CLINICAL SCIENCES

Whole-Body Vibration Intensities in Chronic

Stroke: A Randomized Controlled Trial
LIN-RONG LIAO1,2, GABRIEL Y. F. NG2, ALICE Y. M. JONES3, MEI-ZHEN HUANG2, and MARCO Y. C. PANG2
1
Department of Physiotherapy, Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, CHINA;
2
Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong, CHINA; and 3School of
Allied Health Sciences, Griffith University, Gold Coast, AUSTRALIA

ABSTRACT
LIAO, L.-R., G. Y. F. NG, A. Y. M. JONES, M.-Z. HUANG, and M. Y. C. PANG. Whole-Body Vibration Intensities in Chronic Stroke:
A Randomized Controlled Trial. Med. Sci. Sports Exerc., Vol. 48, No. 7, pp. 12271238, 2016. Purpose: A single-blinded randomized
controlled study was conducted to investigate the effects of different whole-body vibration (WBV) intensities on body functions/
structures, activity, and participation in individuals with stroke. Methods: Eighty-four individuals with chronic stroke (mean age = 61.2 yr,
SD = 9.2) with mild to moderate motor impairment (ChedokeMcMaster Stroke Assessment lower limb motor score: median = 9 out of
14, interquartile range = 711.8) were randomly assigned to a low-intensity WBV, high-intensity WBV, or control group. The former
two groups performed various leg exercises while receiving low-intensity and high-intensity WBV, respectively. Controls performed the
same exercises without WBV. All individuals received 30 training sessions over an average period of 75.5 d (SD = 5.2). Outcome
measurements included knee muscle strength (isokinetic dynamometry), knee and ankle joint spasticity (Modified Ashworth Scale),
balance (Mini Balance Evaluation Systems Test), mobility (Timed-Up-and-Go test), walking endurance (6-Minute Walk Test), balance
self-efficacy (Activities-specific Balance Confidence scale), participation in daily activities (Frenchay Activity Index), perceived envi-
ronmental barriers to societal participation (Craig Hospital Inventory of Environmental Factors), and quality of life (Short-Form
12 Health Survey). Assessments were performed at baseline and postintervention. Results: Intention-to-treat analysis revealed a sig-
nificant time effect for muscle strength, Timed-Up-and-Go distance, and oxygen consumption rate achieved during the 6-Minute Walk
Test, the Mini Balance Evaluation Systems Test, the Activities-specific Balance Confidence scale, and the Short-Form 12 Health Survey
physical composite score domain (P G 0.05). However, the timegroup interaction was not significant for any of the outcome measures
(P 9 0.05). Conclusion: The addition of the 30-session WBV paradigm to the leg exercise protocol was no more effective in enhancing
body functions/structures, activity, and participation than leg exercises alone in chronic stroke patients with mild to moderate motor
impairments. Key Words: CEREBROVASCULAR ACCIDENT, REHABILITATION, EXERCISE, HEMIPARESIS

S
troke is one of the leading causes of long-term dis-
ability and is an important public health concern (9).
One of the major physical impairments experienced
by individuals with stroke is muscle weakness, particularly
in the paretic limbs (8,15,32). It is well documented that
Address for correspondence: Marco Y.C. Pang, Ph.D., Department of
Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom,
Hong Kong, China; E-mail: Marco.Pang@polyu.edu.hk.
Submitted for publication September 2015.
Accepted for publication February 2016.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal_s Web site (www.acsm-msse.org).
0195-9131/16/4807-1227/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE
Copyright 2016 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000000909
isometric and dynamic muscle strength are correlated to
other important functions, such as walking endurance (8,15),
walking velocity (8,15), and balance skills (15,24). Limita-
tions in these functional activities may lead to poor com-
munity reintegration, triggering a vicious cycle of further
deterioration of physical functioning, and reduced societal
participation (32). Thus, it is important to tackle problems
arising from muscle weakness and associated functional is-
sues in stroke rehabilitation.
Whole-body vibration (WBV) therapy, in which vibratory
signals are delivered to the human body through a vibration
platform, has gained increasing attention in neurorehabil-
itation. Only eight randomized controlled studies have examined
the efficacy of WBV on different aspects of neuromotor
function poststroke, such as leg muscle strength, balance,
spasticity, and mobility (5,6,17,22,3436,38), with inconsis-
tent results observed. Of the seven studies that measured leg
muscle strength (5,17,22,3436,38), three (43%) reported

1227

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 significant effects associated with WBV (3436). Two (29%)
of the seven studies that measured balance (5,6,17,22,23,34,38)
generated positive findings, with Chan et al. (6) reporting an
CLINICAL SCIENCES
improvement in weight distribution between the two legs in
standing, whereas Tankisheva et al. (34) reported an increase
in equilibrium score during standing on a moveable surface
(34). In addition, a significant reduction of spasticity (6,26)
and an improvement in mobility after WBV (6,23) were
reported in 50% and 40% of the trials, respectively. A recent
meta-analysis of eight WBV trials on patients with stroke
revealed that the effects of WBV on muscle strength and
mobility performance remain inconclusive (40). Another re-
cent systematic review of nine WBV clinical trials on stroke
patients generated a similar conclusion (18). The limited
number of studies and their methodological weaknesses (only
two of the trials provided level one evidence) could partially
account for the inconclusive results (18). Thus, good-quality
clinical trials with larger study cohorts are required to study
the efficacy of WBV among individuals with stroke (18,40).
Discrepancies in results observed within the literature
could be due to the vast differences in WBV parameters
(WBV intensity, choice of exercise, and exercise duration)
and characteristics of participants across studies (18). In-
deed, specific factors required for a successful treatment
outcome cannot be identified because differences exist in
multiple parameters across studies. No previous trial has
attempted to vary any of the above parameters and compare
their effects. Among the various parameters, WBV intensity
may be a key factor in determining treatment success. Pre-
vious EMG studies in able-bodied individuals (29) and
individuals with stroke (19,21) revealed that the EMG am-
plitude of major leg muscle groups during WBV exposure
was significantly augmented as WBV intensity was in-
creased. Thus, it was postulated that higher WBV intensities
should be more effective than lower intensities in improving
leg muscle strength after a period of exercise training. The
current study was designed in such a way that the effects of
two different WBV intensities on leg muscle strength could
be compared.
Another knowledge gap identified in systematic reviews is
the relative lack of activity and participation outcomes in
previous stroke WBV trials (18,40). The health consequences
of stroke are multidimensional, and this context should be
taken into consideration when selecting outcome measures.
Therefore, the framework of this study was constructed based
on the International Classification of Functioning, Disability,
and Heath model (39), by incorporating outcomes of body
functions/structures (e.g., muscle strength and spasticity),
activity (e.g., mobility, walking endurance, and balance),
and participation levels (e.g., participation in community
activities). According to this model, there is a dynamic in-
teraction between body structures/functions, activity, and
participation, meaning that impairments in body structures/
functions may influence activity and participation outcomes.
Therefore, by addressing impairments (e.g., muscle weak-
ness) through the proposed intervention, it was postulated that
1228 Official Journal of the American College of Sports Medicine
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
activity and participation may also improve. The inclusion of
outcome measures in body structures/functions, activity, and
participation domains would provide a more comprehensive
picture of the therapeutic value associated with the experi-
mental intervention.
The objective of this randomized controlled trial (RCT)
was to investigate the effects of different WBV intensities
on body functions/structures, activity, and participation in
community-dwelling individuals with chronic stroke. It was
hypothesized that 1) adding WBV to exercise training would
lead to significantly greater improvements in body functions/
structures, activity, and participation outcomes, compared with
the same exercise regimen without WBV, and 2) the high-
intensity protocol would induce significantly more gain in the
same outcomes, compared with the low-intensity protocol.
METHODS
Design
The present investigation was a single-blinded RCT, in
which the assessor was blinded. The study was registered at
ClinicalTrials.gov (NCT01822704). The reporting of this
WBV clinical trial was in accordance with the recommen-
dations of the International Society of Musculoskeletal and
Neuronal Interactions (31).
Participants and Sample Size
The study was conducted at a research laboratory at the
Hong Kong Polytechnic University. The inclusion criteria
were as follows: diagnosis of hemispheric stroke persisting
for more than 6 months before the time of enrolment, age
Q18 yr, community dweller, a score of 6 or higher on the
Abbreviated Mental Test (1), and the ability to stand with
or without aid for more than 90 s. Patients were excluded if
any of the following conditions were present: brainstem or
cerebellar stroke, other neurological disorders (e.g., spinal
cord injury), neoplasms, severe cardiovascular diseases
(e.g., requiring a pacemaker and uncontrolled hyperten-
sion), pain that affected the ability to participate in phys-
ical activities, pregnancy, vestibular conditions, recent
fractures or metal implants in the lower limbs, or other serious
medical problems.
The sample size was estimated based on evidence from a
previous WBV study that investigated the leg extensor EMG
activity during WBV in individuals with stroke (19), using
G Power 3.1 software (Universitat Dusseldorf, Germany).
Liao et al. (19) demonstrated that WBV training induced
significantly higher levels of muscle activity in the paretic
leg, with effect sizes ( f ) of 0.460.93 (i.e., large effect sizes).
To be more conservative, a medium effect size was assumed
(convention: f = 0.25). Based on a 2  3 repeated-measures
ANOVA, with an alpha value of 1% and power of 80%,
the minimum sample size required to detect a significant
grouptime interaction effect would be 21 subjects in each
http://www.acsm-msse.org
group (total of 63 participants). We used a more stringent
alpha value because of the inflated probability of making
type I errors due to multiple testing. To account for a 15%
attrition rate, we aimed to recruit a minimum of 75 participants
(25 per group). Written informed consent was obtained from
all participants. The principles of the Declaration of Helsinki
were followed, and the study was approved by the Human
Research Ethics Review Subcommittee of the Hong Kong
Polytechnic University.
Recruitment and Randomization
The recruitment of participants took place from February
2013 to February 2014 via the Hong Kong Stroke Associa-
tion. Those who expressed interest in participating in the
study were initially screened through telephone interviews,
followed by a face-to-face assessment session. After eligi-
bility was confirmed, participants were then randomized into
FIGURE 1CONSORT flow chart.
WHOLE-BODY VIBRATION AND STROKE
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
the low-intensity WBV group (LWBV), the high-intensity
WBV group (HWBV), or the control (CON) group using a
1:1:1 allocation ratio (Fig. 1). To ensure concealed alloca-
CLINICAL SCIENCES
tion, subjects were randomly assigned to groups using sealed
opaque envelopes distributed by an off-site researcher who
was not involved in the recruitment of participants, provision
of exercise training, or measurement of outcomes. The last
participant completed the postintervention assessment on
May 20, 2014.
Interventions
All participants received WBV exercise training three
times a week for a total of 30 sessions. A minimum 1-d rest
period was scheduled between training sessions. Extra ses-
sions for missed appointments were arranged to ensure that
all participants completed all 30 sessions. All exercise training
took place in the same research laboratory of the Hong Kong
Medicine & Science in Sports & Exercised 1229
 Polytechnic University. Exercise sessions for the three groups
took place at different times of the day, such that the partici-
pants from each treatment group could not observe what ex-
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ercises the other groups received. Each exercise session began
with 10 min of warm-up exercises and ended with 10 min of
cooldown exercises (general stretching exercises in a sitting
position and exercise using a cycle ergometer).
Participants in the LWBV group (n = 28) and HWBV
group (n = 28) received exercise training on a WBV platform
that delivered synchronous WBV (Gymna Fitvibe Medical
System, Gymna Uniphy Pasweg, Bilzen, Belgium). The
choice of WBV and exercise protocols (Table 1) was
adapted from a previous study that examined muscle activ-
ity during WBV exposure among individuals with stroke
(19). In that study, WBV intensities similar to our LWBV
protocol induced significantly higher leg muscle activity
compared with the control condition (19). The highest level
of leg muscle activity was attained during deep squat,
semisquat, forward, and backward weight-shift exercises
(19). Therefore, these exercises were chosen in this study to
optimize the activation of major leg muscle groups (Table 1).
Knee extension while in an erect standing posture was
avoided to minimize the transmission of WBV to the head
(29). In addition to dynamic exercises, static exercises were
included in the training protocol because daily activities in-
volve both static (isometric) and dynamic muscle work. In-
deed, similar to dynamic muscle strength (8,24), isometric
leg muscle strength has been shown to be strongly correlated
with other important functions poststroke, including walk-
ing endurance, walking velocity, and balance ability (15).
Moreover, previous WBV trials in older adults and in-
dividuals with stroke have provided no clear evidence that
using a combination of static and dynamic exercises (23)
is inferior to dynamic exercises (17,35) or static exercises
alone (5,34,38).
Dynamic exercises (exercises 13, Table 1) were per-
formed in cycles of 3 s, with 20 repetitions per minute. A
metronome was used to pace the participants in performing
the exercises at the desired rhythm. A rhythm of 20 repeti-
tions per minute was selected, based on our pilot study,
which demonstrated that most individuals were able to
perform the exercises at this pace for 1.5 min without
experiencing excessive fatigue, while finding it sufficiently
TABLE 1. Parameters of WBV and exercise protocols.
Group Frequency (Hz) Amplitude (mm) Peak Acceleration (g)
LWBV 20 1 1.61
HWBV 30 1 3.62
CON 0 0 0
Exercise Protocol Starting Position
1. Dynamic weight shift side Stand on the WBV platform with feet placed
to side width apart at shoulder width, with bilateral
knees flexed at 10-
2. Dynamic deep squat Same as exercise 1
3. Dynamic forward and Same as exercise 1
backward weight shift
4. Static semisquat Same as exercise 1
1230 Official Journal of the American College of Sports Medicine
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challenging. For the static exercise (Exercise 4, Table 1), the
participants were asked to sustain the semisquat position for
1.5 min in each repetition. A rest period of 1.5 min was
given between each exercise repetition.
The training protocol had a progressive design, with
a gradual increase in the duration of exercise (from 12 to
18 min per session) over the course of the treatment period,
as tolerated. We increased the exercise duration as a means
of progressing the intervention, given that reduced exercise
endurance is often a problem poststroke (32). We did not
increase the frequency of exercise training sessions (e.g.,
5 dIwkj1), mainly due to feasibility issues. In the current
training program, patients were already required to travel
three times a week to our exercise facility, which was quite a
distance from the homes of several participants. Further-
more, patients were often accompanied by their primary
caregiver. Increasing the frequency of training may have
increased travel expenses, burden to the caregiver, and
possibly the attrition rate. Nonetheless, the exercises used in
this study were quite challenging for the participants, who
had varying degrees of physical impairments. Having at
least one rest day after a training session was designed to
facilitate participant recuperation and to enable better exer-
cise performance in the next training session. The exercises
were progressed only if tolerated by the participants. The
RPE was also monitored (2). If the participant reported an
RPE 9 15, the exercise would be terminated, and a longer
rest period (e.g., 3 min or longer, as requested by the par-
ticipants) was given before proceeding to the next exercise.
An RPE value of 15 was chosen because it was found to be
the optimal cutoff for identifying individuals who attained a
peak RER of Q1.10 (an indicator of maximal exertion) (27).
We used the same standard to monitor all exercises to ensure
safety. Apart from the longer rest period, no modification of
the rhythm or movement was made to the next exercise if an
RPE 9 15 was reported during the previous exercise. If the
participant reported excessive fatigue, muscle soreness, or
pain from the previous training session, the exercise duration
was not progressed during that session.
The WBV settings were validated by a triaxial accelerome-
ter (Model 7523A5; Dytran Instruments Inc., Chatsworth,
CA), as recommended by the International Society of Mus-
culoskeletal and Neuronal Interactions (31). The frequency of
Duration per Exercise (min) Repetitions Total Exercise Duration (min)
1.5 2 (sessions 115) 12 (sessions 115)
3 (sessions 1630) 18 (sessions 1630)
Movement
A metronome was used to guide the subjects in performing the exercise at
a rhythm of 20 repetitions per minute (i.e., 3 s per cycle). Shift body weight
as much as possible onto the paretic side, then shift onto the nonparetic side.
Follow the same rhythm as exercise 1 to flex the bilateral knees to 70- and
then return to the starting position
Follow the same rhythm as exercise 1 to shift body weight forward as much
as possible with ankle in plantarflexion. Then shift body weight backward
as far as possible with ankle in dorsiflexion.
Flex both knees to 30- and hold for 1.5 min and then return to the starting position.
http://www.acsm-msse.org
the WBV signals used was 20 Hz and 30 Hz. Frequencies
higher than 30 Hz and amplitudes higher than 1 mm were not
used in this study due to the very high peak acceleration
values generated (14). Signal distortion is more severe with
high-amplitude vibration signals (14). WBV frequencies be-
low 20 Hz were not used because they may induce a con-
siderable resonance effect, resulting in amplification of the
vibration signals and possible adverse effects (14). Our pilot
work also showed that the high-intensity protocol demanded
a substantial exercise effort from the stroke participants,
without causing excessive fatigue.
The CON group completed the same movements while
standing on the same WBV platform, but no WBV was de-
livered (i.e., WBV device was turned off). Treatment ses-
sions for all three groups were supervised by a researcher
(researcher/participant ratio = 1:2). All participants per-
formed the same exercises while standing on the WBV
platform (Table 1). The training instructions and exercise
progression pattern were the same for all three groups. The
participants were asked to report to the research team if there
was any change in medications during the study period.
Outcome Measures
Outcome measurements were performed between February
2013 and May 2014. Demographics and other relevant infor-
mation (i.e., medications, medical history) were collected at
the baseline assessment. The level of impairment of the leg
and foot was evaluated using the Impairment Inventory of
the ChedokeMcMaster Stroke Assessment (CMSA) (11).
The rating for each body part was based on a seven-point
ordinal scale, with higher scores indicating better motor
recovery. The ratings for the leg and foot were summed to
yield an overall CMSA motor score for the paretic lower
limb. The Functional Ambulation Category (score range =
05; 0 = nonambulatory, 5 = independent) was used to indi-
cate walking ability (13). The following outcomes were
measured at baseline (within 1 wk before the commencement
of the exercise training) and postintervention (within 1 wk
after the completion of 30 treatment sessions) by the same
blinded assessor.
Primary Outcome
Muscle strength. The knee extension and the flexion
muscle strength of both the paretic and the nonparetic leg
were measured by a dynamometer (NUMAC NORMTM
Testing & Rehabilitation System, Computer Sports Medi-
cine, Inc., Stoughton, MA). Isometric, isokinetic concentric,
and eccentric muscle strength were tested. After a practice
trial, each participant performed a maximal voluntary iso-
metric contraction of knee flexion and extension at two
knee joint angles, 30- and 70- of knee flexion, respectively.
The peak torque value (NIm) was registered. Isokinetic knee
concentric and eccentric flexion/extension contractions
through a range of movement between 70- and 10- of knee
WHOLE-BODY VIBRATION AND STROKE
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
flexion at a fixed angular velocity of 60-Isj1 were also
measured. An angular speed of 60-Isj1 was chosen, as
this has been commonly used in previous stroke studies
CLINICAL SCIENCES
(5,17,26,34). Previously, it has been noted that a substantial
proportion of individuals with stroke are unable to perform
at higher angular velocities due to factors such as severe
spasticity, which was also apparent in our pilot testing. The
peak power value (W) was recorded. For all test conditions,
three trials were performed with a 2-min rest period between
trials. Data were then averaged and normalized by the
participant_s body weight to yield the mean isometric
strength (NImIkgj1) and concentric and eccentric strength
(WIkgj1) of knee flexion and extension in each leg. Muscle
strength measurements using isokinetic dynamometry have
been shown to be highly reliable in individuals with chronic
stroke (5,17,26).
Secondary Outcomes
Spasticity. Spasticity in the knee extensors and ankle
plantarflexors was assessed using the six-point Modified
Ashworth Scale (MAS) (0 = no spasticity, 4 = affected part
rigid). The MAS is widely used to evaluate muscle tone in
stroke research and has acceptable reliability (Kendall_s tau
correlation = 0.847) (25).
Balance. The 14-item Mini Balance Evaluation Systems
Test (Mini-BESTest) was used to evaluate balance perfor-
mance in everyday functional activities (37). The total score
on this test ranges from 0 to 28, with higher scores indicating
better balance ability. The Mini-BESTest has good psycho-
metric properties when used in individuals with stroke, with
excellent internal consistency (Cronbach_s alpha = 0.89
0.94), intrarater reliability (intraclass correlation coefficient
[ICC] = 0.97), and interrater reliability (ICC = 0.96) (37).
Walking endurance. The 6-Minute Walk Test (6MWT)
was administered while oxygen consumption (V O2) was
continuously recorded using the FitMatei metabolic system
(Cosmed, Rome, Italy). At the beginning of each testing
session, the system was calibrated according to the manu-
facturer_s guidelines. The total distance covered (m) and the
mean V O2 rate (mLIkgj1Iminj1) during the last 30 s of the
6MWT (a measure that is moderately associated with peak
V O2 in individuals with stroke) were used for subsequent
O2 measured during the 6MWT and the
analysis (7). Both V
distance covered have shown high testretest reliability in
individuals with stroke (ICC 9 0.95) (7).
Functional mobility. Functional mobility was measured
with the Timed-Up-and-Go (TUG) test (28). Each participant
was asked to stand up from a chair, walk forward for 3 m, turn
around, and walk back to the chair and sit down, as quickly as
possible. The time taken to complete the test (in seconds) was
measured using a stopwatch. The TUG test was carried out
twice, with trials separated by a 1-min rest period. The aver-
age of the two trials was used for subsequent analysis.
Balance self-efficacy. Balance self-efficacy was eval-
uated using the Activities-specific Balance Confidence (ABC)
Medicine & Science in Sports & Exercised 1231
 scale (3). Participants were instructed to rate their level of
confidence in performing each activity without losing their
balance, using a numerical rating scale from 0 to 100, with
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higher scores denoting better balance confidence. The scores
for each item were summed and then averaged to obtain
the total ABC score. The ABC scale has been demonstrated
to be a reliable and valid tool for evaluating balance self-
efficacy in individuals with stroke (3).
Participation in daily activities. The Frenchay Ac-
tivity Index (FAI) was used as a measure of participation
(12). The FAI records the frequency of participating in so-
cial activities and performing more complex activities of
daily living (e.g., domestic chores, outdoor mobility, and
leisure). Each of the 15 items was rated on a scale from 0 to
3, yielding a total score of 15 to 60 (1529: inactive or re-
stricted participation; 3044: active; and 4560: highly ac-
tive) (12). The construct validity and reliability of the FAI
has previously been established (ICC = 0.87) (12).
Perceived environmental barriers to societal
participation. Participants also rated their perception of
environmental barriers to societal participation using the 25-
item Craig Hospital Inventory of Environmental Factors
(CHIEF) (20). The score for each of the 25 items was cal-
culated by multiplying the magnitude score (small problem,
1; big problem, 2) by the frequency score (range: daily, 4;
never, 0) to yield a product or overall impact score. Items
relating to work or school, when the respondent was neither
working nor in school, were considered not applicable and
were not scored. The total CHIEF score is the mean of up to
25 overall impact scores. Liao et al. (20) demonstrated that
the CHIEF is a reliable and valid tool for evaluating the
perceived environmental barriers to societal participation
among individuals with chronic stroke.
Quality of life. Quality of life was assessed using the
Short-Form 12 Health Survey, version 2 (SF-12, Chinese
version) (16). A mental health composite score and a phys-
ical composite score were generated (range: 0100), with
higher scores denoting better health-related quality of life.
Statistical Analysis
All statistical analyses were performed using IBM SPSS
software (version 20.0; IBM, Armonk, NY, USA). A more
stringent significance level of P G 0.01 was set due to the
multitude of outcomes involved. Descriptive statistics (e.g.,
mean and standard deviation) were used to indicate central
tendencies and variability of the data. One-way ANOVA (for
continuous variables), chi-square tests (for nominal vari-
ables), and KruskalWallis tests (for ordinal variables) were
used to compare the baseline characteristics of the three
groups. An intention-to-treat analysis was performed. For
those who dropped out from the study, the results of the
baseline assessment were carried over to the subsequent as-
sessments using the last observation carried forward (LOCF)
method (30). One key assumption of LOCF is that patients
who do not receive treatment maintain status quo (30).
1232 Official Journal of the American College of Sports Medicine
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
However, in reality, many intervention programs are designed
to prevent the deterioration of patients who are expected to
get worse without intervention. Therefore, the LOCF method,
by assuming that the past continues unchanged, may result in
an overestimation of treatment efficacy or an underestimation
of harmful effects. However, we chose to use LOCF because
our participants were in the chronic stage of stroke and were all
ambulatory and thus should not experience major deterioration
in leg muscle strength or other health outcomes in the absence
of the WBV intervention during the study period (about 75 d
on average). Previous chronic stroke WBV trials also have not
reported substantial deterioration in health outcomes in the
CON group (5,17). Therefore, we felt that the LOCF is a rea-
sonable imputation method, given the context of this study.
The KolmogorovSmirnov test was used to check normality
of the data. ANOVA (mixed design; between-subject factor:
group; within-subject factor: time) was used to compare out-
come variables across the two time points (i.e., baseline and
postintervention). Contrast analysis was performed within each
group post hoc, when appropriate. As the MAS was an ordinal
variable, between-group comparisons of the postintervention
scores were made using the KruskalWallis test (which gen-
erated H statistics that were tested using the chi-square dis-
tribution), followed by post hoc MannWhitney tests, as
indicated. The above analyses based on the intention-to-treat
(ITT) principle were repeated after excluding the dropouts
(i.e., on-protocol analysis). Among the various outcome var-
iables, only the 6MWT and the Mini-BESTest had well-
established minimal clinically important difference (MCID)
values, at 34.4 m (33) and 4 points (10), respectively. The
proportion of individuals who achieved an improvement in
the 6MWT Q 34.4 m or Mini-BESTest Q 4 points was com-
pared across groups using the chi-square test.
Secondary analysis was performed to identify the factors
that may be related to better treatment outcomes after WBV
training. The change scores (postintervention score minus the
preintervention score) of the LWBV and HWBV groups for
each outcome were correlated with the corresponding baseline
scores and relevant characteristics of the participants (e.g., age,
time taken to finish the 30 sessions of exercise training, base-
line outcome measure scores, etc.) using either Spearman_s rho
or Pearson_s correlation, depending on whether the assump-
tions for parametric analysis were fulfilled.
RESULTS
Of 113 individuals with stroke who were screened for
eligibility, 84 fulfilled all selection criteria (see the CON-
SORT flow diagram in Fig. 1). Twenty-eight participants
were randomly allocated to each of the LWBV (8 women),
HWBV (10 women), and CON (4 women) groups, respec-
tively. A total of 74 participants completed the training
programs and postintervention assessments (Fig. 1). The
overall attrition rate was 11.9%. Of the four dropouts in the
HWBV group, one withdrew after the baseline assessment,
and three dropped out after having completed 1, 9, and 13
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TABLE 2. Characteristics of participants.
All Subjects (n = 84) LWBV (n = 28) HWBV (n = 28) CON (n = 28) P*
Basic demographics

CLINICAL SCIENCES
Age (yr)a 61.2 T 9.2 60.8 T 8.3 62.9 T 10.2 59.8 T 9.1 0.457
Sex (men/women) 62/22 20/8 18/10 24/4 0.178
Body mass index (kgImj2) 24.5 T 4.4 24.1 T 5.8 24.7 T 3.2 25.1 T 3.8 0.630
Stroke characteristics
Poststroke duration (yr) 8.5 T 4.6 8.5 T 5.2 8.1 T 4.2 9.0 T 4.6 0.456
Type of stroke, hemorrhagic/ischemic (n) 35/49 12/16 12/16 11/17 0.952
Hemiparetic side (right/left) 51/33 20/8 19/9 12/16 0.058
CMSA lower limb score (214)b 9 (711.75) 8 (711.75) 8 (711.75) 9 (711) 0.165
Paretic knee MAS of spasticity score (04)a
0/1/1.5/2/3/4 (n) 24/28/23/9/0/0 7/10/6/5/0/0 7/9/9/3/0/0 10/9/8/1/0/0 0.456
Median (IQR) 1 (02) 1 (02) 1 (02) 1 (02)
Paretic ankle MAS of spasticity score (04)
0/1/1.5/2/3/4 (n) 7/10/35/24/7/1 3/4/17/4/0/0 1/3/10/11/2/1 3/3/8/9/5/0 0.254
Median (IQR) 2 (22) 2 (13) 1.75 (04) 1.75 (03)
Mobility status
Functional ambulation category (05) 5 (45) 5 (45) 5 (45) 5 (45) 0.794
Walking aids indoors (none/cane/quad/frame/rollators/wheelchair) (n) 75/6/3/0/0/0 26/2/0/0/0/0 23/2/3/0/0/0 26/2/0/0/0/0 0.340
Walking aids outdoors (none/cane/quad/frame/rollators/wheelchair) (n) 31/38/3/6/0/6 10/15/1/0/0/2 9/11/1/5/0/2 12/12/1/1/0/2 0.569
Participants with at least one fall in the past 12 months (n) 30 8 10 12 0.537
Comorbid conditions
Total number of medical conditions 1.8 T 1.0 1.6 T 0.9 2.0 T 1.1 1.9 T 1.0 0.736
Hypertension (n) 16 5 6 5 0.926
High cholesterol (n) 50 16 17 17 0.952
Medications
Total number of medications 4.3 T 1.8 4.0 T 1.6 4.4 T 1.9 4.6 T 1.9 0.584
Antihypertensive agents (n) 31 7 14 10 0.151
Hypolipidemic agents (n) 50 16 17 17 0.952
Antidiabetic agents (n) 14 5 5 4 0.918
Muscle relaxants (n) 6 3 1 2 0.584
Compliance
Time taken to complete 30 training sessions (d) 75.5 T 5.2 74.9 T 4.8 74.5 T 4.9 76.9 T 5.7 0.729
Maximum time lapse between training sessions (d) 7.1 T 2.0 7.1 T 2.0 7.2 T 2.2 7.0 T 1.9 0.474
IQR, interquartile range; n = number count.
a
Mean T SD presented for continuous variables.
b
Median (interquartile range) for ordinal variables.
*P values for between-group comparisons.

sessions, respectively. In the LWBV group, five individuals
dropped out after having completed 3, 5, 6, 9, and 19 ses-
sions, respectively. One participant from the CON group
withdrew after having completed 24 sessions.
Demographics
Demographic information is summarized in Table 2. All
participants were ambulatory; 75 did not require any walk-
ing aid indoors. The CMSA motor score for the paretic
lower limb (median = 9 out of 14, interquartile range = 7
11.8) revealed that the motor impairment level was mild
to moderate. There was no significant between-group dif-
ference in any of the demographic (Table 2) or outcome
variables at baseline (P 9 0.05) (Tables 3 and 4). The on-
protocol analysis after removal of dropouts yielded similar
results (see Table, Supplemental Digital Content 1, which
shows the on-protocol analysis, http://links.lww.com/MSS/
A666). None of the participants reported any changes in
medications throughout the study period.
Training Duration
Among those who completed all of the postintervention
assessments, the mean number of days taken to complete the
30 sessions of exercise training showed no significant dif-
ference among the three groups (P = 0.729) (Table 2). The
maximum time interval (mean number of days) between
two training sessions was also similar among the three
groups (P = 0.474) (Table 2).
Adverse Events
One participant from the LWBV group reported mild
knee pain after WBV therapy and five reported fatigue (three
from the LWBV group and two from the HWBV group)
(Fig. 1). These participants eventually dropped out of the
study. The remaining participants were able to increase their
duration of exercise, as described in our protocol (Table 1).
Outcome Measures
ITT analysis. In the ITT analysis, there was a significant
time effect for several muscle strength measures on the pa-
retic side (i.e., isometric flexion and extension at 70-, and
concentric flexion) (P G 0.01; Table 3), TUG, 6MWT dis-
tance, V O2 during 6MWT, Mini-BESTest, ABC, and the
physical composite score domain of the SF-12 (P G 0.01;
Table 4). However, none of the variables showed significant
timegroup interactions (P 9 0.01). The KruskalWallis
test revealed no significant differences in the postinter-
vention knee MAS (W2 = 0.230, P = 0.891) or ankle MAS
scores (W2 = 0.642, P = 0.725) among the three groups. A
total of 12, 11, and 12 individuals showed an improvement

WHOLE-BODY VIBRATION AND STROKE Medicine & Science in Sports & Exercised 1233

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 CLINICAL SCIENCES

TABLE 3. Intention-to-treat analysis: primary outcomes (muscle strength).

1234
Comparison GroupTime Time
CON (n = 28)a LWBV (n = 28)a HWBV(n = 28)a at Baseline Interaction Effect Effect
Mean Change Mean Change Mean Change
Pre Post (95% CI) Pre Post (95% CI) Pre Post (95% CI) P P P
Paretic side
Isometric extension at 70- (NImIkgj1) 1.41 T 0.58 1.48 T 0.59 0.07 (j0.05 to 0.19) 1.33 T 0.38 1.42 T 0.44 0.09 (j0.05 to 0.22) 1.31 T 0.52 1.49 T 0.55 0.19 (0.08 to 0.29) 0.099 0.326 0.001*
Isometric flexion at 70- (NImIkgj1) 0.42 T 0.25 0.47 T 0.26 0.05 (j0.01 to 0.08) 0.29 T 0.21 0.35 T 0.21 0.05 (0.03 to 0.08) 0.37 T 0.21 0.45 T 0.25 0.08 (0.03 to 0.14) 0.710 0.438 G0.001*
Isometric extension at 30- (NImIkgj1) 0.85 T 0.37 0.86 T 0.39 0.02 (j0.11 to 0.15) 0.84 T 0.27 0.83 T 0.29 j0.01 (j0.09 to 0.12) 0.85 T 0.35 0.86 T 0.37 0.01 (j0.12 to 0.14) 0.997 0.931 0.881
Isometric flexion at 30- (NImIkgj1) 0.62 T 0.32 0.63 T 0.35 0.01 (j0.06 to 0.08) 0.52 T 0.20 0.56 T 0.24 0.04 (j0.03 to 0.11) 0.61 T 0.26 0.63 T 0.29 0.19 (j0.09 to 0.13) 0.272 0.890 0.359
Concentric extension (WIkgj1) 0.63 T 0.39 0.66 T 0.32 0.03 (j0.04 to 0.10) 0.55 T 0.28 0.61 T 0.27 0.06 (j0.01 to 0.13) 0.62 T 0.38 0.59 T 0.24 j0.03 (j0.19 to 0.13) 0.622 0.482 0.517
Concentric flexion (WIkgj1) 0.19 T 0.19 0.27 T 0.24 0.08 (j0.03 to j0.13) 0.18 T 0.19 0.20 T 0.19 0.02 (j0.02 to 0.06) 0.21 T 0.19 0.24 T 0.18 0.03 (j0.04 to 0.09) 0.856 0.258 0.006*
Eccentric extension (WIkgj1) 1.34 T 0.61 1.50 T 0.65 0.16 (j0.04 to 0.35) 1.36 T 0.38 1.38 T 0.44 0.02 (j0.11 to 0.15) 1.35 T 0.61 1.40 T 0.59 0.05 (j0.20 to 0.30) 0.992 0.575 0.169
Eccentric flexion (WIkgj1) 0.80 T 0.44 0.81 T 0.33 0.01 (j0.11 to 0.13) 0.69 T 0.28 0.76 T 0.28 0.08 (j0.03 to 0.19) 0.71 T 0.43 0.76 T 0.37 0.05 (j0.08 to 0.17) 0.531 0.720 0.166
Nonparetic side
Isometric extension at 70- (NImIkgj1) 1.98 T 0.58 2.07 T 0.54 0.09 (j0.07 to 0.24) 1.68 T 0.50 1.77 T 0.48 0.09 (j0.05 to 0.23) 1.74 T 0.60 1.85 T 0.54 0.11 (j0.05 to 0.26) 0.221 0.982 0.026
Isometric flexion at 70- (NImIkgj1) 0.76 T 0.23 0.78 T 0.24 0.02 (j0.02 to 0.07) 0.66 T 0.18 0.66 T 0.18 0.01 (j0.04 to 0.05) 0.70 T 0.22 0.75 T 0.25 0.05 (j0.01 to 0.12) 0.110 0.433 0.068
Isometric extension at 30- (NImIkgj1) 1.15 T 0.29 1.19 T 0.37 0.04 (j0.09 to 0.17) 1.06 T 2.45 1.08 T 0.25 0.02 (j0.06 to 0.10) 1.11 T 0.37 1.12 T 0.35 0.02 (j0.11 to 0.15) 0.150 0.941 0.442
Isometric flexion at 30- (NImIkgj1) 0.97 T 0.33 0.97 T 0.38 0.00 (j0.09 to 0.10) 0.84 T 0.24 0.85 T 0.24 0.01 (j0.06 to 0.09) 0.85 T 0.27 0.91 T 0.33 0.06 (j0.05 to 0.16) 0.506 0.669 0.354
Concentric extension (WIkgj1) 0.96 T 0.42 1.11 T 0.31 0.14 (j0.03 to 0.31) 0.93 T 0.32 0.96 T 0.35 0.03 (j0.08 to 0.14) 0.99 T 0.37 0.97 T 0.38 j0.02 (j0.11 to 0.08) 0.982 0.184 0.164
Concentric flexion (WIkgj1) 0.53 T 0.29 0.63 T 0.23 0.10 (j0.00 to 0.20) 0.53 T 0.17 0.56 T 0.21 0.04 (j0.04 to 0.11) 0.54 T 0.19 0.59 T 0.21 0.05 (j0.04 to 0.13) 0.844 0.526 0.017
Eccentric extension (WIkgj1) 1.61 T 0.78 1.84 T 0.54 0.23 (j0.10 to 0.56) 1.65 T 0.16 1.59 T 0.54 j0.06 (j0.24 to 0.13) 1.77 T 0.53 1.80 T 0.69 0.03 (j0.16 to 0.22) 0.588 0.229 0.329
Eccentric flexion (WIkgj1) 1.03 T 0.51 1.11 T 0.31 0.07 (j0.12 to 0.26) 0.93 T 0.31 0.98 T 0.32 0.05 (j0.03 to 0.13) 1.00 T 0.40 1.03 T 0.43 0.02 (j0.09 to 0.14) 0.614 0.874 0.196
a
Mean T SD presented for continuous variables.
*P G 0.01.

Official Journal of the American College of Sports Medicine

in this outcome.

DISCUSSION
training duration).
Secondary Analysis

(i.e., the CON protocol).

provements in these outcomes.

peutic effect for strength outcomes.

analysis, http://links.lww.com/MSS/A666).

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
value) postintervention in the CON, LWBV, and HWBV
18 participants exhibited an increase of Q4 points (MCID

However, the grouptime interaction effects were not sig-

benefits? The findings of the current study were in contrast
the paretic leg, indicating that the participants with poorer
groups, respectively. No significant between-group differ-

activity, and participation outcomes than leg exercises alone

LWBV or HWBV protocols to a leg exercise protocol was
LWBV group. A significant negative correlation was

paretic knee. As with the LWBV group, participants with

and extension strength (r = j0.832, P G 0.001), eccentric
tions between the change scores and their respective base-

with both hypotheses established. In all cases, certain leg

protocol analysis), with similar results found (see Table,

nificant, indicating that adding either LWBV or HWBV to

concentric strength (r = j0.490, P = 0.008) of the non-
line scores for concentric flexion (r = j0.510, P = 0.006)

j0.554, P = 0.002) of the paretic knee, and isometric ex-

neuromuscular function tended to have greater improvement
found between the baseline scores and the change scores for
spective baseline values and other relevant factors (e.g.,
the change score of each outcome measure and their re-

Does WBV stimulation confer any additional

HWBV group. There were significant negative correla-
knee flexion eccentric strength (r = j0.509, P = 0.006) in
mine whether there was any significant association between
also performed after removal of the dropouts (i.e., on-
Mini-BESTest (W2 = 0.446, P = 0.800) that was at, or be-
and HWBV groups, respectively, after the intervention pe-
in the 6MWT Q 34.4 m (MCID value) in the CON, LWBV,

http://www.acsm-msse.org
the leg exercise protocol did not confer an additional thera-
muscle strength variables showed significant time effects,
no more effective in enhancing body functions/structures,
The key finding of this study was that the addition of
poorer neuromuscular function tended to have greater im-
In the secondary analysis, an attempt was made to deter-
Supplemental Digital Content 1, which shows the on-protocol
an improvement in the 6MWT (W2 = 0.098, P = 0.952) or
riod. With respect to the Mini-BESTest scores, 18, 20, and

indicating significant improvement after the training period.

tension strength at 30- (r = j0.500, P = 0.007) and flexion
flexion (r = j0.554, P = 0.002) and extension strength (r =
yond, the respective MCID values. All analyses above were
ence was found in the proportion of subjects who achieved
 Results related to the efficacy of WBV training on muscle

0.002*

G0.001*
G0.001*
G0.001*

G0.001*

G0.001*
0.239
0.106
0.964

0.507
Effect
Time
strength in individuals with stroke after 412 wk of training

P
have been mixed (18,40). Although several studies reported

CLINICAL SCIENCES
Interaction Effect
no significant effects (5,17,22,38), Tankisheva et al. (34)
GroupTime

0.981**
0.725**
and Tihanyi et al. (35) observed positive effects with WBV

0.197

0.920
0.446
0.440

0.323
0.296
0.895
0.386
0.865
0.440
P
on muscle strength outcomes. Although several reasons may
exist for the discrepancies in results between the current
report and these two studies, a key issue may be related to
Between-Group
Comparison
at Baseline

the design of the CON group. In both the current study and
0.617

0.276
0.526
0.718
0.368
0.303
0.503
0.854
0.604
0.186

0.839
0.872
P

previous research that reported no significant between-group

CHIEF-C, Chinese version of the Craig Hospital Inventory of Environmental Factors; IQR, interquartile range; MCS, mental health composite score; n = number count; PCS, physical composite score.
differences in muscle strength outcomes (5,17,22,38), the
CON group performed exactly the same exercises as the
14.0 T 17.2 j3.8 (j2.1 to j5.6)
209.6 T 75.6 246.3 T 79.5 30.6 (14.5 to 46.7)

3.5 (j0.8 to 7.7)

0.3 (j1.5 to 2.1)
0.6 T 0.5 j0.1 (j0.2 to 0.1)

2.5 (j3.0 to 8.0)

0.1 (j0.7 to 1.0)

6.4 (1.6 to 11.2)

Mean Change

5.0 (3.3 to 6.6)

3.8 (0.5 to 7.1)

WBV group. In contrast, Tankisheva et al. (34) and Tihanyi
(95% CI)

et al. (35) included a comparison group that engaged in

different activities. Specifically, Tankisheva et al. (34) found
a significantly greater increase in isometric and isokinetic
a
HWBV (n = 28)

knee extension torque (240-Isj1) in the paretic leg for the

69.6 T 15.9 73.1 T 17.0

101.2 T 74.1 92.1 T 10.9 j9.1 (j38.3 to 20.1) 86.1 T 13.2 92.5 T 13.2
11.7 T 3.1

18.6 T 4.6

24.1 T 6.4

40.1 T 9.4
61.6 T 74.5 49.6 T 10.4 j12.0 (j41.3 to 17.3) 49.9 T 13.7 52.4 T 9.6
1 (02)
2 (12)

WBV group when compared with the comparison group that

Post

engaged in habitual physical activities. Thus, it is possible

that better outcomes observed in the WBV group were re-
lated to the leg exercises performed while standing on
11.6 T 3.3

17.9 T 9.0

13.6 T 4.7

23.9 T 6.2
0.7 T 0.6

36.3 T 7.9
1 (02)
2 (22)
Pre

the WBV device rather than the WBV stimulation itself.

In the study by Tihanyi et al. (35), the WBV group (WBV
plus conventional rehabilitation) experienced a significantly
j.1 (j5.7 to j2.5) 20.2 T 14.8 16.6 T 17.0 j3.6 (j5.9 to j1.3)
39.3 (21.8 to 56.8) 203.6 T 82.4 253.6 T 90.7 50.0 (20.1 to 80.0)

23.3 T 7.4 j0.2 (j1.7 to 1.4)

0.7 T 0.5 j0.1 (j0.2 to 0.1)

2.8 (j0.2 to 5.8)

greater improvement in eccentric and isometric knee exten-

Mean Change

1.0 (0.4 to 1.5)

4.9 (3.7 to 6.2)

4.9 (1.4 to 8.3)

(95% CI)

sion torque in both legs compared with a comparison group

that received conventional rehabilitative treatment only. The
positive improvement in muscle strength reported in the
a
LWBV (n = 28)

WBV group could be attributable to the leg exercises and

76.8 T 14.6 81.6 T 16.8

longer total treatment time rather than the WBV stimulation.

11.5 T 2.8

18.0 T 5.3

42.4 T 6.2
1 (01)
2 (12)
Post

Considering the overall available evidence, no study has

convincingly demonstrated that WBV stimulation has a
positive effect on muscle strength in individuals with stroke.
10.6 T 2.9

13.0 T 4.4

23.4 T 7.2
0.7 T 0.6

39.6 T 8.6
1 (0.32)
2 (22)

A recent meta-analysis also revealed that WBV induced no

Pre

significant effect on isometric and eccentric knee extension

strength among individuals with stroke (40). Therefore, the
results of this study further consolidate the current body of
1.6 (j0.2 to 3.4)
0.6 T 0.4 j0.03 (j0.1 to 0.1)

49.3 T 11.7 48.9 T 10.7 j0.3 (j3.7 to 3.2)

7.4 (3.6 to 11.2)
0.9 (0.2 to 1.6)

6.1 (4.6 to 7.5)

3.4 (0.3 to 6.5)

3.7 (1.3 to 6.1)
Mean Change

evidence in showing that WBV had no effect on leg muscle

(95% CI)

**P value for comparison of MAS postintervention score (KruskalWallis test).

strength poststroke.
An alternative explanation for the lack of significant ef-
fects on muscle strength is that the intensity of the WBV
a
CON (n = 28)

stimulation may not be high enough. Higher intensities were

22.4 T 24.0 18.3 T 23.3
209.4 T 75.0 248.7 T 92.6

73.2 T 18.8 80.6 T 15.3

87.3 T 13.2 90.7 T 12.4

11.1 T 2.4

19.4 T 4.7

23.5 T 6.2

41.7 T 8.0

not used in this study as the high peak accelerations gener-

1 (02)
2 (12)
TABLE 4. Intention-to-treat analysis: secondary outcomes.

Post

ated have the potential to cause injuries, such as damage to

fragile bones and back pain (4,14). Increasing vibration ac-
Mean T SD presented for continuous variables.

celeration magnitude has been found to be associated with

10.2 T 2.3

13.3 T 4.1

21.9 T 7.4
0.6 T 0.5

38.0 T 7.4
1 (0.32)
2 (22)
Pre

an increased risk for developing greater lower back pain

and disability over time among professional drivers, during a
12-month follow-up period (4). In repetitive exposure to
Ankle spasticity median (IQR)
Knee spasticity median (IQR)
Body functions and structures

high load, the possibility of fatigue damage to fragile bones

(mLIkgj1Iminj1)

6MWT distance (m)

cannot be excluded (14). On the basis of these reasons, al-

VO2 during 6MWT

though the duration of exposure in a typical WBV session is

Mini-BESTest

much shorter than that in occupational exposure and that the

Participation

CHIEF-C
TUG (s)

vibration-induced effects are short in duration (in the order

SF-12

*P G 0.05.
Activity

MCS
ABC

PCS
FAI

of milliseconds), caution was exercised by avoiding higher

WBV intensities in this study (14). A previous RCT has
a

WHOLE-BODY VIBRATION AND STROKE Medicine & Science in Sports & Exercised 1235

Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 shown that WBV at an intensity of 0.96g1.61g was not
effective in improving muscle strength in people with
chronic stroke (17,26). Adding WBV at an intensity of 1.61g
CLINICAL SCIENCES
has been shown to augment the EMG activity of the major
leg muscle groups during exercise by approximately 10%25%
(19,21). The intensity used in this study for the HWBV group
(3.62g) was even higher and would presumably have induced
greater muscle responses. However, a recent study on in-
dividuals with chronic stroke (21) showed that the rela-
tionship between the WBV intensity and the level of
muscle activation was nonlinear; increasing the WBV in-
tensity from 0.96g to 1.61g only led to an additional
3%5% increase in leg muscle EMG amplitude. Thus,
further increasing the WBV intensity beyond a certain
point may no longer effectively increase EMG activity.
Therefore, despite the use of higher WBV intensities in
this study, this may not necessarily translate into sub-
stantially higher muscle activation level compared with
lower WBV intensities.
Finally, the lack of significant results in this study may be
related to the observation that WBV may be beneficial for a
very select group of individuals only. Secondary analysis
revealed that those with more severe deficits had a tendency
to gain a greater degree of improvement from WBV training.
Significant time effects were also detected for body
functions/structures (V O2 rate), activity (TUG, 6MWT dis-
tance, and Mini-BESTest), and participation levels (ABC
and physical health domain of SF-12), indicating that all
three groups experienced improvement in these outcomes
after the training period. However, the lack of a grouptime
interaction on these outcomes indicated that the WBV
stimulation itself did not confer any additional effects. As
WBV did not result in any significant effect on the muscle
strength and spasticity variables (body functions/structures),
a significant treatment effect on the related outcomes at the
activity and participation levels, which often have multiple
determinants, would not be expected. In addition, the fact
that the WBV therapy did not involve any walking-related
activities may account for the nonsignificant treatment effect
on the mobility outcomes observed. Nevertheless, our re-
sults generally concurred with the available body of evi-
dence. Only four studies have previously investigated the
influence of WBV on mobility function poststroke after
38 wk of training (5,17,23,38), and only Merkert et al.
(23) reported better performance in the TUG test in the
WBV group. However, their CON group engaged in con-
ventional rehabilitation, whereas the WBV group received
additional WBV training on top of conventional rehabili-
tation. Thus, their WBV group had a greater total treatment
time than the CON group. This factor, rather than WBV
stimulation, may better explain the outcomes in the WBV
group. Six studies have assessed balance after 312 wk of
training (5,17,22,23,34,38), and only one of these reported
positive results (34). Finally, only one study has investigated
the effect of WBV therapy on social participation, using the
Stroke Impact Scale, and found no significant effect compared
1236 Official Journal of the American College of Sports Medicine
Copyright 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
with sham vibration (5). Taken together, the present results
are generally in line with previous studies in showing that
WBV does not induce improvement in activity and partici-
pation outcomes. A similar conclusion was made in a recent
meta-analysis by Yang et al. (40).
Limitations. This study has several limitations. First, the
findings should not be generalized to patients who are in
the acute/subacute stage of recovery, or who have severe
motor impairments, because the participants in the present
study were all in the chronic stage and had mild to mod-
erate impairments poststroke. Second, participants and the
trainer were not blinded to group allocation, but this would
be difficult to achieve in the context of the exercise trials
used. However, all efforts were made to minimize any
possible bias (e.g., assessor blinding, separate exercise
periods for the three groups, etc.). Third, we did not in-
crease the frequency of training sessions as a means of
progressing the exercises because of practical issues. Fi-
nally, no long-term follow-up assessment was performed.
Any potentially beneficial or harmful long-term effects of
WBV remain uncertain.
Future directions. On the basis the results of the cur-
rent study and the body of evidence accumulated from pre-
vious trials (18,40), the clinical use of WBV in stroke
rehabilitation could not be recommended at this point. Fur-
ther research should be performed in this area. As revealed
in our secondary analysis, WBV may be more applicable to
those who are more severely impaired. Future research
should test the feasibility and efficacy of using WBV in a
more homogeneous sample of people who have a greater
severity of stroke-induced motor impairment. It would be
interesting to also assess the effects of WBV in acute stages
of stroke recovery, when impairment levels are often more
severe. Furthermore, we only compared the effects of dif-
ferent WBV intensities, and further research is required to
compare different WBV parameters (type of vibration
stimulus and duration of WBV). For example, there is some
preliminary evidence from a meta-analysis that vertical
(synchronous) WBV is more beneficial than side-alternating
WBV in improving mobility poststroke (40). Further studies
are also needed to investigate fundamental questions such as
the transmissibility of WBV signals and how transmissibil-
ity varies with different WBV parameters and exercises
performed. Finally, electrophysiological studies should be
performed to address the physiological mechanisms associ-
ated with the application of WBV poststroke.
CONCLUSION
In summary, although WBV therapy is safe and feasible
for individuals with chronic stroke, the addition of the WBV
paradigm used here (LWBV and HWBV protocols) to a leg
exercise protocol was no more effective in enhancing body
functions/structures, activity, and participation than leg ex-
ercise training alone in community-dwelling individuals
with mild to moderate chronic stroke impairments.
http://www.acsm-msse.org
 This study was supported by the General Research Fund pro-
vided by the Research Grants Council (PolyU 5245/11E). The WBV
device was provided by SOOST Limited.
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