral position.
study from the Research Ethics Committee of the Uni- Three maximum efforts were performed alternately for the
versity of Benin Teaching Hospital, Nigeria. Prior to the affected hand, with three-second contractions and ten-sec-
STEP, a  detailed explanation of the test, training pro- ond rest periods between the attempts. The best of three
gramme and; the objectives and intricacies of the study attempts was recorded. The following test instructions
was provided to the participants and then the participants were provided: “you must squeeze the handle as hard as
signed a participant’s informed consent form before par- possible keeping both your body and arm in position”. The
ticipating in this study. Thereafter, the participants were same tone was used during the briefings, and no verbal en-
made to undergo a  12-week STEP of a  frequency of 3 couragement was offered. The instrument calibration was
times per week (Monday, Wednesday, and Friday) with assessed periodically throughout the study.
each session lasting for 50 minutes at 70% one-repetition
maximum (70% 1RM). The training programme focused Method of data analysis
on exercises aimed at improving the gait velocity and grip Data generated were analyzed using descriptive statis-
strength of the participants, in order to increase their func- tics of mean and standard deviation to summarize the pro-
tional status to meet their daily challenges. The gait ve- file of the participants. Then, the analysis of variance for
locity and grip strength of the participants were measured repeated measures (ANOVA) was used to test the hypoth-
prior to and after the training. eses. Statistical significance was accepted for α = 0.05. All
the analyses were performed using the IBM SPSS Statis-
Gait velocity training tics, version 20.0.
Aim: To increase the mobility of the participants.
Equipments: An open space within the gymnasium/de- Results
partment and a stopwatch.
Procedure: Each participant was made to walk a distance
of 10 m from one end of the gymnasium to the other. The results of the grip strength and gait speed regis-
Instruction: From the starting point, each participant tered before and after the 12-week STEP programme are
was instructed to walk without a walking aid as fast as he/ shown in Table 1.

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Alteration in gait velocity and grip strength of stroke survivors 79

Table 1.  Mean (±SD) pre- (0) and post- (1) programme values of gait velocity (V) and handgrip force (HG) for stroke
survivors

Groups V0 [m/s] V1 [m/s] HG0 [N] HG1 [N]

Ischaemic (n = 15) 0.532 ± 0.293 0.945 ± 0.302 101 ± 86 205 ± 217
Haemorrhagic (n = 15) 0.544 ± 0.296 0.949 ± 0.351 89 ± 80 181 ± 188
All 0.538 ± 0.289 0.947 ± 0.322 95 ± 82 193 ± 200

n = frequency within a group or subgroup.

Hypothesis testing significant effect of the programme. For example,�����������

Suputtita-
Hypothesis 1: Rejected: there was a significant increase da et al. [19] found no significant difference in grip strength
in gait velocity (F1, 28 = 108.6, p < 0.001; η2 = 0.795). between groups measured by a dynamometer after 2 weeks
Hypothesis 2: Rejected: there was a significant increase of bimanual upper extremity training among chronic stroke
in grip strength (F1, 28 = 17.72, p < 0.001; η2 = 0.388). patients. Moreover, Stinear et al. [17] studied 9 stroke pa-
Hypothesis 3: Not rejected: there was no effect of group tients, who received active-passive bimanual movement
on gait velocity (F1, 28 = 0.006, p = 0.9883; η2 = 0.00002). therapy using a purpose-built machine that facilitated pas-
Hypothesis 4: Not rejected: there was no effect of group sive rhythmical flexion/extension of the paretic wrist using
on grip strength (F1,28 = 0.126, p = 0.7253; η2 = 0.0045). active flexion/extension of the less-affected wrist. They also
reported insignificant improvement in grip strength at post-
Discussion treatment. The same result was reported by Stoykov et al.
[18] after 8 weeks of arm training among 24 stroke survivors
with chronic stroke and moderate upper limb impairment
The STEP was found in the present study to have a sub- who received functional bilateral or unilateral arm training.
stantive effect on the gait velocity of stroke survivors. This That is, there were no significant differences in grip strength
finding contrasts with the study of Pomeroy et al. [12], who between groups after treatment 3 times per day for 8 weeks.
reported no significant difference in the gait velocity between Furthermore, other researchers [16, 22] also reported in-
the treatment and the control groups among stroke survivors significant an improvement in the paretic grip strength of
following the STEP. In a related study carried out by States stroke survivors measured by a  hand dynamometer after
et al. [15], on overground physical therapy gait training for a few weeks of arm training. The discrepant findings among
chronic stroke patients with mobility deficits, an insignificant studies might also be due to methodological nuances, such
finding was also reported. Furthermore, the finding of this as the timing of measurements, statistical modelling, etc.
study is also not in agreement with the study of Moseley et However, the STEP had a different effect between haemor-
al. [9], who reported insignificant effects of treadmill training rhagic and ischaemic stroke survivors in their gait velocity
and body support for walking after stroke. These contrasting in the present study. The significant difference in the gait
findings might be related to variation in study methodology velocity between haemorrhagic and ischaemic stroke survi-
including subject characteristics or differences in the training vors could be a result of differences in the pathophysiology
protocols and measurements of gait velocity. This could also of the two types of stroke (haemorrhagic and ischaemic),
be as a result of differences in the gradients/chronicity or clin- which could cause variation in motor weakness, thereby re-
ical characteristics of stroke morbidity. However, there are sulting in a difference in walking velocity.
several other studies which demonstrated significant effects However, the limitations of this study were that only
of therapeutic exercise training on gait velocity of stroke sur- the STEP was considered because of difficulty in monitor-
vivors and thus agree with the findings of the present study. ing other activities of the participants, such as prescribed
For example, Peurala et al. [11] examined the effectiveness of medications and other home programmes, and the severity
body-supported gait training and floor walking in 45 ambula- of stroke was not taken into consideration due to inadequate
tory patients with chronic stroke, and observed faster gait ve- clinical investigations and incomplete documentation.
locity after the intensive rehabilitation programme. Likewise,
gait velocity of stroke survivors with hemiparesis during the Conclusions
six-minute walk has also been reported to have increased by
62% following a 12-week therapeutic intervention [5].
Similarly, the findings of this study on the effectiveness It is therefore concluded that:
of STEP on grip strength of stroke survivors did not enjoy • The participants’ gait velocity and grip strength impro-
the support of many researchers who found and reported no ve substantially following STEP.

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80 Hammed I. Adebisi et al.

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and floor waking in patients with chronic stroke. Arch.
Phys. Med. Rehabil., 86(8): 1557-1564. © University of Physical Education, Warsaw, Poland

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