The Feasibility of non-motorized Treadmill Training on Lower Extremity Muscle Strength,Balance,and Gait in Patients with Stroke: A Pilot Study

Abstract

Background

Non-motorized treadmills have been used for health improvement in healthy individuals and for enhancing physical fitness in athletes. However, there is a lack of research focusing on their use with patients with stroke.

Objective

This study aims to assess the impact of non-motorized treadmill training on lower limb strength, balance, and gait in patients with stroke, and compare it with flat ground walking training.

Methods

The participants included 22 patients with stroke, divided into two groups: non-motorized treadmill training group (n = 11) and flat ground walking training group (n = 11). All participants underwent 20 training sessions, 30 min each, five times a week for four weeks. Outcome measures included the digital dynamometer, Medical Research Council scale (MRC), Berg Balance Scale (BBS), Four Square Step Test (FSST), 6-Minute Walk Test (6MWT), and GAITRite.

Results

The non-motorized treadmill training group showed significant improvements compared to the flat ground walking group in hip abductor and extensor muscle strength, knee flexor and extensor muscle strength, MRC, BBS, FSST, 6MW and gait parameters (p < 0.05).

Conclusions

Non-motorized treadmill training may be considered an effective gait rehabilitation method in clinical settings for patients experiencing stroke with reduced lower limb strength, balance, and walking ability.

Keywords

postural balance muscle strength gait stroke

Introduction

Patients with stroke experience impaired fine motor skills, balance, and walking ability due to complex functional disabilities, resulting in limitations in performing functional activities necessary for independent daily living (de Haart et al., 2005). Muscle weakness in patients with stroke is a limiting factor for functional rehabilitation, affecting walking speed and endurance, hindering independent walking (Bohannon, 2007). Balance is essential for independent living alongside walking, serving as a powerful indicator of functional recovery and walking ability (Neptune & Vistamehr, 2018). Balance in patients with stroke is related to weight shifting ability (de Haart et al., 2005). Patients with stroke often exhibit higher weight support on the unaffected side, resulting in asymmetrical gait (Szopa et al., 2017).

Research into gait and balance recovery in patients with stroke has explored various therapeutic approaches. One of these approaches, Weight-supported treadmill training, commonly used for gait training, is not only beneficial for walking recovery but also enhances muscle strength, improves balance, and relearning motor control patterns during walking (Dobkin, 2004). Treadmill training has demonstrated promising benefits in stroke rehabilitation, especially in enhancing walking distance and overall motor function (Gelaw et al., 2019). For patients with stroke, task-oriented and repetitive treadmill walking training is known to be an effective method for motor learning (Dean et al., 2000).

On a non-motorized treadmill, patients with stroke must determine their walking speed themselves in order to maintain balance (Fullenkamp et al., 2018). Additionally, they must periodically adjust their speed to maintain it, and they need to adjust their step cycle and stride length. This requires greater neuromuscular control (Smoliga et al., 2015). Research on non-motorized treadmills has also investigated physiological intensities such as muscle activation and energy expenditure (Montgomery et al., 2016; Morgan et al., 2016; Smith et al., 2006; Snyder et al., 2011). Training studies have compared lower limb strength changes between Non-motorized treadmill training (NMTT) and conventional treadmill training (Franks et al., 2012).

Research on NMTT specifically targeting patients with stroke is currently lacking, with only cross-sectional studies comparing flat ground walking and walking speed, and examining changes in step frequency and stride length when increasing speed. There is a need to confirm the effectiveness of non-motorized treadmills in the walking training of patients with stroke who require active participation in walking. Therefore, this study aimed to investigate the effects of NMTT conducted with speed increments and maintenance on lower limb strength, balance, and gait in patients with stroke, aiming to propose effective walking rehabilitation strategies.

Methods

Participants

This study was conducted with 24 patients with stroke admitted to K Rehabilitation Hospital located in Guri City, Gyeonggi Province, South Korea. Participant recruitment was conducted over the course of one month. The inclusion criteria for participants in this study were as follows: individuals who had experienced a stroke at least 6 months prior, were at Brunnstrom recovery stage IV or higher, capable of walking independently for at least 10 min with or without the use of a cane, had a Mini-Mental State Examination-Korean (MMSE-K) score of 21 or above indicating adequate communication and ability to follow instructions (Rowland et al., 2006), had no ambulatory issues due to orthopedic surgery or foot joint deformities, had no other conditions affecting walking apart from stroke. The exclusion criteria for participants in this study were as follows: individuals who vestibular or cerebellar disorders, as well as those with visual or auditory impairments (Marigold & Eng, 2006).

Study Procedure

This study employs a two-group pretest-posttest design. The selected research participants were given a detailed explanation of the experimental procedures and subsequently completed a consent form for their participation in the study. Participants are randomly divided into two groups using a lottery method based on the intervention: the NMTT group and the flat ground walking training (FGWT) group. This study involved six therapists with over four years of clinical experience, who conducted assessment, analysis, and training for each patient group using a single-blind method. This study was conducted after obtaining approval from the Institutional Review Board of S University (Approval No. 2-1040781-AB-N-01-2016135HR). All participants had their muscle strength of the affected lower limb measured using a digital muscle tester (Manual Muscle Tester, Lafayette Instrument, Lafayette, USA, 2004) before and after the experiment, recording scores on the Medical Research Council scale (MRC). Additionally, evaluations included the Berg Balance Scale (BBS), Four Square Step Test (FSST), gait analysis using a gait analyzer, and a 6-Minute Walk Test (6MWT).

All participants underwent the assigned training for a total of 20 sessions over 4 weeks, with each session lasting 30 min and conducted 5 days a week. Participants with a training participation rate below 80% were excluded from the study. Additionally, both groups received conventional physical therapy as per the hospital's inpatient rehabilitation program, consisting of 30 min sessions twice daily, 5 days a week, over the same 4 week period.

The NMTT group had one participant drop out due to inadequate participation (below 80%) caused by an upper limb fracture, while the FGWT group had one participant drop out due to discharge, resulting in a total of 22 participants excluding these two individuals who participated in the study.

Non-motorized Treadmill Training

In this study, we utilized a non-motorized treadmill (Speedfit treadmill, SPT-1000C, Drax. Inc., Korea, 2016) (Figure 1) and a POLAR heart rate monitor (POLAR RS400sd, Polar Electro Inc., USA, 2012) (Figure 2) for NMTT. For NMTT, participants wore a POLAR heart rate monitor strapped to their chest while performing the exercises. The NMTT consisted of three cycles: walking at 40% of the target heart rate for 4 min, followed by walking at 60% of the target heart rate for 5 min, totaling 9 min of walking per cycle, with a 1 min rest period between cycles. This sequence was repeated three times during the session. The permissible heart rate tolerance range was set at ±5 bpm. Participants were allowed to hold onto the handrails for safety. Participants underwent walking training for 30 min per session, 5 times a week, over a period of 4 weeks. Throughout the entire training period, a therapist stood beside the participants to ensure safe execution of the walking exercises. They monitored and maintained a consistent heart rate to sustain the training intensity (Franks et al., 2012; Pang et al., 2013).

Figure 1.

Non-motorized treadmill.

Figure 2.

POLAR heart rate monitor.

Flat Ground Walking Training

For FGWT, participants wore a POLAR heart rate monitor strapped to their chest and performed walking exercises on a track measuring 8 meters wide by 14 meters long. The FGWT consisted of three cycles: walking at 40% of the target heart rate for 4 min, followed by walking at 60% of the target heart rate for 5 min, totaling 9 min of walking per cycle, with a 1 min rest period between cycles. Participants in the study were allowed to wear assistive devices as needed and were provided with canes for added safety measures. Throughout the entire training period, a therapist accompanied the participants to prevent accidents and ensure consistent training intensity. The study subjects underwent 30 min walking sessions, 5 times a week, for 4 weeks.

Conventional Physical Therapy

Conventional physical therapy included Bobath's neurodevelopmental therapy, proprioceptive neuromuscular facilitation (Pohl et al., 2002), joint range of motion, stretching, strengthening, and ground walking training (Yang et al., 2010). All participants received conventional physical therapy sessions lasting 30 min each, twice daily, five days a week, over a period of 4 weeks.

Outcome Measures

In this study, digital dynamometers were used to measure the strength of hip abductor and extensor, as well as knee flexor and extensor. Muscle strength of the lower limbs was assessed using the MRC. Balance abilities were evaluated using the BBS and FSST. To investigate spatiotemporal metrics of gait, a high-reliability, validity, and sensitivity gait analysis system (GAITRite, CIR system Inc, USA, 2008) was utilized. Additionally, walking endurance was assessed using the 6MWT.

Statistical Analysis

All statistical analyses in this study were conducted using SPSS 18.0 (SPSS Inc, Chicago, USA) to analyze the characteristics of variables. To determine the normality of the measured variables, Shapiro-Wilk tests were conducted. Since the data did not satisfy normal distribution, non-parametric tests were employed. Sociodemographic variables of the participants were analyzed using descriptive statistics, while medical characteristics were analyzed using mean and standard deviation. Between-group homogeneity was tested using Chi-Square analysis and the Mann-Whitney U test. The change before and after intervention was assessed using the Wilcoxon Matched-Pairs Singled-Ranks test. A significance level (α) of 0.05 was used for all statistical analyses.

Results

The study initially selected 24 participants. However, 2 were excluded: 1 due to low participation and 1 due to a sudden discharge. As a result, 22 participants participated (Figure 3). Both the NMTT and FGWT groups demonstrated homogeneous general and medical characteristics (Table 1). The comparison of lower limb strength on the affected side is shown in Table 2, and balance is shown in Table 3. The comparison of general walking characteristics is shown in Table 4, with the affected side shown in Table 5 and the unaffected side shown in Table 6.

Figure 3.

Experimental diagram.

Table 1.

General Characteristics of Subject. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	χ2/z(p)
Gender			0(1)
Male	7	7
Female	4	4
Age (years)	54.91 ± 11.66	5309 ± 10.02	−0.326(0.717)
Height (cm)	167.73 ± 10.09	164.18 ± 8.45	−0.892(0.372)
Weight (kg)	65.73 ± 9.69	66 ± 9.1	−0.066(0.947)
MAS (score)	0.82 ± 0.6	0.82 ± 0.6	0(1)
Onset (months)	23.09 ± 14.05	22.9 ± 16.06	−0.099(0.921)
MMSE-K (score)	24.73 ± 2.57	24.6 ± 2.59	−0.432(0.665)
Stroke type			0.188(0.665)
Infarction	7	8
Hemorrhage	6	5
Affected side			0(1)
Right	5	5
Left	8	8

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training; MAS: Modified Ashworth Scale; MMSE-K: Mini-Mental State Examination-Korean.

Table 2.

Comparison of Lower Limb Strength on the Affected Side. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	z (p)
Hip extensor (kg)
Pretest	12.04 ± 1.62	12.48 ± 1.59
Posttest	13.54 ± 1.35	13.07 ± 1.78
Post-Pre	1.84 ± 0.72	0.6 ± 0.51	−3.712 (< 0.001)
z (p)	−2.937 (0.003)	−2.714 (0.007)
Hip abductor (kg)
Pretest	7.28 ± 0.99	7.66 ± 1.77
Posttest	8.83 ± 1.35	8.34 ± 1.91
Post-Pre	1.55 ± 0.62	0.68 ± 0.4	−3.251 (0.001)
z (p)	−2.934 (0.003)	−2.666 (0.008)
Knee flexor (kg)
Pretest	6.22 ± 1.34	6.55 ± 1.39
Posttest	7.64 ± 1.39	7.09 ± 1.35
Post-Pre	1.42 ± 0.43	0.53 ± 0.64	−3.28 (0.001)
z (p)	−2.936 (0.003)	−2.497 (0.013)
Knee extensor (kg)
Pretest	7.95 ± 0.95	8.21 ± 1.61
Posttest	10.59 ± 1.46	8.65 ± 1.85
Post-Pre	2.65 ± 1.15	0.43 ± 0.49	−3.711 (< 0.001)
z (p)	−2.936 (0.003)	−2.293 (0.022)
MRC (score)
Pretest	15.45 ± 3.34	15.5 ± 3.83
Posttest	17.55 ± 2.88	16.59 ± 3.74
Post-Pre	2.09 ± 0.83	1.09 ± 0.54	−2.605 (0.008)
z (p)	−2.952 (0.003)	−2.965 (0.003)

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training; MRC: Medical Resaearch Council.

Table 3.

Comparison of Balance Ability. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	z (p)
BBS (score)
Pretest	47.36 ± 3.35	48.73 ± 5.18
Posttest	51.63 ± 2.61	50.73 ± 4.92
Post-Pre	4.27 ± 1.17	2 ± 1.41	−2.81 (0.005)
z (p)	−2.994 (0.003)	−2.842 (0.004)
FSST (score)
Pretest	21.3 ± 8.02	21.57 ± 11.12
Posttest	17.16 ± 6.4	20.68 ± 10.9
Post-Pre	−4.14 ± 2.81	−0.89 ± 1.21	−2.659 (0.008)
z (p)	2.845 (0.004)	2.134 (0.008)

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training; BBS: Berg Balance Scale; FSST: Four Square Step Test.

Table 4.

Comparison of General Walking Characteristics. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	z (p)
Walking speed (cm/s)
Pretest	48.19 ± 28.92	56.27 ± 28.68
Posttest	61.53 ± 30.7	62 ± 31.82
Post-Pre	13.33 ± 7.68	5.73 ± 11.16	−2.071 (0.04)
z (p)	−2.934 (0.003)	−2.402 (0.016)
Cadence (step/min)
Pretest	76.08 ± 28.61	80.15 ± 19.6
Posttest	85.24 ± 28.73	82.86 ± 19.62
Post-Pre	9.16 ± 6.92	2.71 ± 7.21	−2.265 (0.023)
z (p)	−2.934 (0.003)	−2.134 (0.033)
6MWT (m)
Pretest	191.09 ± 87.92	205.86 ± 103.04
Posttest	219.36 ± 103.82	216.73 ± 107.25
Post-Pre	28.27 ± 25.81	10.86 ± 18.8	−2.037 (0.041)
z (p)	−2.847 (0.004)	−2.135 (0.033)

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training; 6MWT: 6-Minute Walk Test.

Table 5.

Comparison of Walking Characteristics of the Affected Side. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	z (p)
Step length (cm)
Pretest	36.07 ± 11.71	41.81 ± 13.61
Posttest	42.39 ± 13.04	45.02 ± 13.31
Post-Pre	6.32 ± 3.79	3.21 ± 4.4	−1.544 (0.123)
z (p)	−5.934 (0.003)	−1.956 (0.05)
Stride length (cm)
Pretest	72.57 ± 22.76	80.36 ± 26.6
Posttest	84.26 ± 22.71	84.12 ± 28.31
Post-Pre	9.87 ± 7.26	3.31 ± 6.01	−2.137 (0.033)
z (p)	−2.934 (0.003)	−2.092 (0.036)
Single limb support (%)
Pretest	22.7 ± 8.79	23.97 ± 7.43
Posttest	25.33 ± 7.36	25.07 ± 7.76
Post-Pre	2.64 ± 2.03	1.1 ± 1.78	−2.004 (0.045)
z (p)	−2.936 (0.003)	−1.824 (0.068)
Double limb support (%)
Pretest	48.17 ± 15.28	45.15 ± 12.73
Posttest	41.62 ± 10.85	43.33 ± 14.66
Post-Pre	−6.55 ± 4.98	−1.83 ± 4.78	−1.971 (0.049)
z (p)	−2.845 (0.004)	−1.689 (0.091)

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training.

Table 6.

Comparison of Walking Characteristics of the Unaffected Side. (n = 22).

	NMTT (n = 11)	FGWT (n = 11)	z (p)
Step length (cm)
Pretest	36.48 ± 12.18	38.73 ± 13.92
Posttest	41.77 ± 11.41	40.48 ± 15.71
Post-Pre	5.28 ± 4.28	1.75 ± 2.99	−2.078 (0.038)
z (p)	−2.845 (0.004)	−1.972 (0.049)
Stride length (cm)
Pretest	73.53 ± 22.63	80.07 ± 27.33
Posttest	84.17 ± 22.44	85.48 ± 29.38
Post-Pre	10.64 ± 5.37	4.79 ± 5.51	2.303 (0.021)
z (p)	−2.934 (0.003)	−2.296 (0.022)
Single limb support (%)
Pretest	28.93 ± 7.23	30.94 ± 6.08
Posttest	32.59 ± 5.04	32.26 ± 6.94
Post-Pre	3.66 ± 3.88	1.33 ± 4.59	−1.775 (0.076)
z (p)	−2.578 (0.01)	−1.26 (0.208)
Double limb support (%)
Pretest	49.28 ± 15.59	45 ± 11.64
Posttest	43.25 ± 12.47	43 ± 13.21
Post-Pre	−6.03 ± 5.87	−2 ± 4.25	−1.939 (0.052)
z (p)	−2.49 (0.013)	−2.055 (0.04)

Values are mean ± standard deviation. NMTT: non-motorized treadmill training; FGWT: flat ground walking training.

All muscle strength variables significantly increased in both groups post-training, with the NMTT group showing statistically significant improvement compared to the FGWT group (p < 0.05). MRC significantly increased post-training in both groups, with the NMTT group showing statistically significant improvement compared to the FGWT (p < 0.05).

The BBS and FSST significantly improved post-training in both groups, with the NMTT group showing statistically significant improvement compared to the FGWT group (p < 0.05).

Walking speed, cadence, 6MWT significantly increased post-training in both groups, with the NMTT group showing statistically significant improvement compared to the FGWT group (p < 0.05).

The step length of the affected side significantly increased in the NMTT group after the training, with no significant difference between the groups. The stride length of the affected side significantly increased in both groups after training, with the NMTT group showing significantly greater improvement compared to the FGWT group. The step length and stride length of the unaffected side significantly increased in both groups after training, and the NMTT group showed significantly greater improvement compared to the FGWT group.

In the single limb support and double limb support of the affected side, the NMTT group showed a significant difference after training, and it significantly improved compared to the FGWT group. The single limb support on the unaffected side significantly increased after training in the NMTT group, with no significant difference observed between the groups. The double limb support on the unaffected side significantly decreased in both groups, with no significant difference observed in the change between the groups.

Discussion

The primary goal of major therapies for promoting post-stroke recovery is to enable them to recover independently (Ostwald et al., 2009). The treadmill is the most commonly used device for gait recovery in patients with stroke (Guzik et al., 2018). However, the treadmill, due to its motor-driven belt movement, significantly reduces ground reaction forces during terminal stance compared to overground walking (Hutchinson et al., 2021). In this study, a non-motorized treadmill was used, which differs from standard treadmills where a constant speed is maintained passively. On a non-motorized treadmill, patients actively engage in walking by pushing and propelling the belt with both affected and unaffected limbs. This requires functional execution and concentration on walking tasks to maintain the speed (Montgomery et al., 2016).

In previous studies, aerobic exercise starting at 40–50% of the target heart rate and progressing to 60–80% has been recommended for patients with stroke to recover fitness, walking speed, and walking endurance (Pang et al., 2013). In this study, participants performed walking exercises at 40% of their target heart rate for 4 min, followed by 5 min at 60% of their target heart rate, with 1 min of rest between intervals, repeated for a total duration of 30 min. In this study, NMTT was regulated based on heart rate intensity, differing physiologically from flat ground walking (Smoliga et al., 2015).

In a non-motorized treadmill, since the belt must be propelled with each step, users actively support their body weight with both lower limbs, unlike walking on flat ground (Franks et al., 2012). This promotion induces muscle activity of the hip abductors, hip extensors, and knee extensors during NMTT, suggesting that muscle strength may improve compared to FGWT. Non-motorized treadmill walking requires the lower limb in stance phase to propel and maintain the belt's movement, necessitating activation not only of the hip and knee extensors but also the knee flexors (Montgomery et al., 2016). This increased the activity of the knee flexor muscles, leading to improved strength.

The hip and knee extensor muscles play a crucial role in walking on an incline, with their activation increasing as the incline becomes steeper (Liu et al., 2020). Non-motorized treadmill walking requires active engagement of the legs, similar to walking on flat ground, but differs in that while flat ground walking occurs on a level surface, non-motorized treadmill walking involves a slightly curved surface, simulating a slight incline (Smoliga et al., 2015). It is speculated that such inclines encourage greater engagement of muscles around the hip and knee joints, thereby influencing muscle strength recovery.

Lower limb strength in patients with stroke has a strong correlation with scores on the BBS, and it is considered an indicator of both lower limb strength and walking speed in patients with stroke (Kluding & Gajewski, 2009). It has been reported that the activation of the hip abductor during hip flexion plays a crucial role in maintaining the body's center of mass over the supporting limb during the transition from double limb support to single limb support in the stance phase of walking (Pai et al., 1994). In this study, it is speculated that the recovery of hip abductor strength stabilized the hip joint during weight shifting to the affected side, thereby influencing improvement in the BBS (Gottschalk et al., 1989).

The FSST is a dynamic postural balance assessment designed to evaluate the ability to quickly step over obstacles in various directions (Jeong & Chung, 2024). The recovery of knee extensor strength supports and maintains knee stability during the stance phase and allows for the progression to the swing phase of the opposite limb. Dynamic balance in the sagittal plane during gait is created by the interaction between gravity and the hip abductors (MacKinnon & Winter, 1993). The support of body weight and forward progression control are achieved by the quadriceps, gastrocnemius, and soleus muscles (Pandy et al., 2010). In this study, the NMTT group exhibited greater increases in the strength of hip abductors and extensors, as well as knee flexors and extensors, compared to the FGWT group. This is believed to have contributed to the improvement in the FSST, which requires movement in multiple directions and stability during movement.

The recovery of lower limb strength in patients with stroke is closely associated with increased walking speed. Increases in hip, knee, and ankle joint extensor strength reduce stance phase duration and contribute to increased walking speed (Jung et al., 2020). In this study, it is presumed that the recovery of lower limb strength had an impact on improving walking speed.

There was a high correlation found between the MRC and the 6MWT (Pradon et al., 2013). Another study found a strong correlation between knee joint strength and 6MWT (Ozgozen et al., 2020). In this study, significant improvements were observed in the 6MWT in the NMTT group compared to the FGWT group. Increases in hip and knee joint strength and MRC were also noted. These findings suggest that the recovery of lower limb strength through NMTT contributed to increased walking endurance in patients with stroke.

Patients with stroke typically exhibit a decrease in single limb support on the affected side and an increase in double limb support (Roth et al., 1997). In this study, the changes in affected side single limb support are attributed to the recovery of hip abductor strength, enabling weight bearing during the stance phase. Additionally, the recovery of knee extensor and flexor muscles provides stability to the lower limb, resulting in a significant increase in affected side single limb support. It is hypothesized that the increase in affected side single limb support is associated with a decrease in double limb support.

The ultimate rehabilitation goal for patients with stroke generally is independent walking. This study investigated the effects of NMTT on lower limb strength, balance, and gait in patients with stroke. NMTT significantly improved lower limb strength compared to FGWT. This was effective in influencing weight shifting and weight bearing on the affected side, contributing to balance recovery. Furthermore, it was found to be beneficial not only for walking speed but also for walking endurance.

Limitations of this study include the small sample size, making it difficult to generalize the findings. Additionally, there is a limitation in not comparing the training effects with those of a regular treadmill, which is regrettable. Therefore, future research should involve a larger number of participants and compare NMTT with conventional treadmill training to assess biomechanical factors.

Conclusion

This study investigated the impact of NMTT on lower limb strength, balance, and gait abilities in patients with stroke. The research results showed that NMTT led to significant improvements compared to FGWT in lower limb strength, BBS, FSST, walking speed, cadence, affected side single limb support and double limb support, and unaffected limb step length and stride length. Therefore, it was confirmed that NMTT is effective in improving lower limb strength, balance, and walking ability in patients with stroke. Therefore, it is suggested that NMTT can be applied as a program to increase lower limb strength, balance, and walking ability in chronic patients with stroke who face difficulties in functional recovery during their training programs.

Footnotes

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iDs

Taewoong Jeong

Yijung Chung

Ethics Statement

This study complies with the Declaration of Helsinki and was performed according to the Institutional Review Board of S University (Approval number: 2-1040781-AB-N-01-2016135HR).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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